Clinicians and Patient Advocacy: Real Patient-Centered Care

Patient Advocacy as the First Duty of a Clinician

My son Bill at the beginning and end of his time in the army

When I was in my clinical training decades ago, my mentors taught me that my first duty is to be a patient advocate. That means everything that I do professionally must be driven by what is best for the patients that I am responsible for. Now, we call that patient-centered care. Everyone still talks about patient-centered care, and clinical institutions brag about their patient-centered care incessantly. But it is all talk, and that is why confidence in medical leadership is consistently eroding. “In 1966, 73 percent of Americans said they had great confidence in the leaders of the medical profession. In 2012, only 34 percent felt the same way, according to a 2014 study published in the New England Journal of Medicine. Similarly, in a 2017 SERMO survey, 87 percent of U.S. physicians said patients trust their doctors less than they did 10 years ago.”

Confidence and trust are based on patient assessment of the ethics of a profession and their trust in us is eroding. In just 5 years, the number of Americans who believe medical doctors have high or very high ethical standards has fallen from 65 to 56 percents. This loss of faith in us is especially tragic because the promise of scientific medicine has never been greater. Now we know that aging and chronic diseases are both driven by changes in gene regulation that cause increased oxidant production and inflammation that damage our tissues. We understand these processes well enough to block them very precisely and increase the length of your fully functional life.

These patient concerns are rooted in reality. The needs of American patients have changed very dramatically since they trusted us so much in 1966. Americans are living longer, and they are much more likely to be obese. That means chronic illnesses are a much bigger problem than they were then. Today, chronic diseases are the leading cause of premature death, disability, and they generate most healthcare costs. One dollar out of every five spent on anything in our country is spent on healthcare and 86% of that spending goes to the care of chronic conditions. Yet we have almost totally failed to change our medical system to meet these realities. This book was written over two decades ago, and very little has changed: “Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case. Crucial reports from disciplined review bodies document the scale and gravity of the problems. Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm.” The root cause is a massive failure in medical leadership.

In 1966, medical doctors had a much bigger say in medical policy and priorities. Today, the least trusted professions determine medical policy and priorities. Today business executives, insurance executives, and their political allies run the show. Clinicians are mere pawns on their board. It is no longer about patient advocacy. It is about extracting as much money as possible from sick people to satisfy stockholders and fund the campaigns of their allies.

Many of you think that I am overstating the case, but I am not. The first coronary artery bypass surgeries were done in the early 1960s. That is over 60 years ago, and it made sense then. Patients who had chronic heart artery blockages had chest pain with exertion and those people had a risk of heart attack that was greatly increased. Opening the arteries to prevent heart attack and sudden death made sense then, but the best cardiologists in the country proved conclusively 30 years ago that opening arteries does not prevent heart attack or sudden death. In stable patients, optimal medical therapy for heart artery disease is the most effective treatment. A landmark study in 2008 proved that patients on optimal medical therapy alone did just as well as patients on optimal medical therapy that had chronically blocked arteries opened with a stent. Opening the artery with a stent provided no additional protection beyond optimal medical therapy alone in preventing sudden death or heart attack. A mountain of scientific evidence supports that statement.

But most laymen still believe that opening arteries is the answer to preventing sudden death or heart attack and that is no accident. Only a very few large American health systems have teams to assure that every patient they treat with heart artery disease receives optimal medical therapy. When they talk about providing the best heart care in their community, they are always talking about their cardiologists who find chronically blocked heart arteries and open them. That is because opening arteries generates much more money than providing optimal medical therapy and optimal medical therapy makes it much less likely that you will need a stent or a bypass. Insurance companies and large health systems make more money from opening arteries. They are ignoring their duty to be patient advocates. They do not provide patient-centered care. They are providing care that meets the needs of providers and institutions. Somehow Americans sense that and that is why they don’t trust us and they believe our ethical standards are declining.

We can only change that by making our conduct more ethical and becoming more trustworthy. Professional conduct that leads to confidence and trust does not just happen. My mentors in medical school consistently helped me understand my primary duty of being a patient advocate first and foremost. Let’s use my example to help you understand. As a patient advocate, it is my duty to help patients with heart artery disease understand that they are ten times more likely to be alive in 5 years if they use optimal medical therapy and they will save $20,000 dollars a year in medical costs. It is my duty to help them understand that a stent will not keep them from dying or having a heart attack. It is my duty to recommend what is best for them and if it decreases my income that does not change my duty.

My oldest son went to West Point and in many ways we are in the same business. My job is keeping my patients alive, and his job was to accomplish the mission while keeping his soldiers alive. As with clinicians, it is critical that his men believe their commander is ethical and trustworthy. It is critical that they believe their commander has their back and duty is a central feature of military culture. The West Point motto is “Duty, Honor, Country” and it is far more than a motto. It is the center of cadet culture.  Another central part of their culture is this: “A cadet does not lie, cheat, or steal or tolerate anyone who does.” Those are the values that professionals in life or death endeavors should be governed by. We share that. I have lived it. He has lived it, and his brother lives it. Duty, honor, and patriotism are family values too.

If any of this makes sense to you, you owe it to yourself to listen to General Douglas MacArthur’s “Duty, Honor, Country” speech that he delivered to the West Point cadets during his last visit to his beloved alma mater. He was 82 years old, and this was his farewell speech to the corps. Every West Point cadet has been inspired by that speech. Please take 15 minutes and listen to it. General MacArthur was one of the leaders of the greatest generation in World War II. He led army troops across the Pacific in the conquest of Japan. I think this is the greatest speech ever delivered by an American military leader. I am incapable of hearing it without tears welling up in my eyes. In it, the general says of the corps, “The long gray line (West Point graduates) has never failed us. Were you to do so, a million ghosts in olive drab, in brown khaki, in blue and gray, would rise from their white crosses, thundering those magic words: Duty, Honor, Country.” There you have the answer to our failed medical system. Effective professionalism requires that same sense of service and dedication to ethical principles that still prevails at the military academies.

This problem is not confined to medicine. It seems to me that duty, honor, and ethics don’t get much play today. It seems that we only celebrate great wealth and power and that is what our leaders strive for. That is what many of our people admire. Some of our leaders can’t complete a single paragraph without a lie or distortion. Until our professions become advocates for the people they serve and deliver care that is patient-centered, we will never have better health at lower cost. Until our leaders serve the people better, we will never have a better country.