Of course, every health care organization will suggest that they practice a “patient-first” ethos. Health care, by definition, has care of patients as its primary goal. Why, then, is it necessary to overtly and explicitly state that Done is a “patient-first” organization, as though this is something new, different, or even revolutionary? Allow me to elucidate an answer to this question and illuminate some of the features that provide Done with a decided advantage in taking on the challenges of ADHD treatment on behalf of patients everywhere.
What is the essence of patient-first engagement? The short answer: a patient-first organization offers the most effective and evidence-based therapies at the lowest total cost.
It is important to underscore that “total cost” does not refer solely to the financial cost, although of course money is part of it. Total cost defines the sum of all negatives included with treatment. It includes physical and emotional pain, side effects, inconvenience, stigma, lost productivity, and other factors too numerous to list. Indeed, it is difficult to measure this cost holistically, accurately, or quantitatively. Despite this challenge, it is essential to weigh the benefits of any treatment against its total cost, since treatments with costs that outweigh the benefits are considered non-starters.
Defining the evidence
Focusing on the positive, how can we determine which treatments are the most efficacious, specifically for ADHD?
I have already mentioned that therapies offered by a clinical organization must be “evidence-based”for the organization to be patient-first As readers may already know, in clinical medicine, the “gold standard” for an evidence-based study is a double-blind and placebo-controlled, with a sufficient number of subjects to maximize statistical significance. Such studies are time-consuming and expensive, to the degree to which if it were required that such studies validate all treatments, virtually no treatments would ever be approved. Thus, there is a spectrum of study designs that could supply evidence for the efficacy of a treatment. Based on the study design, this evidence can be ranked from most to least convincing. There is often, though not always, general agreement on what constitutes sufficient evidence that a given treatment is efficacious.
Evidence-based studies must be contrasted with “anecdotal evidence,” which, in the strict sense of the term, is not “evidence” at all. Anecdotal evidence consists of one or a few reports of successful treatment, but it lacks any comparison to a control group and/or does not have adequate numbers of subjects to achieve statistical significance.
The treatments provided by Done are all evidence-based. Importantly, this does not mean there is a choice of only a few treatments. Fortunately, many treatments have the high-quality evidence to demonstrate that they are effective for ADHD. Nor does the fact that all treatments provided are evidence-based mean that Done providers are “told what to prescribe” or even steered towards a general category of treatments. The clinical leaders of Done agree that the way to ensure evidence-based treatment of the highest quality is to recruit and retain frontline clinicians of the highest quality and trust them to make appropriate decisions on treatment.
The most reliable way to assess whether a practitioner will be of high quality is to examine their training and education. Board-certification in psychiatry, or Board-certification as a psychiatric mental health nurse practitioner, indicates that a clinician has the training and experience to make informed decisions about the provision and administration of evidence-based treatment and to implement that treatment in a manner that meets the highest clinical standards.
Patient-first care at its core
Done will never “prescribe for prescribers” by mandating they provide specific procedures, medications, or therapies. The reason for this is simple and fundamental: human variability, especially in terms of response to medications, is so great that no formula, algorithm, or medical record review can substitute for an evaluation based on human interaction with a skilled clinician. To give the highest quality care, thus putting the patient first, the practitioner who evaluates the patient must be the one who chooses the treatment. Full stop.
Elevating the relationship between clinician and patient to the highest level of consideration is a crucial aspect of Done’s patient-first philosophy. It is often mistakenly assumed that “medication-only” patients neither receive nor benefit from psychotherapy. In fact, any successful treatment of a psychiatric disorder involves psychotherapy. In the case of ADHD, because the primary treatment usually consists of medication, any in-depth psychotherapy – meaning lengthy and frequent sessions – is not usually needed. However, Done’s patient-first model ensures an ongoing relationship with a psychiatric professional for as long as the patient is in treatment with Done. This psychotherapeutic relationship will also maximize both medication compliance and the overall success of the treatment. Done’s model includes regular follow-up for all patients, and takes a holistic approach that rejects the conventional distinction between “therapy patients” and “medication patients.” This honors each patient as an individual, by giving them an optimum treatment plan as unique as their fingerprint. Only an organization that is truly “patient-first” can provide this comprehensive approach.
Patient-first care is such an obvious and mutually beneficial goal that it might seem frictionless to achieve. However, even a goal that is clearly visible to any may have many obstacles along its approach. Unfortunately, that is often the case for patient-first ADHD care. And as always, the greatest challenges arise not from medical factors but from the interaction between the medical and the psychosocial.
