A recent conversation with my friend Peter Fielding, a doctor who lives at our retirement community about patient/client advocates led to some interesting conclusions for both the medical and legal worlds.
When Peter and I discussed the fact that some medical patient and family caregivers councils have set as a goal having a patient advocate for each patient, he said, in effect: “No, you want the system to be so good that nobody needs an advocate.” His point was that if you give everyone an advocate you take away the incentive to improve the system. You just fix each problem as it occurs.
We in the legal system, are in a very different place. We have build a system that assumes that everyone has an advocate, but then made it so that only a small minority can afford one. That’s the worst of all worlds.
So, we are trying to do four things: change the system so that as few people as possible need advocates, find the resources to pay for those who need them even in the transformed system, build ways that less highly trained, and therefore less expensive people, can perform some of the advocacy, and, critically, design good systems that decide who really does need an advocate, and what kind of advocate, even in a reformed system.
Back to the medical system, therefore, the questions become: How can one design a system that behaves so that as few people as possible need an advocate, how can one identify the tasks and situations in which patients still need advocates, how can we provide advocates, with what skills in those situations, and how can those advocates be trained and connected to the system so that they provide the feedback and information that allows the system to even further reduce the need for patient advocates.
In a way, the analog to the last point would be, in the legal system, having part of the role of lawyers be to support the reduction of the need for lawyers. It’s sort of like the role of dentists in promoting fluoride.
In a way, it is what the legal self-help services movement, and the Self-Represented Litigation Network do.
This is a thought starter piece. If we were to pursue the topic we would need to define Advocate and why / for what purposes they may be needed: Technical issues; emotional support ; checking function about treatment details and timing; hotel functions in hospitals; violations of individual autonomy; poor doctor /patient relationship issues and so on. This list of the “ Surveillance Domains” could be quite long.
Clearly we would need a “Systems approach” to mitigate the need ( or some of the need) for Advocacy: probably the most important being the setting of standards which would form the basis of education: self-correcting / self-flagging methods of data recording ; blame free cultural development ; putting patient needs first ; policy and procedures for Quality Improvement , error correction ,and in more critical issues methods and experience in conducting Root Cause Analysis.
Assuming that there will continue to be a need for Patient Advocacy should such a person come to the event/situation on the arm of the patient or should it be the institution which provides independent patient navigators and advocates in support of the usual declared aspiration of “ providing the highest standards of care “.
In practice most hospitals , PCP groups, and other health care organizations have a hard time just keeping up with clinical and bureaucratic demands which are currently placed on their shoulders.
So how can we get enough “ blue sky” to think about ,implement, and then manage such a big task ? A challenge indeed.