Virtual Mentor. November 2013, Volume 15, Number 11: 923-925.
From the Editor
The Empowered Patient: Consumerism in American Medicine
Introduction to the November 2013 issue of Virtual Mentor on patient consumerism.
Consumerism arises when purchasers acquire goods and services from sources other than experts. In medicine, this means patients’ receiving health services and information from sources like the Internet and direct-to-patient advertising.
At its best, consumerism fosters empowerment, a focus on consumer rights. The assumption here is that consumers are better able to make decisions when they have more information, choice, and autonomy. Medical apps, physician-rating websites, personalized health records—all of these are meant to decrease the information asymmetry (“doctor knows best”) between patients and their doctors.
However, these trends pose an ethical dilemma for physicians. On one hand, our role is to help patients become better informed. To that end, I am not only impressed when a patient knows a great deal about his or her illness and desired treatment; I am also relieved because it means that I do not have to explain as much as I would to an uninformed patient. On the other hand, what if the information a patient has is irrelevant or incorrect? How do we balance patient empowerment with quality of care? As more technologies and patient-centered metrics come about, concerns about patient information will require more and more of physicians’ time and energy. This issue of Virtual Mentor explores the many ways in which growing patient consumerism is challenging the patient-physician relationship, medical record-keeping, and even fair allocation of the scarcest of resources—human organs.
The Internet is at the heart of ethical debates over consumerism. Whereas the physician was once the undisputed source of all information medical, today the information that doctors spend years of medical school and residency learning can be accessed by patients at the click of a mouse. Are these sources always right, and what if they are not? Teo Forcht Dagi, MD, DMedSc, MPH, discusses how physicians could approach patient requests based on questionable sources. The Internet also offers a forum to broadcast patients’ experiences with and opinions of physicians and other clinicians. Jim E. Sabin, MD, discusses how physicians struggle to balance patient expectations of care with clinical appropriateness in this new era of transparency.
Of course, consumerism happens beyond the physician’s office as well. The rise of the retail clinic—an easily accessible clinic run by nurse practitioners in the back of your local pharmacy—has led patients to seek not only information but medical services from sources other than physicians. Rachel O. Reid, MD, MS, and Ateev Mehrotra, MD, MPH, discuss the tensions that primary care physicians face between wanting to serve as a “medical home” for their patients while still respecting their agency in choosing to go elsewhere for treatment.
The ethics cases provide the practical framework for more specific instances of patient empowerment. Personalized genetics has been a hot topic in previous Virtual Mentor issues because it offers the potential to use patient-specific information to develop personalized therapeutics. In this month’s journal discussion, Susan P. Pauker, MD, describes guiding a patient through deciding whether to use whole-exome sequencing.
With the rise of the smartphone, consumerism has leapt into an entirely new orbit. Whereas computers have limited portability and ability to track real-time patient data, smartphones can measure your heart rate and blood pressure (among other things) anywhere and at a moment’s notice. Michael A. Batista and Shiv M. Gaglani give us a bird’s eye view of smartphone diagnostics. It is easy to argue that these technologies are no match for a physician’s diagnostic capability, but Batista and Gaglani explain how such technologies can actually improve the patient-clinician relationship.
The natural response to worries about patient consumerism is to implement broad policies regulating it, but this can be difficult in practice. Bo Wang, PharmD, and Aaron S. Kesselheim, MD, JD, MPH, highlight the need to certify the reliability of information in direct-to-consumer advertisements (DTCA) of drugs. Richard Weinmeyer, JD, MPhil, fills in the DTCA picture with a review of legislation on the practice. In a policy forum article, Tara LePage, MPH, and O’Neil Britton, MD, give an overview of personalized health records (PHRs). Designed to engage patients in the management of their own health, PHRs face several barriers to implementation, and LePage and Britton offer strategies for encouraging adoption. In a final policy piece, Eitan Neidich, Alon B. Neidich, David A. Axelrod, MD, and John P. Roberts, MD, discuss the market inefficiencies of organ procurement for the purpose of transplantation and whether a free-market solution is possible or ethical in this area.
The last few articles of this issue take up more general considerations of patient consumerism. Patient satisfaction is cited as the primary method for evaluating the “patient-centeredness” of medical care. In fact, the Centers for Medicare and Medicaid Services now tie hospital reimbursement to comparative performance on patient satisfaction scores. In our history of medicine piece, Richard B. Siegrist, Jr., MBA, MS, CPA, discusses how this metric came about and popular misconceptions about patient satisfaction metrics. In the medicine and society piece, Nancy Tomes, PhD, takes a broad look at the pros and cons of consumerism and how it can shape doctors’ perceptions of “good” and “bad” patients. Finally, Richard J. Zeckhauser, PhD, and Benjamin D. Sommers, MD, PhD, close our issue with an essay—their prescription for how physicians can embrace consumerism, despite some of the inefficiencies it causes.
Patient consumerism is broad in its reach and that is reflected by the variety of articles and topics covered in this issue. I am confident that these articles will help physicians see the benefits and the costs of the empowered patient.
Ravi B. Parikh MS-IV Harvard Medical School Boston, Massachusetts
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