Patient-Centeredness, Patient Engagement & Health Care Quality Improvement – A Physician’s Perspective

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naikA guest post by Aanand D. Naik, MD -  Chief, Education and Training Core in Health Services Research at Department of Veterans Affairs, Michael E. DeBakey VAMC and Assistant Professor of Medicine at Baylor College of Medicine. Houston, Texas.   Reposted from the Blog GeriPal

Improving the health outcomes of older adults with multiple chronic morbidities has been my calling as a physician.  During residency, my colleagues were interested in difficult, rare, or novel cases.  In contrast, I was attracted to the lingering, multiple everyday conditions that older adults faced.  I was also struck by the fact that providing all the recommended screening and treatments for each of their conditions often did more harm than good.

It became immediately clear to me that my role as a clinician was to partner with my patients.  In the end, it was the patient and their family that had to identify health and life goals, prioritize which of those goals were most important, and then work with clinicians to find treatments that best aligned with one’s goals and values.  From this perspective, “non-adherence is a dysfunctional concept.”  The quintessential signs of poor quality of care for multimorbid older adults, e.g., polypharmacy, overutilization, adverse events, often result from a discordance of values and goals between clinicians and patients.

Based on these formative experiences as a newbie physician, I chose to focus on patient-centeredness as a distinct dimension of healthcare quality and identify pathways in which patient-centeredness leads to patient engagement, collaborate goal-setting and improved health outcomes.  More recently, I’ve explored the ‘patient experience’ itself.  Appreciating how someone experiences illness, healthcare, changes in health status and personal growth has profound impacts on how we understand healthcare quality.

Policy experts and researchers often view quality through the lens of expertise, large datasets, and multivariate analysis.  While this perspective has its merits and applications; assessments of quality for most goods and services is intuitive, normative (value-based), and socially constructed. Therefore, we cannot improve healthcare quality without patient engagement; which means communicating about health and healthcare in ways that make quality intuitively obvious to the everyday patient. There are many clinicians, policy experts, patients, and caregivers who think that only experts can judge quality. This perspective is anachronistic—a vestige of a professional view more consistent with a medieval guild rather than the 21st century industrial complex healthcare has become.

This absurd perspective—that patients cannot or should not be asked to understand and judge healthcare quality is the principal cause of hyperinflation within the American healthcare system.  It is ironic that Ford and Apple can create immensely complex products and then ask people of all stripes to judge quality and make high dollar purchases without first taking a crash course in automotive engineering or computer science. There are no screening tests for literacy of the internal combustion engine or static random access memory chip.  From this vantage, patient-centeredness exists when patients can intuitively judge the quality of their chronic illness care just like the quality of their smart phone.

As a first step, patient-centeredness is an approach that engages the patient, focuses patient-clinician discussions on the needs of patients, and opens the door to conversations about values and goals.  The next step is an alignment of treatment priorities with one’s goals and values and then selecting and judging specific treatments that meet those priorities.  Along the way, we will need novel approaches to communicating about and grasping the inherent value of health services and treatments.

This brave new patient-centered world does not diminish the role of clinicians. The key to improving the health outcomes of our older patients (and the overall quality of our healthcare system) is through re-investment in dialogue between patients and clinicians and a strengthening of trust within the patient-clinician relationship.

Follow Aanand Naik, MD on Twitter @empoweringpts

16 Comments

  1. Andrea Simon says:

    During recent anthropolgical research we have been conducting among consumers we were saddened by the overwhelming loss of trust that they are expressing and experiencing in their interaction with Physicians and healthcare providers. Trust is going to be essential if people are going to bp be partners in care, not suspects in a money-motivated system-which is all they focused on. Thoughts?

    • Andrea,

      Thanks for your comments. I’d love to see the data you are referring to.

      It amazes me that at least some physicians, when asked about the decline in the quality of their interaction and communications with patients, are quick to tell me 1) we don’t have the time to communicate with patients and 2) we don’t get paid for talking to patients. The situation is only going to get worse as health information folks convince health care executive to continue to supplant face-to-face physician interactions with health information technology-based (PHRs, EMRs, patient portals and secure email) interactions. Talk about disintermediation.

