Sachin Jain and John Rother’s JAMA commentary, “Are Patients Knights, Knaves, or Pawns?” is an article that begs to be shared. The first time I read it I had to stand up, I was so excited — how can I design a survey to capture these questions?! was my first thought. My second thought was how soon can I post this online and get the debate rolling?
Here’s a quick, wonky summary: Jain & Rother use Julian Le Grand’s metaphor concerning the motivations and behavior of post-war public servants and citizens in Britain as a springboard to consider how health policymakers in the U.S. might anticipate a transition to a patient-centered system or its alternatives. If Le Grand’s thesis is new to you, please read “Power to the pawns: For excellence in public services, should societies rely on altruism or self-interest?” (The Economist, October 30, 2003).
This is a debate that needs wide exposure. So, since the full text of the article is behind a paywall, I’m going to excerpt it lavishly. Here goes (with footnotes translated to links):
Patients as Knights
If a society conceives of patients as well-intentioned knights, it assumes that the will and values of patients should drive the structure and organization of health care, called patient centered by the Institute of Medicine and extolled by leaders and consumer advocates. Patients are trusted to wisely use health care services when necessary and to take responsibility for actions they can take and behaviors they can learn to promote their own well-being. Individual patient decision making and autonomy are the center of the system with patients striving for health and following expert medical recommendations. The role of policy and payment is mainly to empower patients and physicians working together toward shared aims; insurance coverage should make these interactions as facile as possible.
Patients as Knaves
If a society conceives of patients as knaves, policy, management, and education efforts are designed to work against patients, not with them. Waste and even fraud are the behaviors that come most naturally to the knave—and it is the role of physicians and health insurance companies to monitor for this behavior and impose stiff financial penalties to deter it. In this scenario, patients engage in risky habits because they are in denial, confident that few personal consequences will follow, and they are passive regarding consequences because others will subsidize the costs of the medical consequences. They use health care—office visits, hospitalizations, procedures, and diagnostic studies—because they do not want to take responsibility for themselves. Policies and regulation must guard against malfeasance, including high co-payments and high-deductible insurance policies as mechanisms to ensure against knavish patient behavior.
Patients as Pawns
If societies conceive of patients as pawns, efforts are applied to building systems that ensure patients do what is right for themselves and for the health care system, because patients cannot be trusted to do so on their own accord. In this scenario, patients are considered uninformed or generally misguided, with unpredictable and unscientific behaviors. The pawn patient is merely a function of the environment and incentives he or she is given; accordingly, physicians and health insurance companies must be benevolently paternalistic and prescriptively decide on clinical priorities. Shared decision making is irrelevant because the physician is responsible for making sure the patient makes the right decision. The role of health policy and regulation for the pawn patient is to guide every behavior because patients lack judgment to do what is right.
In the implications section, the authors write:
As patient behavior is tied to rising costs, and increasing scrutiny is applied to the volume of health care services consumed, policy discourse often reflects the perspective that patients are an obstacle to, not an enabler of, a functioning health care system. Rather than counting on patients to exercise good judgment in managing health care problems, this view holds that patients should be guided with an increasing menu of behavioral or financial devices and strict regulations. Because it is assumed that patients will not undertake healthy behaviors on their own, they are increasingly subject to directive health and wellness programs by their employers, health plans, clinicians, or communities.
As with physicians, the patient in the United States today is seen either as a knave or a pawn and is seldom viewed as the knight. Patient centeredness is lost in a tangle of insurance arrangements. Nonetheless, most patients do not abuse the health care delivery system or actively injure their own personal health. Many are struggling with access to basic services, and others defer needed treatment because of the high deductible amounts health plans put in place.
Since the publication of this commentary, the landmark study “The Oregon Health Insurance Experiment: Evidence from the First Year” was released, showing that if you give people of few means access to health care, “they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability” (to quote from Gina Kolata’s story in The New York Times). It’s a study that merits a separate post, but let’s forge on.
Next the authors make a point that I’m not sure I agree with:
Many patients seek more information on the internet because they perceive they cannot get needed information from trusted clinicians.
