Koki Kato is the director at Madoka Family Clinic, Fukuoka, Japan, and the deputy director at the Academic and Research Centre, Hokkaido Centre for Family Medicine, Hokkaido, Japan. He is on Twitter: @kokikatokk
Introduction: Uncertainty and clinical decision-making
We make many decisions on patient care with chaotic uncertainty. When the situation is uncertain, we may choose a safer alternative for patients. However, the problem is not so easy. We also need to provide our patients with person-centred care. Unfortunately, patient safety and patient-centred care can conflict.
Safe care? Or person-centred care?
Unfortunately, patient safety and patient-centred care can conflict.
Consider if you provided care for a young adult with special needs, such as congenital epilepsy or mental retardation. The relationship had spanned many years. The primary caregiver was the patient’s mother.
One day, the mother calls you because the patient has a productive cough and looks pale. You visit the patient and diagnose the patient with pneumonia (with a 92% oxygen saturation). You discuss hospital admission with the mother, but she is reluctant. How would you respond to this situation? Would you continue home care?
In any case, we should explore the person’s ideas, concerns, and expectations in such a situation. So you ask why the mother is reluctant to allow the patient’s admission. You then reveal the following narratives. When the patient was a teen, the paediatric neurology team in a university hospital addressed all the problems from epilepsy to pneumonia. They were very experienced in providing care for a child with special needs. However, becoming an adult fragmented the patient’s care because there were no teams to take over the patient’s batch of problems. Moreover, there were no hospital admissions after the patient transitioned to adult care.
Now, you have a long relationship with the patient and the family and know their experience and context. So, again, I ask you. How would you respond to this situation? Would you continue home care?
You might not choose home care because the patient is apparently in acute respiratory failure. Thus, you might first acknowledge her concerns and then explain that the patient needs hospital care to treat pneumonia. Suppose the mother finally accepts the patient’s hospitalisation. Congratulations! You persuaded her!
Imagine that the patient safely recovered and was discharged. So you, the patient and the mother would be happy. However, unexpectedly, she tells you that the patient got disrespectful care in the hospital, such as violent suctioning.
Oh dear… So then, who was happy?
Is patient safety paramount?
Patient safety is one of the most critical aims in medicine. Unsafe care loses sixty-four million disability-adjusted life years annually, consisting of the top ten causes of death and disability worldwide.1 Avoiding unsafe care thus makes significant benefits (or avoids significant harms) to patients, justifying the rule: “Patient safety is paramount”.
However, as we saw in the above imaginary case, following the rule strictly can cause conflict with person-centred care. Therefore, to restore the patient’s and family’s wellbeing, we should have blended patient safety and person-centredness in the optimum proportions.2,3 I am not sure whether it is possible in the above case. However, suppose it was possible; where then did we go wrong?
Continuity of care as a double-edged sword
Continuity of care increases our knowledge about patients and their context and deepens the patient-clinician relationship. Consequently, such continuity enables us to provide better person-centred care.
However, continuity can be a double-edged sword. Continuity of care may lead general practitioners in the wrong direction by making them (ⅰ) overconfident with the familiarity with the patient’s context and preferences and (ⅱ) persuasive about safer treatment options.
Continuity of care may lead general practitioners in the wrong direction by making them (ⅰ) overconfident with the familiarity with the patient’s context and preferences and (ⅱ) persuasive about safer treatment options.
Overconfidence in knowing the patient
When we provide care for specific patients for a long time, we believe we know their preferences and context well. However, such overconfidence can be detrimental to addressing patients’ concerns seriously. Consequently, we might choose safer care, weighing against their concerns.
In general, parents with special needs children are tired, less able to partake in social activities, feel hopeless, worry about the child’s treatments and are anxious about the child’s future.4 In other words, those parents also have special care needs.
We knew that and thus acknowledged the mother’s concerns. Wasn’t it sufficient? Perhaps, to provide safer and person-centred care, we should have further explored other options, such as implementing home oxygen or searching for a hospital that can provide skilled care for young adults with special needs.
Persuasive attitude about the best care
Continuity of care may strengthen our willingness to save patients’ lives.5 In addition, a patient-clinician relationship with a strong bond also positively influences patients’ willingness to accept physicians’ recommendations.6 These two combined are sufficient to let general practitioners persuade patients to choose safer care. However, physician recommendations might not be appropriate if shared decision making fails to include patients’ and families’ preferences sufficiently.
Medicine (scientific medicine) prioritises the cure of diseases, and patient preferences are often considered the second thing. However, it is not completely valid in chronic care, palliative care and even acute care for patients with complex needs. Unfortunately, we sometimes forget this simple principle of family medicine: attaching importance to the subjective aspects of medicine.
- World Health Organization. Patient safety: Global action on patient safety. Published 2019 Mar 25. Accessed 2022 Mar 31. https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_26-en.pdf
- Shah R, Ahluwalia S, Spicer J. A crisis of identity: what is the essence of general practice?. Br J Gen Pract. 2021;71(707):246-247. Published 2021 May 27. doi:10.3399/bjgp21X715745
- Kato K. Wellbeing is the key. Br J Gen Pract. 2021;71(709):346. Published 2021 Jul 29. doi:10.3399/bjgp21X716513
- Caicedo C. Families with special needs children: family health, functioning, and care burden. J Am Psychiatr Nurses Assoc. 2014;20(6):398-407. doi:10.1177/1078390314561326
- Epstein RM, Street RL Jr. Shared mind: communication, decision making, and autonomy in serious illness. Ann Fam Med. 2011;9(5):454-461. doi:10.1370/afm.1301
- Orom H, Underwood W 3rd, Cheng Z, Homish DL, Scott I. Relationships as Medicine: Quality of the Physician-Patient Relationship Determines Physician Influence on Treatment Recommendation Adherence. Health Serv Res. 2018;53(1):580-596. doi:10.1111/1475-6773.12629