      Smart providers will recognize and appreciate the competitive advantage afforded by strong physician-patient relationships and effective patient-centered communications. The rest of the providers out there will simply continue to “just get by” … and so will their unfortunate patients.

      Steve Wilkins

    • family doc says:

      How can patients trust their physicians when they know they’re employed by for-profit mega-corporations?

      • I am not sure most patients are as concerned about who pays the doc’s salary as docs are. Working for a hospital system like HCA is not perceived in the same way as being on Pharma’s payroll. I at least have not seen any research to support that concern. I am sure some raise that concern but somehow it seems that docs that take the time to build strong relationships with patient can transcend the issue.

        Thanks for you comments.

        Steve Wilkins

      • Joyce N. DeWitt says:

        I would respectfully submit that doctors and the mega corporations they work for have to make money. I may be wrong, but when compared to the years of school it takes to train a doctor, and the cost, plus the costs they encounter for all the insurance they have to have, additional training they do, fees for associations that they belong to, I expect that they would and should be paid handsomely. After all, most of them don’t even start earning big money until they are in their early 30′s, so they have catching up to do, and loans to pay off. If they work for a big corporation, then that business has to pay the high rental fees for the buildings they are in, along with the salaries of all the support staff and nurses, and all of the equipment, supplies, etc. and probably lots of things that I haven’t even thought of. I have no idea how it works, but maybe doctors in the group have to pay a chunk into it just for these kinds of things. There better be a profit margin for the corporation or they won’t be able to continue. I wouldn’t distrust a doctor, or any other professional, on the basis of their employment by a “for profit mega-corporation.” I see it as a plus if they are under the umbrella of a big group, if that group has high standards and outstanding professionals. All the doctors that I have seen in the last 8 years have been in that category and I’ve never had any doctor suggest anything that made me suspicious, or prescribe anything that was not absolutely needed. Perhaps I’m naive, but I don’t understand not trusting a doctor because he works for a big group.

  2. “Assessing goals and values before identifying treatment to meet those priorities” makes sense. But this assumes that the patient understands that s/he has treatment choices, and that there might be more than one way to solve his/her problem. I could be wrong, but don’t most patients approach their physician with an expectation of a “cure?” Do we need to recharacterize the office visit as a collaboration on choice of treatment? That was my experience, and money was the driver. On a high deductible HSA, I had to balance cost against efficacy. My doctor came up with a plan to do both, with limits that would kick in the deferred, more expensive therapy. This was a perfect collaboration. I am a happy patient. Now if I could just figure out what that PFT is going to cost me :)

    • Natasha,

      Think of patient-centeredness as like market research. From my perspective, respecting a patient’s desire to let the clinician make important decisions is just as patient-centered as involving the patient that does want to be involved. It’s all about honoring the patient’s preference where practicable. Trying to force patients into doing something contrary to their preferences, like using PHRs or web portals, is not patient-centered at all…in fact it is very provider centric.

      Steve Wilkins

  3. Mark says:

    Steve, this is why it is critical for the various entities in the delivery of healthcare to empower/engage/educate the member/patient/consumer. Recognizing it is difficult to do, a smarter consumer of health care will make better choices and engage their providers for answers that are relevant to their situation. An organized and educated patient is also more efficient for the provider – so there are additional benefits.

    • Mark,

      Thanks for your comments. If only it were as simple as empower/engage/educate…whatever those words mean. One of the huge problems facing us patients…is that we don’t speak the same language as physicians…nor do we in many cases share the same definitions of health, pathways to achieving health and so on. Giving people information is not enough to change patient behavior regardless of how “exciting or cool” the technology used to communicate the information. I can tell you my idea of being an organized and educated patient is very different from my physician’s perspective of the same. Until patients and physicians get on the same page little I suspect is likely to change. Getting everyone on the same page is what patient-centered communications is all about.

