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December 20, 2019

Bridging the Gap Between Where the Quality Metric Ends and Real Life Begins—A Trusting Relationship

Author Affiliations
  • 1Department of Family Medicine, Oregon Health & Science University, Portland
JAMA Intern Med. 2020;180(2):177-178. doi:10.1001/jamainternmed.2019.5132

A few weeks ago, I was poring over the latest evidence-based guidelines for treating hypertension with one of our medical students, hoping it would enlighten us regarding how to craft our recommendations for a patient with persistent hypertension whom I had known for 15 years. On the surface, the American College of Cardiology/American Heart Association guidelines for treating hypertension seemed straightforward. We should add a third agent (calcium channel blocker) to the 2 she had already been prescribed (thiazide diuretic and angiotensin-converting enzyme inhibitor). When we looked for evidence to assure us that this recommendation was the best one for a patient with comorbid obesity, asthma, generalized anxiety disorder, depression, and polycystic ovary disease, we found very little. Furthermore, we reviewed quality metric parameters for how primary care physicians are assessed in adequately lowering a patient’s cardiovascular disease risk and found no guidance in how to factor in her history of adverse childhood experiences, unstable housing, unemployment, and food insecurity in assessing how much the addition of a new antihypertensive medication might lower her risk for cardiac disease.1-3 I did not have a good answer when she asked me, “Dr DeVoe, given my history and tendency to experience side effects with every new medication we try, is this one going to be any different?” And where was the evidence-based guideline to answer her questions about whether spending money to buy this medication was more important than buying the healthy foods we had also recommended?

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    2 Comments for this article
    Whole Person Care
    Wayne Jonas, MD | Samueli Integrative Health
    Dr. DeVoe illustrates beautifully the disconnect between the evidence-based medical model and person-centered care.

    Guidelines are made to treat disease and not the whole person, yet it is the whole person who always shows up needing to be heard, respected and empowered. Without the time, system, and payment models to care for the whole person as they are, we will never have health care grounded in the everyday evidence of life.

    We need completely new models of primary care and coverage.
    If only ABIM would understand this gap
    Umbrine Fatima |
    If only ABIM would understand this gap, and the insurers who cut reimbursement when quality metrics are not met, and so on and so forth.

    Increasingly physicians are held to super-human standards, and patients labelled "non-compliant" for medicolegal protection. Interestingly, the average life expectancy has been dropping in US. Need I say more?