Pew Internet’s research consistently shows that the internet is a supplement to advice from health professionals — that we can agree on. But my observation, based on the literature and my own research, is that patients seek information online for a much wider variety of reasons. Here are three:
- trusted clinicians dispense information, but patients want to do more research on their own to better understand it
- less-trusted clinicians dispense information, but patients want to fact-check it
- a peer patient or caregiver has more or better information than any clinician on some topics
And the grand-daddy of all reasons, probably the most common:
- patients go online to get health information wholly unconnected to a clinical encounter, without reference to whatever information a trusted clinician might offer to them
The authors close out this section with a heck of a good question:
How can society avoid inflicting harm on the patients whose needs remain great and genuine while guarding against abuses by the few whose needs are not?
The recommendations section is very interesting. If I could wave a magic wand, I’d make it a wiki so I could see the changes suggested by authors and reviewers as well as the suggestions from readers, both health professionals and consumers. The ideas laid out are excellent, but I wish for so many more:
The success of innovations in care that seek to improve coordination and reduce unnecessary and harmful overuse will rely on effective connections to the motivations of patients toward better health. For the vast majority of patients, these motives are consistent with their behaviors. Psychological theory suggests that health plans that create a “gaming” mentality by clearly establishing a distrustful relationship with patients and families may backfire. Unless patients trust that clinicians have their best interests first and foremost, any barriers to seeking service will be seen simply as money-saving measures and create the impression that these services are something the patient ought to be able to get and therefore ought to want.
As better outcomes and lower costs are sought by innovative delivery models and new communication technologies, patients must be engaged as trusted partners, not as passive subjects or manipulative knaves. Coordination of care requires communication with patients, their families, and other members of the health care team, often including community resources. Optimal outcomes are not possible without the patient at the center expressing his or her personal values and goals for treatment, trusting that clinicians share that focus.
There are a small number of patients who abuse the system by habit or by pathology (ie, Munchausen syndrome or hypochondriasis). Still, Le Grand offers an important warning that warrants repetition: it is critically important to understand and get true motivations right. Best intentions will fail if persons largely of a knavish quality are treated as knights, but the same may be true for “policies fashioned on a belief that people are knaves if the consequence is to suppress their natural altruistic impulses.”
Now’s your chance: what do you think?
Susannah, this is a great post that deserves thoughtful reading and commenting!
Have already bookmarked it! During the quick read (I’m on mob.internet now)have taken mental notes for comments..
It happens that yesterday, while waiting my turn to be examined at the hospital, I had with me “How Doctors Think” by Dr. Jerome Groopman to reread two chapters for which I have two unfinished blog posts. This second reading revealed more aspects that I had noticed in February, when I first read it.
Well,I think that many of the comments I could made to the above post have their root in Dr. Groopman’s book….
Correction to the above
This second reading revealed more aspects that I had NOT noticed in February, when I first read it.
Knight, Knaves or Neither? Asking the right questions is often as important as the answer.
Many of us have been working in and developing in patient centered systems for decades have come to learn that what is often missing is not simply that we need systems and tools that are designed around patients needs but an even more sophisticated understanding that health care is “social” and happens in the context of “relationships” vs the individual.
We see this in everything from how our friends BMI influences ours to patients who find support via Facebook for a sick child.
Much of the country isn’t where we are yet at places like Mayor or Group Health though of course. Taking a look at the “roles” we play as patients is a critical first step but we also need to move past the Western belief in the supremacy of the individual and look at the systems in which they receive their care.
You can’t really expect the lone patient to take on large complex powerful systems on their own and come out ahead very often. Changing the environment or playing field and the rules of the healthcare system are just as important as changing the role of the players.
I’m a huge fan of the research you’ve done and presented, and in fact of the momentum of e-patients and patient-centered care as a concept and movement. In fact, the nonprofit and website I run is really predicated on the concept that patients can become remarkably sophisticated and critical components toward their own best care.
