However, with the future of the ACA now so unclear, l wonder how our efforts to provide patient-centered care will be affected.

Patient-centered care is defined by the peer-reviewed health policy journal Health Affairs as a “medical system in which care revolves around the patient, as opposed to the current physician-centered care. The goal is to improve clinical outcomes and patient satisfaction rates by improving the quality of doctor-patient relationships and decreasing the utilization of diagnostic testing, prescriptions, hospitalizations and referrals.”4


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The Institute of Medicine (IOM) defines patient-centered care as “providing care that is respectful of and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”5

The Picker Institute’s Eight Principles of Patient-Centered Care offer this definition: Respect for patient’s values, preferences, and expressed needs; coordination and integration of care; information, communication and education; physical comfort; emotional support and alleviation of fear and anxiety; involvement of family and friends; continuity and transition; and access to care.6

The World Health Organization (WHO) released guidelines for routine antenatal care on November 7th, 2016, in the setting of a human-rights–based approach in order to prioritize person-centered care and well-being and to reduce morbidity and mortality.7 Their guidelines address nutrition, maternal and fetal assessment, interventions, and health systems available for support. Their recommendations are based on evidence of harm vs benefit, values, resources, equity, acceptability, and feasibility.

Although it sounds good in theory, and many parts of the recent opinion letter reflect what we doctors already normally do in routine practice, I see very little management changes in the field of obstetrics. In obstetrics, we face increasing pressure to let patients make their own management decisions in order to improve patient satisfaction and reduce malpractice claims — despite the fact that patients are often ill-equipped to make these medical decisions. Allowing patient involvement causes interruption of the workflow and inefficiency — against increasing pressure for physicians to conform to evidence-based medicine, algorithms and medical guidelines. Basically, the physician’s and the patient’s agendas are often at odds.

An example of this mismatch can be seen in a recent study. The researchers asked pregnant women if they would follow a physician’s advice to treat preterm labor.  The majority of women surveyed said that they would choose to avoid medical prevention of preterm birth.8 Of the women who said that they would use suggested prevention, 60.2% had a preference for one type of prevention over others. But even more of an eye-opener — 84.5% reported that they would use sources other than their health-care provider to make decisions on treatment, and the Internet was the top choice for information.

This study matters for many reasons. It shows that patients are comfortable with patient-centered care. It is completely acceptable for a woman to choose her management, even if the physician disagrees or the treatment the woman prefers is not evidence-based.  The study also highlights the growing distrust of medical professionals.

How do we get patient-centered care into our OB system? It will be difficult. Although it is paternalistic to say so, most patients do not have the knowledge to make the best medical decisions. Add the increasingly fragmented care by OB hospitalists and difficult decision-making that involves not one, but two patients — along with higher-risk patients. It is a lot to ask. 

That being said, we must continue to embrace good communication, good relationships, and inspire trust so that physicians can provide and patients can receive the best prenatal and delivery care.  ACOG is an advocate for both providers and patients, and their most recent committee opinion reminds us that in normal labors, there is less to do and worry about. That should allow us to relax a bit.

References

  1. “Approaches to Limit Intervention During Labor and Birth:  American College of Obstetrics and Gynecology; Committee Opinion No. 687.”Obstet Gynecol. 2017;129 (2): e20-e28. doi: 10.1097/AOG.0000000000001905
  2. “Quality Patient Care in Labor and Delivery: A Call to Action.” American College of Obstetrics and Gynecology.  Updated December 1, 2011. Available at:  https://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-Improvement/Call-to-Action-Paper.pdf?dmc=1&ts=20170210T1430113271 Accessed February 10, 2017.
  3. Khoong E.  “When Patient-Centered Care Becomes Patient-Dictated Care.” MedPage Today. Updated September 21, 2015. Available at:  http://www.kevinmd.com/blog/2015/09/when-patient-centered-care-becomes-patient-dictated-care.html  Accessed February 15, 2017.
  4. Rickert J.  “Patient-Centered Care: What It Means and How to Get There.”  Health Affairs.  Updated January 24, 2012.  Available at: http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/ Accessed February 10, 2017.
  5. “Crossing the Quality Chasm: A New Health System for the 21st Century.” Institute of Medicine.  March 2001.
  6. “Picker Institute’s Eight Principles of Patient-Centered Care.” Picker Institute. Updated April 15, 2015. Available at: https://nexusipe.org/informing/resource-center/picker-institute%E2%80%99s-eight-principles-patient-centered-care  Accessed February 10, 2017.
  7. Tunçalp Ӧ, et al. “WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience – Going Beyond Survival.” BJOG. 2017.]. doi: 10.1111/1471-0528.14599 [Epub ahead of print]
  8. Ha V and McDonald SD. “Pregnant Women’s Preferences for and Concerns about Preterm Birth Prevention: A Cross-Sectional Survey.” BMC Pregnancy Childbirth. 2017;17 (1): 49. doi: 10.1186/s12884-017-1221-z

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