I get the impression from a recent post on KevinMD that a lot of physicians and other providers are having trouble with the term patient-centered. I can understand this given the penchant for us health care folks for using fancy names and acronyms to discuss otherwise straight forward concepts. The other day I came across a simple test for identifying a patient-centered provider when you actually encounter one. It can be used by patients to evaluate their physicians. Physicians, PAs, Nurses and other providers can also use this same tool to evaluate whether they are patient-centered nor not.
Here We Go
If you are a patient…
- Do you feel that your doctor is always trying to persuade you to follow their ideas of good health?
If you are a doctor or other provider…
- Are you always trying to persuade your patients to follow the care recommendations you have given them?
If you answered “yes” to either of these questions, then your doctor (or you if you are a provider) are not patient-centered. More than likely your physician/provider (or you) are physician-directed or provider-directed in their patient interactions.
How Can I Say This?
Patient-centered care is also known as collaborative care – you know – where doctors and patients share information and collaborate on decision-making. If your doctor (or you) were patient-centered, rather than tell you what you should be doing, they would routine engage you in the following types of conversations during your visit:
- Help you identify and address your primary concerns.
- Encourage you to talk about the emotional aspects of your health problems
- Help you identify and choose goals that are relevant and important to you
- Respect your right to make decisions with which they disagree
The problem with patient-centered care is that so few people, whether patient or provider, have ever really experienced it. Seriously…when was the last time your physician asked you what you wanted to discuss during your visit, asked if you agreed with their diagnosis or treatment, or ever asked you if you were depressed? When was the last time your doctor really listened to you rather than just going through the motions.
To this point, here’s a quote from a comment I received from a physician on my last post about the importance of being patient-centered.
I’ve come to realize how important listening is, not just to make patients feel good, but for a number of practical reasons. Most doctors, I fear, think of listening as something you do as little of as possible, just until you’ve made up your mind what the patient has and what the doc is going to do about it. Beyond that it becomes a passive exercise, essentially a waste of time.
WOW! My Doctor Actually Listened To Me!!
As a practice administrator or hospital executive, can you image how powerful it would be if patients walked out of your facilities telling their family and friends that their doctors (including hospitalists) actually took the time to listen to them?
Listen to patients….my God what a novel concept!!
That’s my opinion…what’s yours?
Source:
Anderson, R. M., & Funnell, M. M. (2010). Patient Empowerment: Myths and Misconceptions. Patient Education & Counseling, 79(3), 277-282.
Mind The Gap 
In reference to the post “Why hospitals and physicians should get serious about patient-centered care” I completely agree with the concept even thou this would mean a paradigm shift in most healthcare circles in South Africa specifically. Opening the door to this type of service would make all service providers responsible to the patient from end to end and in doing so, hopefully reduce costs and not escalate costs even further. On face value I must comment that one of the aspect that will require serious deliberation is the approach in dealing with hypochondriacs of society and how they are dealt with in this pocess.
Excellent post.
You do realize, however, that the type of patient-centered care you are proposing is in direct opposition to the growing pay-for-performance movement. In P4P, the physician’s income is based on forcing the exact same treatment plan on every patient, regardless of the patient’s input. At a certain point, the physician will feel significant financial pressure to discharge the “non-compliant” patient from the practice.
And though you may disagree, it is absolutely impossible to adequately deal with a patient with DM, HTN, hyperlipidemia, obesity, and depression (a very common presentation in primary care) AND cover your four bullet points in a meaningful manner without significantly increasing the length of the appointment. It cannot be done in 6 seconds!
Southerndoc,
You really pose 2 questions in your comment 1) is “being patient-centered” compatible with meeting the requirements associated with P4P and 2) is there enough time during the routine visit to do everything that needs to be done for patients vis a vis chronic care management.
Regarding the first question, you of course are correct about P4P reimbursement incentive is tied to some set of measures, PQRI, HEDIS, etc. While the performance outcomes are non-negotiable, what is negotiable is how one goes about achieving the outcomes. Say a type 2 diabetic patient needs their annual consult with a diabetic nutritional educator. You mention to the patient that it’s that time again when they should meet with a diabetic counselor to discuss your nutrition plan. Your patient pooh poohs the need to do so. Basically, as you already know, a patient-centered approach would have you investigate the patient’s reluctance, i.e., their motivations, fears etc. for scheduling a consult. Undoubtedly the reason for their reluctance will surface and you can then problem solve a work-around together with the patient.
If this was a new patient, you are right, 6 seconds would not be enough. But for returning patients, presumably who you have gotten to know them over a series of visits, it might be. For example,. the guidelines call for 4 minimum of 4 visits a year for a type 2 diabetic. With each visit you ideally gain more insight into the patient’s thinking and behavior such that you will have a better idea how to tailor you comments at the next visit. The point is that you don’t necessarily need to do everything (gain paint insights ) at every visit. Similarly a problem-solving approach will become second nature for the doc. There’s a fair amount of literature to support this. In my other life I am working on an interactive IT solution for off loading much of this work back to the patient, But that’s another story. Hope this helps. Sorry the discussion on KevinMD got a bit out of hand.
