By Prudence L. Gourguechon on 4/21/2010 4:04 PM
Dr. Donald Berwick, pediatrician and Professor of Health Policy at Harvard University, was nominated this week as President Obama’s choice to lead the Centers for Medicare and Medicaid Services (CMS), arguably the most influential health care body in the country. Alas, Dr. Berwick can expect weeks or months of delay on his nomination as it makes the political rounds in Congress.
Meanwhile, as Dr. Berwick and we await his confirmation, it’s worthwhile—and inspiring—to consider some of his thinking on healthcare.
APsaA’s legislative representative Jim Pyles alerted us to some of Dr. Berwick’s writings, which I can only describe as quietly astonishing. This is a fairly long post only because I found so many of Dr. Berwick’s words worth quoting.
In an article entitled What ‘Patient-Centered’Should Mean: Confessions Of An Extremist published in the journal Health Affairs 28 (4) 2009, Berwick does indeed provide a radical view of health care that comes down to a premise that what is needed is a commitment to a sort of radical listening.
“For better or worse, I have come to believe that we—patients, families, clinicians, and the health care system as a whole—would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives.”
Berwick articulates three principles of patient centered health care, the most intriguing of which is “nothing about me without me”. He insists on transparency and participation, but in a way that makes these principles, which can appear as a sort of policy pabulum, mightily powerful.
"My proposed definition of “ patient-centered care” is this: The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in al l matters, without exception, related to one’s person, circumstances, and relationships in health care."
“In this view, a patient- and family-centered health care system would be radically and uncomfortably different from most today.”
Berwick suggests a number of examples, including
“Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows).”
Of particular interest to our organization, which has taken such a vigorous role in trying to protect patient privacy, Berwick adds as another of his 8 examples,
"Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them."
Berwick then tackles the supposed objection that patient centered health care, while it may meet the needs and wants of patients and families, could potentially have ill effects on the clinician. Berwick elaborates:
“Does patient-centeredness require of the doctor self-denial and martyrdom? Will it exhaust us? I think not. I believe, rather, that the moats we dig between patients and clinicians can drain spirit from both. When in a caring relationship we deny to the other what we could with free hearts give, we both suffer from the denial; one loses the help, the other loses the joy of helping."
Berwick then praises an essay by Parker Palmer, “A New Professional: The Aims of Education Revisited,” in which, Berwick asserts,
‘Parker Palmer argues against definitions of professionalism that separate human beings from their own feelings and hearts. He writes, in part: We will not teach future professionals emotional distancing as a strategy for personal survival. We will teach them instead how to stay close to emotions that can generate energy for institutional change, which might help everyone survive.’
Berwick:
“Ask patients today what they dislike about health care, and they will mention distance, helplessness, discontinuity, a feeling of anonymity”
That’s what scares me: to be made helpless before my time, to be made Ignorant when I want to know, to be made to sit when I wish to stand, to be alone when I need to hold my wife’s hand, to eat what I do not wish to eat, to be named what I do not wish to be named, to be told when I wish to be asked, to be awoken When I wish to sleep.
Reading – and responding viscerally to—Dr. Berwick’s essay, I realized there are certain things I have come to think of as “psychoanalytic values”. Individual freedom and autonomy, access to and value of ones emotional life, connections between people, continuity and coherence, giving, the power of healing contained in a relationship, (and an understanding of how that can go wrong), and sustaining what is private, personal, subjective, individual.
It is particularly astonishing to see these values elucidated and promoted by a man who could be considered to be the country’s top health care policy wonk. The language of health care policy is often as dense and abstruse as any jargon I’ve ever seen. Mechanical, technical, split off from the human beings allegedly involved. Donald Berwick’s language is as personal and human as it could possibly be.
It’s worth thinking about what “psychoanalytic values” might be. It’s worth hoping that this man who thinks in terms of the individual’s subjective experience gets control over the nation’s health care dollars. |