Responsible Patient-centered Care.

Patient-centered care (PCC), an integral part of the diabetes care lexicon, is defined as providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.[1] While this definition has survived the test of time, it raises many queries as well.[2] Does the treating physician abdicate all decision-making to the patient, who then decides targets, strategies, and tools of treatment? Does the physician accept patient-centered preference and values, even if they compromise with biomedical efficacy? More importantly, does the patient-centric physician respect and respond to all patient demands in the affirmative, even if they affect his or her safety and well-being?

Such questions create an ethical dilemma, especially for students of medicine, who may read the definition of PCC in a literal sense. How should a patient-centered physician behave? What are his responsibilities and rights? As a corollary, what are the rights and responsibilities of a person with diabetes who seeks care from a patient-centered physician or a patient-centered health-care system?

We have previously described the attributes of a good diabetes care professional as an acronym CARES (confident competence, authentic accessibility. reciprocal respect, expressive empathy, and straightforward simplicity).[3] In this editorial, we suggest the concept of responsible patient-centered care (RPCC), delivered by a responsible patient-centered physician (RPCP), and health-care system.

RPCC is that in which the physician or health-care team take on the responsibility of ensuring that the person with diabetes is offered all relevant information, in an understandable manner, so that he or she can take part in a shared decision-making process, which offers the potential for achieving optimal therapeutic outcomes, without ignoring his or her biopsychosocial context. RPCC also implies that the physician or health-care team fulfill their duty in a responsible manner, considering the implications of any decision on all stakeholders [Table 1]. RPCC encourages shared responsibility between the members of diabetes care team, including medical and nursing personnel, and family members. RPCC extends to health policy makers, to provide diabetes-friendly health-care facilities, and to civil society, to create a healthy social environment.[45] This approach in embedded in national guidelines from India.[67]

Table 1

Responsibility: Domains

To describe RPCC, we suggest a list of ten R's, which indicate the core values of this health-care philosophy [Table 2].

Table 2

The 10 Rs of responsible patient-centered care

Respect: RPCC providers should be sensitive toward the psychosocial reality and personal or sociocultural beliefs of the person with diabetes and his or her family. This respect should be conveyed through both verbal communication and nonverbal gestures

Responsiveness: The RPCC team should respond to cues offered by the person with diabetes, which may indicate his or her attitudes, wishes, or needs. Motivational interviewing techniques, such as WATER,[8] are an effective way of doing so

Restrain from self-harm: In a life-threatening, organ-threatening or limb-threatening clinical situation, (irrational) beliefs may place the person with diabetes at the risk of harm. For example, a person with oral drug inadequacy may resist insulin initiation. This can have both short-term (e.g., worsening of a foot ulcer, leading to amputation) and long-term impact (e.g., poor control leading to a stroke). The RPCC team should counsel the individual and restrain him or her from self-harm

Realism or realistic approach: RPCC should include psychosocial assessment and addressal in its her ambit. This includes getting a realistic idea of the patient's social background, including availability of financial and emotional support. This will help in designing a management plan which can be adhered to within available resources

Resource husbandry: The RPCP should be able to add to, or work within, available resources, by matching physiological needs with pharmacological knowledge and psycho-socio-financial understanding. In a pay from pocket market, for example, the RPCP may decide to prescribe an expensive, but extremely effective, antibiotic to a patient with limb-threatening disease. In the interest of cost containment, however, he or she may discontinue statins or multivitamins, or postpone a due vaccination, for a finite period

Relevance: Relevance, or prioritization, is an art that the RPCP must master. Relevance is relevant in deciding what information is to be shared in diabetes education, what diagnostic modalities are to be used, and what therapeutic options should be offered. A person with blurring of vision should be offered care relevant to his symptom while another with an incidentaloma detected on an imaging scan should be approached differently

Reach out: The RPCP should not hesitate to reach out to others for support or guidance. “Others” may include medical and health professionals of different specialties, lay educators, family member, community or religious leaders, and policy maker. A “metabolic alliance,” committed to managing diabetes, while keeping the person with diabetes at center, can work wonders

Restrain from other harm: The person with diabetes does not live in isolation but is part of a larger society. Responsibility to the patient does not mean that the physician can shirk his or her duty to society. A patient with recurrent hypoglycemia, who may put other members of society at risk by virtue of his occupation; for example, professional driving, should be counseled to change work. If required, the RPCP should notify the authorities. A similar situation may be encountered if a patient contracts a disease such as HIV. In such cases, the RPCP should follow local rules and regulations

Revision: RPCC is a dynamic and ongoing process. Frequent assessments and audits should be made, with mid-course correction being done whenever suboptimal outcomes are noticed, or anticipated

Reflection: PCC is a philosophy, a way of thinking and practice and a style of working. It is an integral part of diabetes care and should be embedded in every communication and action. The astute RPCP should reflect on what PCC conveys, and how this concept can be implemented in the best way possible. This is an ongoing process; a task that continues throughout one's professional career.

To our readers, we say: We hope you get better and better at RPCC. We hope we do, too.