This is the case because there is unfortunately a real difference between the current care patients get and the best care that is currently available. As I see it, this is primarily because
1) the doctor is not aware of the best treatment (understandable with a rapid escalation of medical knowledge and need to become narrowly specialized to really stay on top of the field)
2) the doctor is incentivized in terms of more money or far less effort to pursue an option that remains justifiable but not really optimal
Of course, offering great information (their own data and the evidence for best treatments) to patients is a way to ensure that they’re getting excellent care. There is nobody more motivated than the patient and caregivers. However, one issue that is very central in the debate about patient-centered care is that there is also an incongruity between what is optimal for the patient and what is most optimal for society in general, and in this question, nobody is more biased than the patient and caregivers. Specifically, US society will need to come to terms with the concept that we can’t afford to do every treatment for every patient if we want to have any hope not to collapse under the skyrocketing cost of health care, and patients are in a very poor position to make a fair judgment about what costs for treatments that are mostly paid for on a societal level are truly justifiable. If every patient has a menu to order anything they might want at a meal where the bill is going to just be split, we end up with a system that somehow manages to be even more financially untenable than our current one that incentivizes doctors to do more and more interventions, regardless of the benefit.
I believe this issue is one that will need to be acknowledged and addressed to make patient-centered care a viable leading strategy.
Jack makes an interesting point above, namely, “If every patient has a menu to order anything they might want at a meal where the bill is going to just be split, we end up with a system that somehow manages to be even more financially untenable than our current one that incentivizes doctors to do more and more interventions, regardless of the benefit.”
To me, that is an argument for baking the tenet of shared decision making into the health care system. Having a fair assessment of risks and benefits in rational terms (i.e., a 100% increase in survival is the same thing as shifting from a 1% to 2% chance in survival. It feels very different pending how it is stated), and taking patient values into consideration as a valuable aspect of the care provided, will help to curb the notion that an all you can eat buffet guarantees that everyone gets fat.
I very much agree that shared decision making is completely appropriate — a bidirectional discussion is extremely valuable. But we need to have some EXTERNAL limits imposed on what is financially viable to pursue, based on a semblance of value vs. the costs of interventions, since it’s in neither the physician’s nor the patient’s self interest to be remotely cost-effective in their care decisions most of the time.
Jack, agreed 100%. I am eager to see the extent to which the ACO model is adopted, as one way of rethinking the external limits.
The problem is, of course, that the healthcare system has to handle knights, knaves and pawns…because all are out there in the population. A complicating factor is that each of us is capable of being each role at any given time.
We may have been a pawn in the hospital a month ago, but a knight in the doctor’s office yesterday.
And since policies to deal with a knave can have a negative impact on a knight, any policy can be counterproductive at some point.
Excellent post, Susannah. Thanks. Seems important to examine people’s underlying assumptions as they assign labels. Also, to poll medical schools as to their teaching models. If physicians are taught to address patients at a fourth-grade level (as they are), the patient as pawn notion is built into hc systems. If the assumption is that only wealthy people are virtuous, and hc should only belong to the virtuous, then most patients are knaves.
One commentator above seems to link the idea of hc with greed — ergo the idea that hc must be rationed (by who?).
In my universe, a physician who treats patients as pawns is a knave, since this a) justifies shoddy care and b) justifies blocking record release to cover up wrong doing.
I don’t buy the greed notion regarding patient overuse of the system. It is antithetical to any idea of health as balance, which means cultivating a healthy lifestyle to avoid overtreatment or overuse of physicians, medicine. The assumption is that the American hc system can make you sick, like nosocomial disease after hospital admission. that’s like being greedy to see the dentist. Better to floss lol
The issue isn’t greed so much as that patients cannot be expected to self-regulate their allocation of resources when there is a very pervasive sense that: 1) More is better, and 2) Newer and more expensive is better, that are inculcated into US society.
