Don’t Believe Everything You Think

I saw a T-shirt the other day that said, “Don’t believe everything you think.” Funny, and ironically thought-provoking. If we can’t believe what we think, what can we believe? That afternoon I had seen a 72-year-old patient, Mr. B., who recounted to me that the day prior to his visit he had confused night with day. Up to that point (and subsequently), Mr. B. had been doing well, with no overt symptoms of cognitive impairment. The day before our visit, however, he reported that he had taken his usual evening shower around 6 p.m. (his second of the day per his routine); when he went into the shower, he knew it was evening—when he emerged 10 min later, toweled off, got dressed and went downstairs, he had shifted forward 12 h and thought it was actually morning. As he told us, the evening and morning light were similar, so there were no obvious external clues to orient him. He went downstairs, poured himself his morning cereal and turned on the BBC news. It was only when the phone rang and his friends informed him he was late for his weekly card game that he realized it was actually 8 p.m. and not 8 a.m. In less dramatic fashion, we in general medicine are increasingly questioning some long-held beliefs about how to deliver high-quality care to patients. Deeply held assumptions (for example, that quality care depends on a robust relationship between one doctor and his or her patients) are giving way to new and transformational experiments in delivery of care. This issue of JGIM features several such examples. Schwartz et al.1 report on a cluster-randomized controlled trial incorporating panel management assistants into primary care teams, with and without panel management education, in the context of a VA Patient Aligned Care Team, or PACT (the VA equivalent of a patient-centered medical home [PCMH]). The goal was to improve management of hypertension and smoking cessation. The panel management assistants were college-educated non-clinicians, and they were given responsibility for communicating with patients for referrals, sending mail reminders, and conducting motivational interviews by phone to reinforce behavior change. In the end, the intervention did not improve clinical outcomes, but there will no doubt be an increasing focus on population health and away from reliance on the doctor–patient dyad to improve health. Another study in this issue of JGIM examined the impact of the PCMH on outcomes in primary care. In a qualitative study, Fontaine et al.2 interviewed physicians and others at nine primary care practices in Minnesota in order to explore the facilitators and barriers to establishing a successful PCMH that these diverse practices had encountered. Among other themes, they found that increasing patient involvement in care through mechanisms such as patient and family advisory councils was key to successful implementation of a PCMH. Now considered essential, inviting patients and families to participate in measures to improve clinic policies and procedures would have been considered strange not long ago. Another model for improving population health, not dissimilar to panel management assistants, involves the use of “patient navigators.” Balaban et al.3 report on a randomized controlled trial that used patient navigators to reduce readmissions among high-risk, low-socioeconomic-status patients. Language-concordant panel managers provided coaching and other assistance to help patients manage the transition from hospital to home, with the main outcome being 30-day hospital readmissions. As in the Schwartz study, this study failed to demonstrate an overall improvement in the primary outcome, but did decrease readmissions in older patients while increasing them in younger patients. Like many of these early interventions in population health, there are more questions raised than answered, but undoubtedly, a new paradigm is emerging for how best to care for primary care patients. Unlike Mr. B., who only temporarily lost his orientation, this new paradigm will require a permanent change not only in what we think, but also in what we believe.