The ripple effects of the opioid epidemic
Currently, the greatest difficulty of ADHD treatment is inherent in the fact that scientific studies of the highest quality consistently find that a single class of medication, the psychostimulants, is the most efficacious. Why is this a problem? As is well known, psychostimulants are classified by the U.S. Drug Enforcement Agency as controlled substances, because they have the potential to result in dependence.
In itself, this classification would be little more than an inconvenience. However, the psychosocial factors mentioned above have made substance dependence one of the most emotionally charged, politicized, and distorted areas in all medicine. This has been indubitably true for well more than half a century. Then, just when it seemed the subject could not become more fraught with conflict, the opioid epidemic reared its ugly head, and the topic of substance dependence became host to still more controversy, politics, and intense emotion.
To be clear, psychostimulants are a class of medication entirely distinct from opioids. The only commonality of the two categories is that both may produce dependence. However, the horrors of the opioid epidemic were such that several classes of medication known to have at least some dependence risk have now been “tarred with the opioid brush,” meaning that because both can be addictive, it is assumed by some that prescription stimulants are responsible for horrors like those from prescribed opioids.
Because of the negativity transferred from the opioids to all classes of potentially addictive medications, prescribers have become reluctant to treat disorders for which the treatments of choice are possibly dependence-producing. Perhaps that was natural initial reaction, but unfortunately, the collateral damage of this reluctance to treat ADHD is increased skepticism about ADHD, including about the validity of the diagnosis. These changes in attitude have led to highly undesirable effects, such as reluctance or even refusal to refill stimulant prescriptions when needed and increased suspiciousness of patients’ motives for starting or attempting to continue treatment for ADHD. The change of status of modafinil, a medication at times useful for ADHD, from non-controlled to controlled may also be related to this change of climate about ADHD treatment..
The reputational damage to ADHD and its treatment, caused in part by this fallout from the opioid epidemic, has been severe among the general public as well as in the clinical community. . The most extreme viewpoint rejects the ADHD diagnosis altogether, regarding it as a “label” that serves as an “excuse” for laziness or a simple lack of intelligence or ability. Subscribers to this view regard people who suffer from ADHD as out to get an unfair advantage or as simply “wanting to get high.” Even those that believe there is validity to the concept of ADHD as a disorder can stigmatize and act on stereotypes, for example by suggesting that treatment should be severely time-limited or by insisting that interventions documented as less likely to be effective always be given preference, even in dire situations or for severe cases.
What is best for patients now and in the future?
Given these myriad challenges, how can a truly patient-first approach to ADHD be achieved? As with all evidence-based treatments, the best way to a patient-first approach is through the selection and education of clinicians. A clinician guided by the patient-first philosophy will make treatment decisions based only on the evidence provided by clinical science, combined with her or his knowledge of the individual being treated. Unbiased, objective, and informed.
My hope is that clinical interventions that put the patient first will become the rule rather than the exception and help to counteract the early and pernicious inculcation advocating the practice of defensive medicine that most clinicians receive in training…
…if “pernicious inculcation” of a defensive approach to medicine seems exaggerated, let it be said that in training, we have been at times encouraged to weigh what would be best for our welfare as career professionals against what would be best for the patient. This is an example of a “patient-second” approach and one that Done plans to transcend.
How is the tug-of-war between practicing. defensively versus in a patient-first manner specifically relevant to ADHD treatment? The very concept of “patient-first” implies the familiarity with the patient as a unique human being for whom it is necessary to put his or her needs “first,” meaning ahead of all other considerations. Using the insights gained from the in-depth initial evaluation and from the ongoing meetings with the patient, the Done clinician can make an assessment that looks beyond statistics or stereotypes to the underlying individual reality of that person. These insights often serve to ameliorate any problems with prescribing evidence-based treatments of choice, such as psychostimulants.
To truly provide patient-first care, the misperceptions about ADHD and its treatments that are summarized above must be corrected. This is where careful psychiatric research that pays close attention to psychosocial factors will play a crucial role. If research is focused on differences between populations, the clinician can use this information to honor the human diversity that exists even within one “diagnosis.” Knowledge of such research results in a flexible, humanistic approach rather than a “one-size-fits-all” approach, which regrettably, is otherwise the default approach..
Mch such research has been performed and published, but due to lack of provider time or motivation, access to it may be limited.. Continuing the education of clinicians on the scientific evidence regarding ADHD treatment plays a crucial role in the provision of authentically patient-first care. Such education has been a key piece of Done’s activities since inception, and it will continue to be second to none.
All of Done’s activities are directed towards the same goals:
Never let patients feel their needs are secondary.
Let’s always put patients first!