In just about every ICU in the US, unfathomable sums of money are consumed to treat many patients with absolutely futile care because doctors and patients don’t want to have hard conversations about the reality that patients actually die. Even when it’s completely clear to all medical professionals that further treatment is futile and inappropriate, patients and families too often insist that “everything needs to be done” even if great grandma is 89 and has heart failure and is on dialysis already. If you think this is hyperbole, you haven’t walked through an ICU lately. If you ask a patient whether it is appropriate to have an insurance company pay $300,000 for a completely unproven therapy as 5th line treatment for their cancer, you will rarely if ever hear someone say, “I don’t think that’s a good use of limited societal resources”. If patients/families were required to pay 50% or even 20% of the exorbitant costs just of the care that all medical professionals concur is completely futile, we’d see a lot fewer desperately ill people spending 30 days on a ventilator just because people want to hold out for a miracle.
Intelligent discussions about limiting care are almost always short-circuited by shrill cries of “death panels” and “health care rationing”, but that’s just short-sighted denial of the terrible problem that costs for our health care system are completely untenable. Health care systems all over the world review the actual benefit and value of many treatments and set limits on what to support — and still the world continues to turn on its axis.
This isn’t to say that people can’t pay for whatever interventions they want that don’t meet the criteria for coverage. But the point is that we should enable everyone to get what they need before we leave people without very effective treatments and cover wildly expensive but unproven or clearly ineffective therapies because patients or caregivers decide they want them. People can pay to upgrade to first class, but the system should cover all people getting to fly coach to get where we all need to be.
The fact that you don’t seem aware that the above is not news but taken for granted by smart patient-consumers would seem to validate the above points: you assume patients are at the 4th grade level and they need your help in wise distribution of hc resources. You aren’t talking about “patients” but Tea Partiers. You should probably spell that out and then fight the appropriate political battle.
I run a nonprofit dedicated to providing huge amounts of free information that is extremely sophisticated to cancer patients around the world, and the entire premise is that patients can become remarkably sophisticated about their own care. I spend a ton of my free time providing this information for no financial gain, and within the medical community I have been a leading proponent of e-patients.
The lesson I have learned here is that I can expect to be flamed by hostile commentary by trying to engage with proponents of participatory medicine.
You are a charming ambassador for the e-patient movement, Christine.
I’m not being mean, although you assume wrong on about three counts, but ACOR list members have for years been accessing the type of information you present on your website. If we waited for physicians or even physician-activists to “provide” current info., we or our loved ones would be dead. That is very nice of you, but a doctor advocating for e-patients is sort of an oxymoron. Again, examine your assumptions and audience.
OK, well if it’s not helpful for me to do it, then it would save me a great deal of time and effort to not bother. Do you think you’re really speaking for the e-patient community when you say that there’s no point in my bothering to do this? I guess I’m thrown off by the traffic coming from all over to the GRACE site and the many comments that come just about every day about how there isn’t anything like it available anywhere and that it’s a tremendous blessing for the patient community.
It seems to me that what you’re saying is that e-patients don’t want or need to have physicians directly involved, because that would be paternalistic to suggest that physicians have something to offer that patients can’t find or do just as well themselves. Is that truly a general principle of the e-patient movement? If so, I do think it’s a shame and a mistake to imply that e-patients and doctors are inherently on different sides and that e-patients unilaterally directing all of their care is better than a balanced interaction.
Jack, as we’ve always said, your understanding of participatory medicine matches what the society says – it’s a partnership. Christine is one individual (not a member of the society) with strong views; no individual speaks for everyone.
On the other hand, like many many patients (e.g. many of the Facebook group of IHI Patient Advocates), she had extremely bad experiences with medical care, which almost cost her daughter her life.
She wrote here three years ago about her extremely upsetting experiences (“from one bumbling pediatric institution to another,” etc.).
Those horrors are real but that’s a separate issue from participatory medicine. As it says at the top of the society’s site: “Participatory Medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care.”
Both of you, however strongly you feel about the issues, I ask that you not indulge in ad hominem comments about other participants here. Please stick to the issues, not personal indictments of what you believe people do or don’t understand, their style, etc. Thanks.
Thanks, everyone for the comments so far.
