This post is written in response to Ubel, Scherr and Fagerlin’s target article, “Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy” published in the November 2017 issue of The American Journal of Bioethics.
by Stuart W Grande, PhD, MPA and William A. Nelson, PhD
Overcoming barriers to successful patient empowerment at the point of care is critical to improved patient-provider communications and ultimately to the realization of the dream of preference-sensitive care. In their recent article, “Empowerment Failure: How Shortcomings in Physician Communication Unwittingly Undermine Patient Autonomy,” Ubel and colleagues provide a provocative and engaging commentary on the “failures” of physicians to cultivate an organizational culture and clinical profession where true co-production can occur. Their argument focuses on physician behavior, with less attention given to the powerful forces of medical culture and health care delivery that perpetuate this problem.
We believe patient empowerment through a shared decision-making process in modern medicine is obstructed in two major ways: a continued focus within the profession of medicine on arbitrating the standard of care, and inadequate clinical and administrative organizational leadership attention at sites of care for system-based patient empowerment. We argue that these, not just individual physician failures, are imposing significant obstacles to patient empowerment.
We, therefore propose additional approaches to fostering patient empowerment beyond what Ubel and colleagues described. These include, first, a wholesale reconfiguration of the use of physician professional standards to acknowledge the value of patient-centered communication skills to support patient empowerment. Additionally, such skills can be mediated by the adoption of technological tools that facilitate and measure impact of patient empowerment through shared decision-making. And secondly, an enhanced organizational commitment ensuring shared decision-making from leaders and administrators who drive cultural norms in healthcare.
Eliot Freidson, who wrote on the profession of medicine, points a finger at the American Medical Association’s (AMA) contribution to the formalizing of professional standards and autonomy in American medicine. Based primarily on controlling the production of labor, formalization of authority, and licensure, the AMA has arguably been the single largest influence on American medicine. Others, including Paul Starr, have characterized the AMA for medicalizing certain normative behaviors to increase demand for services, we must also remember that the AMA has been able to control the supply side as well. By setting communication-based and behavioral standards for entry into medical schools and residencies, as well as assessments like board certifications, we must acknowledge the potential contribution of the AMA to positively reshape the current culture of medicine in the US. In this way, the AMA and other large professional organizations have a responsibility to the practice of medicine and setting the standards that support patient empowerment.
If we believe the premise established by Freidson and Starr, the power of professional societies like the AMA to guide and shape standards of care for patient empowerment must be considered. As there is no shortage of data on failures of clinics to successfully implement novel and effective patient empowerment strategies, a more robust approach is needed. Where institutions have failed to empower patients, recent literature shows how patients have taken to using smartphones to empower themselves. As demonstrated in work that examines these new trends, tools like smartphones and digital applications can be used to empower patients to make better decisions in partnership with their physicians. Therefore, formally permitting use of new tools to support standards of care has merit.
Secondly, the process of patient empowerment through shared decision-making occurs in interactions between a patient and their clinical provider, however, these encounters take place in a context – a complex and multi-layered health care delivery system. Rather than limiting our attention to the clinical-patient encounter, there is a need to broaden our focus to the context in which the interactions occur. In particular, we need to pay attention to the health care organization. As described by Nelson and colleagues in the chapter “Implementing Shared Decision-Making: An Organizational Imperative” from the book Shared Decision making in Health Care, administrative and clinical leadership should engender a commitment to the vision and mandate that shared decision-making be a hallmark of the organization’s culture and practices.
Organizational leadership should develop policies directing a system-wide implementation of patient empowerment through shared decision-making. Such a policy would necessitate training and monitoring. Finally, Nelson and colleagues note, administrative leadership, in close collaboration with clinical departmental leaders and front-line health care providers, should operationalize policies through agreed clinical practices. The organizational commitment must also be reflected in the establishment of performance-based standards, and measures that reflect compliance and where needed, improvement over-time. We believe that leaders cannot merely present lofty statements about being a patient-centered organization, they must ensure that it is reflected in all clinic-patient encounters through shared decision-making.
We believe these alternatives can support physicians, patients, and organizations alike from the present bonds of our antiquated and authoritarian health care culture towards a new approach that centers on co-production and patient empowerment.