Role of professionalism in improving the patient-centeredness, timeliness, and equity of neurological care.

A 45-YEAR-OLD, MALE, Spanish-speaking day laborer with a 27-year history of epilepsy sees a new neurologist for advice regarding his medication and midback pain. Six months ago, he visited the emergency department regarding the pain because his primary care physician did not have late afternoon or evening office hours and he feared that if he missed work he would lose his job. Plain-film radiographs suggested osteoporosis, and he was advised to see a neurologist to change his medications. He has been receiving phenytoin for at least 20 years with good control but was never advised to take vitamin D or calcium. He reports that his previous neurologist performed an examination and checked laboratory values, but as there was no translator, the patient had difficulty understanding everything he was told. It took 6 months to arrange for the new appointment as few offices have translator services. This case illustrates some of the serious problems facing patients with neurological diseases despite the fact that their neurologists are highly trained and dedicated clinicians who provide excellent care. This patient’s care falls short in several areas. The care was not effective in that the patient had not received proper preventive care. The care was not timely in the sense that the follow-up visit with the neurologist was delayed. The care was not patient-centered in that it was being driven by resource limitations in the community rather than patient need. The care was not equitable in that the patient was not getting appropriate ongoing and follow-up care because of his limited English proficiency. As is common with many of the problems experienced by neurological patients, the problems in this case were largely system-level problems not under the immediate control of the neurologist. The Institute of Medicine reviewed the serious and pervasive quality problems of the health care system in the United States in Crossing the Quality Chasm: A New Health Care System for the 21st Century in 2001 and identified 6 domains of health care for improvement: safety, effectiveness, efficiency, patientcenteredness, timeliness, and equity. Formal efforts aimed at assessment of evidence related to safety and effectiveness have grown substantially in the past 2 decades with the development of guidelines and health technology assessments by medical specialty and other organizations. Because of the burgeoning health care costs, efforts to improve efficiency have been a focus for government and private payers. Improving the timeliness, patient-centeredness, and equity of care have received relatively less attention. While the physician’s primary responsibility is to serve as the patient’s advocate, the increasing influence of payers and regulators and the perverse incentives related to defensive medicine have undermined the physician’s traditional role. Medical professionalism, broadly defined as “attitudes and behaviors that serve to maintain patient interest above physician self-interest,” has been relegated to less prominence in the midst of these cost, overhead, and administrative burdens on physicians. Yet, along with prudent use of evidence-based best practices, professionalism is likely to hold the most promise within the control of the physician in delivering the type of accountable and integrated care that is reflected in the recently passed federal health care overhaul. Patient-centeredness is a direct consequence of professionalism, and timeliness and equity are more indirect but potentially crucial outcomes.