Baseline and Goals of Treatment

While watching the Red Sox-Milwaukee baseball game on TV last Saturday, the announcers were discussing Julio Lugo, the Red Sox shortstop who had missed 5 games with a concussion. One of them noted that the team had done baseline neuroimaging testing on all the players so if they had a concussion during the season they would have a baseline to compare to their post-concussion tests. I assume that they also did non-imaging neurological testing, such as reflexes and memory, etc., and this was an extension of all the other evaluations the players went through.

The reason I found this interesting is that it highlights the importance of having an understanding of both a patient’s baseline and their goals. For example, the ability of someone to play the piano after a hand injury is healed depends upon whether or not they could play the piano before the injury. (Sorry – that’s from a very old joke.)

Obviously after a professional baseball player has a concussion, the important factors include reflexes and visual focus since hitting a 90+mph fastball and catching a rocketed ground ball requires precise physical abilities. But for the rest of us – and overall healthcare quality – baseline functioning and goals are important because they are different for every patient, and should be a crucial component of the conversation between a patient and their clinical team. Only when the clinician understands what the patient’s abilities were before the illness or injury, can they work with the patient to develop a treatment plan that they hope will get the patient to their goals.

This may all sound silly or simplistic, but too often I have heard stories about patients who complain that their physician has given them the treatment plan without considering their desires or perspectives – as in “this is what where going to do.” Unfortunately, physicians sometimes only see one reasonable treatment course. But patients are as different as baseball parks – and I mean globally from sandlots to Yankee stadium – and their perspectives, concerns and treatment goals really are just as diverse.

I’m ready for blasts from physicians and others on this one, so let me know what you think.

3 thoughts on “Baseline and Goals of Treatment

  1. Pingback: Health Policy and Communications Blog » Blog Archive » Advancements in Understanding Head Trauma and Preventing Long-Term Problems

  2. Jennifer – Thanks for the great perspectives from the trenches. When I lived in Washington DC I volunteered at a free clinic where our clients had significant non-medical issues that made their goals very different than what would be seen in many private practices. The great thing about this clinic (www.BreadfortheCity.org) is that it has legal, food, clothing and social services programs housed on-site, so many of the patients’ other issues could be dealt with comprehensively., i.e. we could help them clinically with their hypertension and diabetes, and have some confidence that not only would they have the right medicines, but they would have a safe place to sleep so they wouldn’t lose their prescriptions and they wouldn’t run out of food at the end of the month.

  3. I think the post on patient baseline and goals for treatment is outstanding – and right on target.

    I practiced general family medicine for 8 years before moving to weight management and preventive medicine four years ago. I always felt that a critical aspect of providing top quality primary care was knowing your patient well. Yes, I know this sounds simplisitic, but it is certainly not simple. Besides knowing a patient’s baseline physical and mental health, it is also critical to understand whether a patient is “stoic”, or a worrier, whether he/she will not rest and relax until every reasonably aggressive workup is done, or whether he/she is content and prefers to sit back somewhat, and let nature take its course to some degree. Of course it is the physician’s job to help all patients, no matter what their inclinations, achieve the best health choices for them. It is the job of the physician to help the patient understand what is reasonable to fear, or not, and what are the reasonable possible approaches to workup and treat a problem. Part of being a top doc is working WITH the patient, to help the patient achieve his or her goals effectively.

    Now that I practice weight management and preventive medicine, it is even more transparent how important it is to know a patient’s baseline and goals. Some of my patients are only slightly above a normal body fat percent, but are triathletes in training, and really need some intensive advice and counselling on diet, exercise, sleep, relaxatinon, and not overtraining or undernourishing themselves. Other patients are hundreds of pounds overweight, and initially just want to be able to move around more easily, improve some health parameters such as cholesterol, and feel in control of their eating patterns. Obviously baseline and goals of treatment are critical in designing programs for the variety of my patients.

    One more thing to remember – baseline health AND patient goals can and do change over time. I’ve had patients lose over 150 pounds – and drop to a BMI of 22. At this point, a patient often begins to have very different goals. Other patients have been competitve athletes for decades, and are now suffering from osteoarthritis, which is beginning to limit their performance. One of my jobs is to help these patients revise and update their own goals, and help them move forward.

    I remember a patient in her mid thirties, a relatively slim athlete, who was dealing with a succession of injuries, and putting on a little weight. One of her biggest frustrations and complaints was an orthopedic surgeon who advocated a very non-aggressive approach to treatment, and suggested that she stop competing. She felt he was telling her to go out on the porch and sit in a rocking chair! Obviously it is important to discuss both baseline, and goals with patients, to provide the best care.

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