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.5 x .5:Deconstructing Margolis–e-Patient Dave

As often happens,a Susannah Fox post has led to lingering questions. This time I’ve figured out what I want to say.:-)

Last week,in a side note on her World AIDS Day post,she inserted this:

…Let’s review the basic math of health services delivery in the U.S.,beautifully,devastatingly summarized by Peter Margolis of Cincinnati Children’s and the C3N Project:

.5 x .5 = .25

As he recently explained:

The dominant paradigm of chronic care delivery in the US is characterized by health “services” “delivered” to relatively passive patients or “consumers” in clinician-mediated encounters using knowledge that is produced by researchers and clinical experts.  In this current system,physicians provide only 50% of indicated care and patients adhere to about 50% of what is recommended.  The result is a system where only about 25% of patients achieve optimal care,despite spending that far exceeds other industrialized countries. What would outcomes be like if doctors and patients got what they needed 90% of the time?

Let’s break apart the first part of that quote:

The dominant paradigm of chronic care delivery in the US is characterized by

  • health “services” “delivered”
  • to relatively passive patients or “consumers”
  • in clinician-mediated encounters
  • using knowledge that is produced by researchers and clinical experts.

And:

In this current system,

  • physicians provide only 50% of indicated care
  • and patients adhere to about 50% of what is recommended.

The result is a system where only about 25% of patients achieve optimal care,despite spending that far exceeds other industrialized countries.  [Italics added]

Lots going on here.

  • The first sentence is about today’s paradigm about healthcare:“all knowledge arises in the profession and is dispensed onto patients.”(“services delivered,”mediated by clinicians,to passive consumers)
    • On this blog (and in our Society) we know otherwise. But most people running hospitals and doctor offices still presume their job is to “do things to us,”including giving us instructions.
  • The second is about the often-observed reality that neither providers nor patients stick to plans.
    • One might guess that this is a human failing.
    • And note that he phrased the result in terms of patient impact: ”only 25% of patients achieve optimal care.”

I wonder:what else does he envision,when he first talks about our current model,and then talks about “.5 x .5 = .25″? Does he assume that part 2 is a consequence of part 1?

I don’t think so –I think they’re two different problems. But I do think that part 1 causes both parties to feel hopeless about part 2.

Or is part 2 a consequence of part 1?  Do we perform more poorly if our assumptions about who has the power are fundamentally flawed?


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