The inspiration for this blog was my Twitter post on Friday, October 14, 2011 12:53pm where I professed “@Cascadia #ITrans n that case its time 2 retire the term DOC order. Order does not exist in a world of participatory medicine. Recommendations do. “ As much as I love Twitter though I felt additional context was needed to substantiate my claim that the phrase physician order needs to go.
Decades ago, patients were admitted to the hospital for days on end, the physician was a male leading the care team, who was a paternalistic, authoritative and directive figure. There was the nurse and the patient in that hierarchy of order and the physician issued orders. Physician orders encompassed every aspect of the patient’s personal health and lifestyle choices including nutrition, exercise, medications, treatments and diagnostic tests. Physician orders were not to be questioned but followed precisely to ensure the care and recovery of the patient. If the patient did not agree to take the medication or participate in the treatment then they were labeled with a term “noncompliant”. In frustration, many patients would choose to leave the facility, against medical advice, as we affectionately refer to as AMA. Inevitably those patients were also the very people that would frequent the emergency room and hospital beds for lengthy stays. These patients were labeled as “frequent flyers” and considered noncompliant trouble makers.
But times are changing and there is a shift in the healthcare paradigm. Not only has there been a balance in the gender makeup of physicians, physicians are also welcoming a new type of healthcare model. Patients and other healthcare professionals such as nurses and therapists are demanding for an open access system eliminating the need for physician orders. In addition payers and government entities are demanding access to patient data and information to help with clinical decision support, population health and care transitions and to educate their beneficiaries/constituents to become empowered and engaged patients with the ability to make decisions about their personal health and wellbeing.
As patients become engaged, empowered and a part of the healthcare team, they are moving the medical profession into the world of participatory medicine. In participatory medicine, the patient is a partner to the physician, and works in a collaborative manner to find the best healthcare options to support their personal values and beliefs. In participatory medicine the physician is offering the patient a host of options to select from utilizing a comparative effectiveness approach. Comparative effectiveness is when care options and treatments are evaluated against one another to find out which is the best based on efficacy and cost. In participatory medicine the physician works with the patient in a consultative manner offering recommendations about care as opposed to issuing orders. It is up to the patient to select the best treatment options based on their lifestyle choices, beliefs and home economics. Therefore in the world of participatory medicine, the physician order is a paradoxical phrase and cannot exist.
As Todd Park (@Todd_Park) was quoted at Putting the IT in Care Transitions (#ITrans) conference on Friday “let’s punch a hole in the wall of disbelief” …it is time to punch a hole in antiquated terminology that is a barrier for change to the healthcare delivery system. Now is the time to retire the phrase physician order and replace with a new phrase that is patient friendly and truly reflective of the physician role. Physician recommendation is quite acceptable in a healthcare model of collaboration and equality.