I published this post on Friday and left immediately for an intensive weekend conference in Boston – Health Foo – so I’ve been out of touch for a day or so. I thought about delaying until I could do a better job of hosting a discussion but decided to go for it, hoping to be able to refer not only to the original commentary but also any comments that come in before I help lead a session on peer to peer health, which will take place this morning.
One of the focusing questions I plan to ask is, “How to trigger an avalanche?” meaning: a majority of U.S. adults are online, have a cell phone, are using social network sites, are gathering health information online. A significant chunk have smart phones, track their own health data, post health related material online, and look for other people who share similar health concerns.
The tools are in place. The culture is shifting to expect that people have access to information and each other. But we are still at the early adopter stage in participatory medicine. What are the elements that must beinplacefor this thing to break wide open?
…forgive the truncation – not loving my iPad keyboard right now.
I joined forces here at Health Foo with two other session leaders – Ron Gutman of Health Tap and Jon Kuniholm of OpenProsthetics.org because they represent points of view which I think may be elements we need for wider adoption: clinicians and networked patients, some of whom are on a far end of the bell curve in terms of how uncommon their condition and how great their need for innovation and better care.
Today’s session will be a conversation among the three of us as well as with the Health Foo attendees, the most open and game group of people I have encountered in my career. Let’s continue the conversation on this blog in the samespiritplease, ie – I know stuff, you know stuff, I can’t wait to learn from you, I can’t wait to help you get out on the high wire of a new idea and catch you if you fall.
Again, thanks so much for the comments. Quite a bit of what I will talk about here today comes from what I have written and read on this blog over the last few months. I am deeply appreciative of the insights and passion shared here.
The question is how new social media can challenge power imbalances in the existing system. How did Murdoch’s media empire get challenged, particularly since the reporters were in league with police? “Participatory medicine” only works if things change on an institutional, not an individual, basis, and the profit/efficiency-centered focus of physicians as evinced on thcb chats alters in some profound way.
Over the 8 years I’ve been involved in empowered patient networks I’ve seen physicians ” give in” to easy sharing of information because they have some system like NextGen in their office and it’s not so hard, because they themselves are techies and enjoy the immediate transfer of information, or they give in to the inevitable. To have an honest discussion about a partnership model it’s necessary for physicians to acknowledge and address why they are so adamantly against the new mode and what they can do to address institutional models that discourage two-way discussion. The issues are simple: instant access to records so patients can educate themselves and check their physicians’ work. This is not a strong view, it’s a different view but it does challenge common common notions of physician authority. As Regina Holiday and others made clear at H2.0 last year, while there may be many cool, profit-producing aps available, this aspect of hc remains in the Dark Ages. I wish an “avalanche” were possible.
There’s an age element: younger physicians are more technologically savvy and less wedded (one hopes) to the old authority models. A gender factor. enough said. and a class factor. As a poor woman, it was impossible to get a second opinion on an iffy mammogram result as per NYT’s Jane Brody’s advice. My young Asian somewhat hip physician understands immediately what I need, in part because I’ve educated her about what’s new in patient advocacy, she educates me willingly about what I need to do, and she’s modernized her office. Her low-paid staff is beyond her, so I have leaned to educate and “insist” on what I need, and she backs me up. No one likes this because it is uncomfortable. The $700 difference between saying “is thisappt your annual physical?” versus “What are your symptoms?” when booking the appointment. the GI had no idea about codes for colonoscopy under the new laws. The difference between $3,000 out of pocket and nothing. Given these two examples, what is the physicians’ interest in mutual dialogue? Exactly 0. The requirements of good patient practice are directly opposed to the insurance coding system. The avalanche comes when available tech enables the patient to bypass the institution and then “educate.” nicely
So, in conclusion (I’m laughing, I tried to let this go), the chess analogy may be generative in the it draws out power imbalances in the system and forces people to examine their roles in the hc system.