      Steve Wilkins

  4. Steve, A nurse navigator or patient advocate often knows the medical speak and systems. As people with a medical professional in the family know, we often view the process much differently and are unafraid of being proactive and assertive. Otherwise, you may risk falling through the cracks in our complex system

    • Jeanne,

      Thanks for your comments. I have done a fair bit of advocacy work myself focusing on lung cancer. There are “gaps and sink holes” throughout health care into which anyone of us may fall…nothing like a good advocate as you say.

      Steve Wilkins

  5. Joyce N. DeWitt says:

    I continue to see my patient experiences as perhaps remarkable compared to others, but I now have come to expect good communication and information as to why my physician wants to do something. Over the past several months, I’ve seen two different orthopedic doctors; one for tennis elbow and the other for back / hip pain. I had filled in their online forms prior to coming in, which asked me to rate my pain, and give other information about how it’s affecting my life. Both doctors asked additional questions at the visit, and did some examination of how my joints were working, flexibility, etc. Both ordered X-rays, and one doctor suggested an MRI after looking at the X-ray. In no way did he insist, he explained why he wanted it but also told me that it was an expensive test. After determining a diagnosis, both asked me if I wanted a cortisone shot, and we talked about advantages and disadvantages. Both carefully showed me on my X-rays and MRIs where the problems are and how it all works. Both suggested additional physical therapy and my back doctor asked me if I wanted to have a prescription for a Tens machine. I did the therapy and got the shots and the machine and the pain is definitely less. One of the key things that I observe about these doctors, and also my internist, is that they are all very friendly, relaxed in their approach, and seem to genuinely like their jobs a lot. So I think that these upbeat kinds of doctors naturally view patient engagement as a good thing. It was the same when I was teaching high school. There were those who viewed student portals as a pain in the neck, and didn’t want to do one on one conferencing or tutoring. And then there were those who viewed that kind of communication and engagement as a positive thing, and crucial to building good relationships with our kids. I loved it when I got an after school email asking about an assignment or even asking what they scored on a test. We collaborated. After all, it was their grade, and their success or failure at stake. And it is the same with patients. It’s our health, and we want to be advised, taught, and encouraged to jump in and point things out or ask questions.

    • Joyce,

      You are lucky to have been exposed to physicians with superior patient communication skills. I, for example can count such personal experiences on one hand. Most of us accept suboptimal physician communications because we don’t realize that there are better alternative “out there.” We just assume that every doctor is the same so why bother switching.

      Thanks as always for your comments.

      Steve Wilkins

  6. There is significant research to show patients are more satisfied with care if imaging studies are performed (even if evidence based guidelines indicate the imaging is not needed). How do you see the partnership with patients in this light?

  7. Aanand Naik says:

    Thank you all for your comments, questions, and observations. I agree with much of what has been said here. Trust within clinical encounters is paramount and fleeting. We need greater attention to the communication that occurs during medical encounters–communication that is person and not disease centric. There is ample evidence on how this type of communication enhances trust, satisfaction, and health outcomes.
    While patient-centered communication needs to happen now and in-full, patient control of health care is under-developed. Simply placing the weight of clinical decision making into a patient’s lap is not what I would advocate–that experiment has occurred and it results in blunt self-rationing of care. We need to do the hard work of redesigning the health care system to provide patients with better context, meaning, and awareness of likely outcomes. This is the “intuitive grasping” of quality that is so common outside of health care but lost within contemporary medicine. We need creativity from within and outside the health care system to make this patient-centered world a reality.

  8. Thank you for your thoughtful post. Conversations about values and goals, and strengthening trust in the patient-clinician relationship is essential.

    We’re working to enhance compassion and healing in healthcare, and created the International Charter for Human Values in Healthcare, starting with the capacity for compassion. The mission of the International Charter for Human Values in Healthcare is to restore the human dimensions of care – the universal core values that should be present in every healthcare interaction – to healthcare around the world. http://charterforhealthcarevalues.org

    

Your article reminds us how important these values are.

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