I really appreciate your input!
Thanks,
Steve
Southerndoc,
I would welcome your thoughts about the question I posed to Kerry above.
Steve
Mr. Wilkins, what you say is very true (and that quote was great, too). I have another “litmus test” to help doctors – and patients, too – determine if the care they are delivering – or receiving – is more patient centered than not.
When I was in medical school in the early ’70’s, one of our attending physicians used to ask the following question when we were discussing a case, the labs, x-ray results, differential diagnosis possibilities, etc. He would stop us and ask: “Are you treating the patient or the disease?” I was perplexed by his comment. I thought it was the same thing. It took me many years to realize the difference. I think patients probably pick up on this much more quickly than we realize.
So, as an example, if I am treating a patient with, say, CHF (congestive heart failure), am I simply treating CHF, or am I treating a patient, a person, who happens to be suffering from CHF? There’s a big difference, though it’s a subtle distinction in the minds of most doctors.
Medical training is generally very effective in teaching us how to treat diseases, but not in how to treat “the patient.” And maybe this is how it should be. Maybe new doctors should be given the opportunity (or required) to go through some additional training or mentoring to develop a more humane (dare I say less clinical?) approach to patients.
As a start, maybe it would be helpful if doctors would simply realize that there is a difference between treating the patient and treating their disease.
JD,
Thanks for your earlier comments as well as those here! I appreciate your willingness to share on this difficult and touchy subject. I believe that if we could improve the way patients and doctors communicate, many of the big problems faced by the health industry would fade away.
You are correct about the need for do a better job teaching communication skills to new physicians …as well as refreshing practicing docs. We should also give serious consideration to teaching patients to take a bigger role in the physician visit.
By the way…that was a great quote…thanks for supplying it!! If you want me to give you credit…let me know…I’d be happy to.
Steve Wilkins
Steve,
Yes, it was my quote. Thank you very much. In that quote I said that listening was important “for a number of practical reasons.” This ties in with something Southerndoc mentioned. He mentioned P4P and some of the barriers to better “performance” such as time constraints as well as a flurry of measures (PQRS, HEDIS, etc) we’re “encouraged” to pay attention to. Now we’re supposed to LISTEN to the patient?! My God!
I am a hospitalist, so in many cases, unlike an office based practitioner, I see patients for only a few visits and over a short span of time. And many I’m seeing for the first time. It’s crucial that I establish a good relationship with them, and often the family, from the outset. I don’t always succeed, but when I do it helps tremendously with the care of that patient. Do I spend more time with the patient? Yes, but not as much as some may think, maybe an 10′ to 15′ on average. At least on the first visit. If I can get to know the patient – and let them get to know me – it sets the groundwork for a better interaction and, I believe, a better outcome. (By “outcome” I mean more than reduced LOS or costs or all 5’s on the patient satisfaction survey they receive after discharge.) If I take the time and actively listen, it allows/encourages the patient to open up, give a better history. As opposed to the all too common routine of peppering the patient with a barrage of questions about their chief complaint, often supplying, or assuming, the answer(s) we want to hear and cutting the patient off when he/she starts to get a bit “long winded.” I can also spend a few minutes explaining what the plan of care is and letting the patient know what tests/procedures/consultations they’re going to have. I consider this active listening, and the extra time, as an investment. And I believe I get a pretty rapid ROI (return on investment), e.g., fewer pages about a “noncompliant” patient who refuses to go for a test until he talks to the doctor about it; or a call asking me if I really want to order a test the patient had a week earlier in her doctor’s office.
If I can engage the patient, convince them to participate in my “game plan”, I believe that compliance is better, their understanding of their condition and treatments for it are better, AND it improves compliance and follow-up after discharge.
I almost forgot. One of the main reasons I try to do the above is that it makes ME feel good. It’s very gratifying when a patient or family member thanks me for finally explaining their disease/medication/physiology to them in language they can understand. Or explaining the enigmatic pronouncements or actions of this or that specialist. Or just thanks me for taking the time to be with them, to take in interest in this person, not just their disease. (hmmm…that idea keeps coming back)
It’s funny, my hearing is slowly getting worse, but my listening is better.
JD,
I would welcome your thoughts about the question I posed to Kerry above.
Steve
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Several of my Mentors in Medicine always advised for me to “listen to my patients because they would tell me what’s wrong”. Sadly taking a history and performing a diagnostic exam is becoming a thing of the past. Unless spoon fed information byb an EMR or a CT scanner, many physicians will shortly be unable to understand the problems of their patinets.