Yes, I think it’s true that there is a visceral and practical resistance among doctors as a general rule about having their recommendations reviewed and second-guessed. Honestly, who believes that they do a perfect job and would be eager to have people looking over their shoulders and able to criticize their job performance very easily? In the same way that the teachers’ union is categorically against having teacher performance monitored frequently by third parties sitting in, or videotaping of their classes that are subjected to replay and critical review, I suspect doctors know that it’s always easy to find fault in their performance when it’s reviewed critically.
Media representations of doctors, from Marcus Welby to House, present doctors as all but omniscient, and this shapes societal expectations (and physicians as a group have been happy to accept the unchallenged authority for decades). Practically speaking, there has been a prevalent presumption that medical care delivers wonderful care to everyone. Of course, that’s not true, as people here know well, but in addition to just having their pride downgraded by being made subject to critical review, the legal expectation of ideal care is baked into the same system. Even if most lawyers aren’t profiteering opportunists trying to capitalize on every medical error, there are still a few too many who are.
I believe that there are few settings in which identification of errors is associated with more punitive consequences than in medicine, where the threat of a lawsuit is advertised on television and a 1-800 number. Other systems that create transparency in hopes of focusing on openly reviewing and obviating errors also aspire to do this without judgment or blame. I expect that doctors will remain resistant to transparency as long as the expectation is that medical care will be ideal and that doctors are not permitted to make errors.
Excellent point. Professors have been subject to this scrutiny for decades. (I recall one undergrad not liking Milton Frieman’s ties.) and the consequences are equally harsh — from the professors’ viewpoint: No tenure. One aspect of physician privilege as embedded and perpetuated in the Marcus Welby model is setting the bar of persecution or discomfort at their level — OMG a lawsuit! Less profit — but the “bar” on medical care for a patient is possible death as well as bankruptcy. The privilege is embedded in expectation about discourse. We need to figure out a way to move beyond the “favor” model of two-way communication (the physician is doing the patient a favor by engaging in dialogue that is not billed) to a mutual model, which means we pawns need some type of leverage — like Yelp!
The lawsuit argument may also be specious, at least in the state of CA. The AMA raised the bar do high, mmp lawyers died out. It’s more a part of popular culture than actuality
The only lawsuits I know of that were successfully prosecuted were sexual assault and sexual harassment.
I’m not saying that there’s a great reason to feel that the fear of a lawsuit from much better transparency is justified, but as long as that’s a widespread perception/fear, it’s a limiting factor either way.
Meanwhile, the issue of falling below the idealized standards that are widely perpetuated but unrealistic is still a real issue. Doctors are likely especially wary of self doubt from being critiqued when expectations of how highly doctors must perform are set extremely high.
I recently heard that one of the premises/challenges of social media transparency is that if we now must expect less privacy, people need to be able to “look good in the shower”, so to speak (and I’m speaking of business practices, ethical behavior, etc., not deviating into mature audience ratings). If the ideal we compare ourselves to is unattainable, it only makes it harder to be open ourselves up to judgment. So I think the concern among docs is partly a concern about lawsuits and partly a concern about not living up to an ideal.
Good comments. I frankly like the new gen docs because few have the authoritarian attitudes of docs of my generation (ouch!). H2.0 speakers addressed this — who was amenable to change, new tech, etc. Not baby boomers! Ouch! Ouch!
The most useful thing I ever read was in the NYTimes, I think, when a physician “talked back” to patient complaints, pointing out how difficult it was to conduct an exam in a noisy hospital setting with a talking patient so QUIET ALREADY patients during an exam! That is useful information since the goal is health and efficiency. I know some docs who refuse to waste their time with obviously non-compliant patients. Fine with me — break with the 100% responsible doc model of hc.
If the goal is mutual dialogue, it helps if the physician acknowledges the profit motive, which my South Asian physician friends tend to do –“We tell our staff we expect to make a good living. If they can’t accept that we fire them”– versus the more Anglo Marcus Welby approach, which results in a lot of passive aggression. “I’m here out of altruism to heal as a favor Gull Dangit! You’d better be grateful for my time” (while I collect your money and say “Next!”). let’s get real here. I see it as the doc works for me. I pay for the lifestyle and expect good service.
