Patient-centered care

 Fever, upper abdominal pain spreading to the right shoulder and signs of peritoneal irritation. I know, I know … Now you might be thinking “what an easy and typical case – that must be cholecystitis”. However, this time I don’t want to know what kind of disease it is. I want to hear what you are going to treat.

A disease? Or the patient, who has the disease?

I prefer the second answer, as each patient is a unique human being,  not a group of symptoms or damaged organs. That is the key concept of today’s topic: a patient-centered healthcare model that McWhinney described as one where “the physician tries to enter the patient’s world, to see the illness through the patient’s eyes”.

Content:

1. What is patient-centered care?
2. Principles of patient-centered care:
   1. Shared decision making
   2. Individualization of care
      1. Communication skills
         1. Fostering healing relationships
         2. Presenting information
         3. Responding to patient’s emotions
         4. Enabling patient self-management
      2. Accessible care
3. Why does patient-centered care matter?

What Is Patient-Centered Care?

In order to really understand the concept of patient-centered care, I have to highlight what patient-centeredness isn’t. 

Basically, it’s the opposite of the traditional medical model (disease or physician-centered), where all attention is given to the patient’s diagnosis and the physician takes care of the patient’s health problem. A physician following this model would prescribe the same treatment for most of the patients with a similar condition.  

Patient-centered care is about involving patients and enabling them to take responsibility for their health with help and correct information from a medical care provider. The physician would develop a partnership with the patient (or even with his/her family) and then they consider treatment choices together based on a patient’s unique preferences, needs, and values.

Officially the Institute of Medicine describes a patient-centered approach as the act of providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

 To keep things simple, it’s nothing more than treating the full patient. However, this can be more challenging than sounds.

Principles of Patient-Centered Care

 Mainly, various patient-centered principles fit under the umbrella of:

1. Patient involvement in health care decision making (shared decision making)
2.  Individualization of care

Principle No.1 – Shared Decision Making

Shared decision making is an alternative to the traditional model in which the physician acts as an all-knowing individual and makes all treatment decisions.

It is the active involvement of the patient when significant health care decisions must be made (for instance, taking drugs that must be used for the rest of one’s life). Beyond presenting the patient with facts about their disease, such as diagnosis and stage, shared decision making is a process by which doctor and patient consider available information about the medical problem, including individualized treatment options and consequences, and then discuss how this information fits with the patient’s preferences for health states and outcomes. After considering the options, a treatment decision is made based on a shared agreement. Most studies illustrate shared-decision making by using “hard cases” as breast or prostate cancer. However, let’s start with a simpler case.

Imagine your patient Katy. She is 25 years old and wants to go on birth control. In a traditional model, you might write a prescription for birth control pills, and move on to your next patient.  But in patient-centered care, you would think about this a little differently: You know that there are multiple contraceptive methods including condoms, birth control pills, rings, patches, or intrauterine devices and most of them are medically appropriate for the majority of women. As a patient-centric physician, you present all available options, discuss its pros and cons, and pay attention to her preferences. For example, some women put greater value on menstrual changes, rather than the risk of pregnancy. What about Katy? 

It turns out she is a flight attendant and won’t be able to take pills every day at the same time. In addition, she experiences heavy and painful periods which interferes with her job and diminishes her quality of life. So, Katy wants to manage these symptoms.

Together you decide that hormonal uterine device would be the best solution because Katy’s periods may go away completely and nausea is not a side effect. . Obviously, that is very important while you are on the plane most of the time… 

By using shared decision making, you helped Katy to identify the birth control option that she is most likely to continue to use correctly. As a result, her reproductive goal should be achieved.

A lot of studies suggest that the traditional model is outdated anyway. First, patients are becoming more educated. They google things, including treatment options that physicians may not have even heard of. Sadly, not all patients are good consumers of reliable medical information (think anti-vaxxers). However, the larger availability of knowledge enables the patient to be more involved  when important health care decisions must be made. Second, most of the time, an abundance of treatment options exist, and there is no one best choice as each has pros and cons (remember Katy’s birth control story). Only the people themselves with help from a physician can identify how those aspects fit one’s life. 

On the other hand, shared decision making has several limitations. Obviously, there is no time for identifying preferences while your patient is in cardiac arrest or any other medical emergency. Also, in some situations only one appropriate option exists, such as a broken hip. In this case, patient involvement in decision making won’t have a huge effect.

All sorts of patient decision aids, including apps and booklets, have been developed. These tools “provide information on the treatment options and help patients clarify and communicate the personal value they associate with different features of the options” (International Patient Decision Aids Standards Collaboration). Reliable examples of aids can be found at https://decisionaid.ohri.ca/AZlist.html.