Great comment about P4P, a program designed by and for insurance companies and a great reason why Doctors should become engaged in the reform process. We need to design programs that serve patients and Docotrs and focus less emphasis on the busywork created by the policy wonks and widgets folks who think all care can be standardized. A checklist can be used to perfrom the quality standardization part of a medcial home leaving time for Doctors to find new ways of being effective or collaborative with each patient.
Kerry,
Glad to hear from you again! Thanks for your comments.
Here’s a question…anyone should feel free to respond. What role can the patient play (just blue sky this topic) in helping change the direction things are going – say starting with demanding a “hands-on physical exam” versus getting a virtual diagnosis via technology?
Please share your thoughts!
Steve Wilkins
Love the post and have a wonderful example of how the collaborative process works. Please read the NYT series by Benedict Carey: Lives Restored. The profile published on October 23rd includes the important role of the MD in the patient’s recovery.
I know the power of collaborative care- I am the “patient” person profiles in this story.
Here’s the link: http://www.nytimes.com/2011/10/23/health/23lives.html?_r=2&scp=1&sq=Keris%20myrick&st=cse
Keris,
Wow what a story! Thanks so much for sharing the link to your amazing personal story. Continued success!!
Steve Wilkins
Interesting comments on the concept of patient- centered care. Healthcare is a business but patient-centered care involves the bedside caregiver more than anyone else. Productivity has become the dirty word when it comes to the actual care of the patient. The cuts I have seen as the most detrimental include taking away the nurse extenders/ assistants/ and or unit support personnel. These are the lowest pay personnel and many working in patient care areas are likely to continue onto nursing school or other healthcare positions. The addition of even more paperwork and boxes to check by the nurse allows very little time at the bedside teaching and caring for the patient. The majority of hospital patient care units are now staffing 6 patients per nurse. So families, when the doctor is too busy to answer your questions and the nurse is running around with stacks of paperwork to justify the work she has had little time to do…mark your patient satisfaction survey appropriately…put the caregivers back at the bedside.
I am a nurse educator who is sad to say I am glad that I am just a few years away from retiring. I do not want to run around trying to get caught up…I want to be with the patient…offering my expert care. Checking the right boxes on paper or in a computer is not giving patient-centered care. It is forcing the nurse to document what the regulatory agencies want…not the care actually provided. Sad but true…In my 35 years of nursing I have seen the changes…Healthcare is a business…I know I need to retire when I can not longer teach patient-centered care…it just is not a priority to the bean counters…until their mom is laying on a stretcher in the ED for hours waiting for the boxes to be checked and a bed is cleaned by the housekeepers that have been cut as well.
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I am a strong proponent of adopting more patient-centered relationships, but as a physician, there have been many, many times when I have asked a patient how he/she would like to proceed or whether they have any concerns about my treatment plan, only to be told, “I don’t know; you’re the doctor.” So although I agree wholehardedly with the concept, we need to make sure patients are ready for this transition, and will actively participate in their own health care processes and accept a level of responsibility for their own health outcomes.
Dr Rubin,
Thanks for your comments. You are spot on! I applaud you for asking the patient how they would like to proceed…many docs aren’t there yet.
Your experiences with “I don’t know..you are the doctor,” are the result of the key industry players (health plans, government, etc, and busy doctors) delegating more and more responsibility for patient care back to the patient. While there is nothing wrong with doing this, the simple fact is, as you astutely noted, we need to tell patients what’s going on and teach/support them how to get involved on a practical basis. Up until now, the patient’s role was limited to the sick role opposite the physician’s role as clinical expert.
Steve Wilkins
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I agree with your simple test, but I find your definition of collaborative care outdated. Many hospital organizations are embracing the concept of interdisciplinary collaborative care and not a physician/patient dyad. I still come across physicians that state they believe in and perform collaborative care, but making a referral out to a therapist is no collaboration.
True collaboration puts the patient at the focus, but allows for multiple voices bring multiple competencies into the conversation. The patient’s “problem list” should not be just a medical list but provide a overview of how the issues identified by the interdisciplinary team are being addressed.
For example, about 50% of patients admitted to general internal medicine unit will have psychosocial or functional barriers that need to be addressed in order to optimize the clinical outcome. In other words, LOS are longer when physicians quarterback the patient’s care with a focus primarily on resolving the medical problems and not considering the perspective of the entire care team (nursing, rehab, and social work/mental health in particular. It is a tremendous challenge to get physicians to give up some of the control and give it to other healthcare professionals.
Steve: you wrote:
“Regarding the first question, you of course are correct about P4P reimbursement incentive is tied to some set of measures, PQRI, HEDIS, etc. While the performance outcomes are non-negotiable, what is negotiable is how one goes about achieving the outcomes. ”
If the outcome is non-negotiable, the question of whether or not your care will be truly patient centered has already been settled: the answer must be “NO”