Why Isn’t It Better?

• Primary health care
• patient satisfaction
• risk management
• patient-centered care
• physician-patient relations

In the past 30 years health service research has described how health care can be made better.¹ Despite this unprecedented knowledge, health care remains seriously deficient in many ways.^{1– 3} Why isn’t it better?

When asked that question, physicians most frequently contend that external regulations, medication costs, and lack of time for patient care are the problems.⁴ But most of us know that we health professionals contribute to the blight as well. Health care isn’t better because we have not designed the systems to deliver exactly what people want and need exactly when they want and need it. Our systems are more often a product of history and self-interest than of a design that matches our clinical resources to patient needs.

Inadequate systems keep us from doing what we ought to do (the most common oversight) or cause us to do things we ought not to have done (the most visible errors).⁵ Several articles in this issue of the Annals of Family Medicine examine our oversights and errors.^{6– 8} Their findings are similar in most ways to studies of medical malpractice in the outpatient setting: lurking among most errors and harms is poor communication.⁹ A typical verbatim among the thousands of outpatient-reported harms reads: “Doctor did not listen to me regarding a medical problem and insisted that it was something else. Gave me prescription that burned my skin and caused great swelling. Could have been avoided if doctor had listened.” These comments reflect a mix of issues, but they almost always mention, in one way or another, poor communication.¹⁰ We health professionals and our patients are just not on the “same page.”

How are we going to deal with these deficiencies given the realities of the demands on our practices? The answer from the experts is that if we want to be on the same page with our patients, we need to be aware, think smart, and think system.

Being aware is the focus of the articles in this edition the Annals of Family Medicine.

Thinking smart requires us to recognize that the more we help our patients become better at self-care, the better their outcomes and the fewer the harms.^{11– 13} We all have our good self-managing patients who show us their medication list and gently correct us when we are about to do something wrong. They live with their illnesses and manage their lives, medications, and tests. Across the nation about 40% of adult outpatients claim to be good at self-care. The rates of reported harms are lowest among chronic disease patients who report good self-management skills and report that they have received excellent explanations from their doctor (0.5 harms per 100 patients per year); patients with poor self-management skills who report inadequate communication have the highest rates of harms (9 harms per 100 patients per year).¹⁰ Helping poor self-managers become better and confident self-managers become more competent seems to be a good way to fix many health care deficiencies.

Thinking system requires us to use every technique and process possible to ensure that we are on the same page. It can begin when vital signs are recorded in the office.¹⁴ It can be augmented by the use of interaction technologies designed specifically for busy office practitioners and their patients.¹⁰ Same-page care can be supported by e-mail, shared medical appointments,¹⁵ proactive telephone contact,^{16, 17} advanced access,¹⁸ and, of course, continuity of care.¹⁹ The challenge for us is to systematize same-page care.

I believe that thinking smart and thinking system can be easily retrofitted into most busy practices.²⁰ But even if the retrofit is not easy for some, it is essential that practices take action. “We are causing harm, and we need to stop it,” Don Berwick says. I hope that readers of this issue are as impatient as Don. Let’s all make it all better.

• Received for publication June 6, 2004.
• Accepted for publication June 9, 2004.

• © 2004 Annals of Family Medicine, Inc.