Principle No.2 – Individualization of Care

Healthcare tailored to each patient’s biological, psychological, social, and cultural background can be called individualized. However, you will never be able to identify someone’s values, preferences, or needs without developing trust, understanding, and empathy first. Thus, excellent communication skills play a major role in patient-centered care.

Communication skills

Once you will graduate medical school, most probably you will never again get feedback about your interactions with patients. However, this shouldn’t be relieving news.Practicing doctors are usually left to learn communication skills on their own, and its quality is far from a patient-centered approach. 

The good news is that it is never too late to start learning additional skills. 

#1: Fostering healing relationships

The involvement of patients can occur only if they trust one’s physician. For this, patients should feel they are equals, and a doctor should treat them as an equal. Meaning that demographic, social, economic differences must be bridged and patient’s values, beliefs, and hopes respected.

#2: Presenting information

Sharing information between physicians and patients is more than just providing facts and figures. The patient-centered physician provides information in a way that is acceptable to patients to help them make decisions about one’s care and treatment. But what does this look like?

For example, it is adapting information to the patient’s level of health literacy. That is crucial, because the ability to understand and apply knowledge about one’s health varies between people. Give information in short, understandable chunks.  Patients shouldn’t be flooded with a huge amount of information, as they may become overwhelmed, anxious, and make poorer health decisions.  Also, it’s worth noting that patients who live with a mental health condition, have a learning disability, or are members of a marginalized group tend to ask fewer questions..

It shouldn’t be  a big surprise that even people without the previously mentioned conditions are uncomfortable when expressing their concerns because they are afraid of looking silly or asking dumb questions. In this case, open-ended questions are crucial. For instance, a patient might not reveal using some herbal medication unless a physician asks “What have you tried?” Another “good” question is: “Any questions?” A patient-centered model should do more and actively invite patients to participate: “A lot of people with your illness often have questions. Could you tell me what you understand so I know if I was clear?” 

#3: Responding to patients’ emotions 

A patient-centered approach is all about treating a person as a whole. That’s why assessment of the emotional weight and psychological impact of the illness must be included in every physician’s routine. It helps to gain the patient’s trust and confidence in medical care as unexpressed emotions often are major obstacles for healing relationships to develop.

For this, BOTH the patient’s disease, and the illness experience should be explored. The last one includes asking patient about:

• Feelings about being ill 

• Ideas about what is wrong with them 

• Impact of the illness on daily life: 

Illness can affect life in ways that a physician may not anticipate. For instance, the inability to 

care for oneself or loss of employment. 

• Their expectations for their visit:

It may include diagnosis, medications (such as analgesics), notes for sick leave, or simply reassurance. 

Empathy can be expressed both verbally and nonverbally. Nonlinguistic examples include respectful silence, touching a patient’s hand (when appropriate), or offering a box of tissues.

However, there is one secret behind these tips. You have to feel a genuine concern about the patient’s emotional distress. The selection of the right words is just an additional tool.

#4: Enabling patient self-management

Sometimes a piece of advice given by a physician isn’t enough to motivate patients to adopt more healthy behaviors. A more patient-centered technique that combats resistance and induces change is needed. Motivational interviewing is one of the examples.

Basically, it’s modifying the direction of a conversation in order to strengthen a person’s own motivation and commitment to change. For instance, it is asking “What do you think it would be like if you weren’t a smoker anymore?” instead of “Do you realize that smoking threatens your health?”

Accessible care

Another aspect of an individualized approach is accessible care. Idealistically, all infrastructure and IT should be designed around the patient’s needs (same-day appointments, access to one’s health information through a personal computer or mobile phone, etc.). However, the purpose of this isn’t just being hospitalized in a comfortable bed or something. It seeks to complement and enhance interpersonal relationships, so that better understanding can be reached.

Why Is Patient-Centered Care Important?

First, the patient-centered model is intrinsically the right thing to do. Behaviors associated with this approach, such as respecting patients’ choices, are simply based on moral values. 

Second, patient-centered care contributes to better health outcomes as well. Immediate effects include the patient feeling less discomfort, becoming more knowledgeable, engaged, and respected. That leads to increased self-care and knowledge, adherence to treatment, reduced diagnostic tests, and referrals. 

Of course, it isn’t all about patients. This approach causes higher physician satisfaction–the practice has more purpose and meaning–and fewer malpractice complaints.

Conclusion

Harold S. Jenkins once wrote: “The truly competent physician is the one who sits down, senses the ‘mystery’ of another human being and offers with an open hand the simple gifts of personal interest and understanding”. 

Whether you are a medical student or a practicing physician, it’s never too late (or too early) to shift your concept of a patient as a malfunctioned machine to a person whose life can turn upside down due to some hardly pronounceable disease. A wide range of patient-centered care techniques can facilitate this journey.   

So, let’s go offer that gift of ‘personal interest and understanding.’!