The next time you find breathing room to attempt something new in the interest of improving care, try this: Ask every patient who walks through your door the following four questions:
▸ Do you suffer from chronic pain?
▸ Is your emotional health stable?
▸ Do you have adequate financial resources?
▸ Do you have the confidence you need to manage your conditions?
These four questions represent a distillation of several decades of research aimed at identifying approaches to care that get patients to step up to the plate and manage their conditions more effectively. They also elegantly address fundamental attributes that can apply to an entire patient base, rather than to a select few.
Many of us have become very good at the delivery of care for patients with big ticket diagnoses, such as diabetes or asthma. Although I applaud those improvements in care, the reality is that many practices have exhausted their resources on managing this handful of patients, with little or no improvement energy left over for all the rest of the patients in the practice.
Just as we would miss patients with hypertension if we did not measure blood pressure, so would we miss a lot of information about our patients' emotional health if we relied solely on our perceptions and gut instincts. Good evidence shows that people with chronic pain or emotional problems don't do as well and end up hospitalized more often.
Using these four questions as a vital sign can help identify individuals who are headed in a bad direction, and can help allocate practice resources. The patient with diabetes who is confident, has no financial or emotional issues, and is not in chronic pain isn't going to require a lot of practice effort. Alternatively, years of research have shown us that the patient with chronic pain and emotional instability will require a lot more attention.
Similarly, we can help patients overcome a lack of confidence. Much of the time, this common problem stems from a patient's history of biting off more than he or she can chew. Losing 25 pounds or running 3 miles a day are laudable goals, but the failure to achieve them results in some patients feeling helpless and giving up. Studies show us the benefit of helping patients make small, achievable changes. Start by asking what he or she can do next Tuesday, and then follow up.
Of course, asking questions will require that you have a plan in place if a problem is uncovered. If you are lucky enough to practice in a region with pain specialists or mental health care providers, have referral information handy. If not, there are terrific guidelines available to help you weigh in on those issues. Although there isn't much a physician can do to address a patient's finances, we can be more sensitive about the costs of the drugs we prescribe.
Finally, I want to acknowledge that asking these questions in everyday practice is a matter of sweat equity. We practice in an environment that pays for volume, not quality of care. Until we figure out a way to finance quality care and not just volume, it is out of pure professionalism that my primary care colleagues would try this simple screen. And yet, an incredible amount of research demonstrates that delivering better primary care would help lower the costs of health care in the United States. Enabling primary care physicians to ask four simple questions—and paying them to follow up on any problems uncovered—would allow us to finally do the job we need to be doing.