As one of our outraged oncologists said when
explaining why his institution was so resistant to a second EXPERT opinion (they were not a first-tier facility for what we needed, “We are a profit making institution!”
Yeah, I get that, but please don’t kill my child while patronizing both of us, withholding critical information, losing slides, violating patient confidentiality, failing to adequately supervise your own radiology department, and, because you’ve assured me repeatedly of the expertise of you and your colleagues, refusing to get expert “niche” pathology.
So to return to Susannah’s query, a dr is not a knave who acknowledges profit and prestige motive, acknowledges the frustrations of the practitioner, refuses to take responsibility for patient’s bad habits, keeps up with new tech, facilitates transparency and accepts responsibility for actual level of service provided. Shoddy service? Yelp! Good service? Same
Then, based on the above, reimagine doctor-consumer institutional etiquette. Reimagine language Beginning with “patient,” which means in practice: You wait on my convenience while I patronize you, refuse access to your records so you can check my work, refuse communication except according to my office phone menu, take your money and tell you what a favor I’m doing for you.
Yikes! We’re supposed to be talking about Patients as Knaves, Knights, etc. Depends on whom you survey. Motivation comes with education.
Great way to raise patient consciousness by having regular consumers answer. Restructure the healthcare system by having the populace rethink their roles as consumers.
What’s also significant in a survey, if insurance companies, hospitals and/or physicians are working on the Patient as Knave concept, or if any political party is (issue the survey to Democrats, Republicans and independents). the survey reveals attitude. If an institution or practitioner sees customers as Knaves, they shouldn’t be serving that customer. Same with teachers.
I’m not familiar with LeGrand, but did read the JAMA commentary. It sort of left me with a ‘so what?’ feeling, wondering what to do or where to go next.
I appreciate the concept of knave and pawn, which together, combine to capture paternalism and lack of trust. I see these as root causes of what we’re trying to correct. Yet, the terms are not terribly intuitive. Worse, they’re from an era called the Dark Ages! Who in the kingdom was treated with respect and given role of true participant? I don’t think anyone.
One problem with the commentary is that stakeholders are too fluid. Providers, payers, patients – all players in complex arena where the goals are often at odds with one another. Insurers treat patients as knaves, wanting to keep costs down. Employers want low costs, but also want healthy enrollees, so act as patients are pawns – designing wellness programs thinking “if they just get exposed to the right things” everything will get better. Providers are a mixed bag. They vary, not just person to person but day to day, or even from patient to patient.
How to questions to get at these perspectives? Easier to do with qualitative studies, asking people how they are treated, what they are told, how they responded. And of course these commentaries always beg the question, WHEN are we going to have a large, prospective cohort of consumers/patients??
True dat! But the advantage of such a survey, administered to different audiences, with different query points (are insurance companies, physicians, patients Knights, Knaves or Pawns?) is that it draws out attitudes in familiar and slightly insulting terms.
If consumers are invited to think of themselves as pawns, it forces them to think who perceives them thus, and why. (if they are pawns, it is because they refuse to participate intelligently in political debate). The fact that insurers and many doctors view them as knaves — potential thieves inclined toward fraud (that’s a laugh), and consumers too stupid to take charge of their health through lifestyle change (Don’t these guys watch Oprah! or Dr Oz?) and “ration” their own use of health care may encourage a revolution. The fact that the study has to invoke Munchausen’s by Proxy as a type of fraudulent over user of hc shows the bias underlying the study. A patient overusing or defrauding the hc system is the exception, rather than the rule. insurers doing the same to patients is the rule rather than the exception. Something is broken here.
Somehow last summer when this came out, it didn’t all sink in – I didn’t take time to go read the short 2003 article you linked to, and didn’t wade through the body of this post. (Increasingly I find myself not doing well with long-ish paragraphs! Getting lazy? Eye problems? Fractional ADD?)
Now that it’s sunk in, I have many many many thoughts. This isn’t a trivial discussion – LOTS to think out.