This is the first in a series of discussions intended for primary care physicians and physicians in training regarding the principles of the Patient Centered Medical Home, this one on Patient Centeredness. Though specific for medical practice, this series may be of interest to anyone curious about how care can and should be delivered.
Isn’t every doctor’s office “patient centered”? If you are a doctor, you are spending money on a waiting room…those chairs are for patients (because for the most part no one else would sit there). In your exam rooms the exam tables are in the center of the room. You can’t help but look directly at the patient for the time you are together. What could be more patient centered?
Patient centeredness demands more of the care team than perceived efficiency. There are long lists available defining it in gory detail. These lists identify the need to consider cultural traditions, patient preferences, and personal situations.These lists tend to run to the long and obvious.
The former director of CMS, Don Berwick, describes a emergency department visit he made with a friend who was about to have a heart cath. He requested permission to be in the procedure room, as a friend instead of as a doctor. Following is his account of the encounter:
The nurse didn’t agree. “Do you want to be there as a friend or as a doctor?” she asked.
“I guess both,” I replied. “I am both.”
“It’s not possible.We have a policy against that,” she said.
The young procedural cardiologist appeared shortly afterward. “I understand you want to have your friend in the procedure room,” she said. “Why?”
“Because I’d feel so much more comfortable, and, later on, he can explain things to me if I have questions,” said my friend.
“I’m sorry,” said the cardiologist, “I am just not comfortable with that.We don’t do that here. It doesn’t work.”
“Have you ever tried it?” I asked.
“No,” she said.
“Then how do you know it doesn’t work?” I asked.
“It’s just not possible,” she answered. “I am sorry if that upsets you.”
Moments later, my friend was wheeled away, shaking in fear and sobbing.
He goes on to define patient centered care in three sentences. These are:
(1) “The needs of the patient come first.”
(2) “Nothing about me without me.”
(3) “Every patient is the only patient.”
How does one operationalize this in a medical practice?Looking at the evidence, here is a good start
- Meet the patient’s expectations. If the patient wants to discuss his or her toe fungus, you had better make it a point to not only have that discussion but have a plan of action for the fungus.
- Communication is the key. The doctor or care provider must take the patient’s problem seriously and explain the condition clearly. If the patient’s life situation (Doc, I can’t afford that medicine) plays a part in the therapeutic decision making, make sure you take it into account.
- The patient is always in control. They choose whether or not to put pill in their mouth anyway so you might as well ask if they plan to do so up front and if they do not negotiate an alternative.
- Patients want to be included in decision making. Decision making not only takes into account physical needs but emotional and spiritual needs as well.
- Spend time with patients. The average doctor- patient interaction is 12 minutes. Letting the patient say what he or she wants only adds an average of 30 seconds to that time , which is then made up by fewer phone calls from the patient. Admittedly, there are some who will abuse this. For those, see below.
- Technical skill is assumed. Don’t do anything to reflect badly on yours
- Appearance isn’t what you think. Patients prefer in order of preference: “semi-formal” attire with a smile; “semi-formal” attire without a smile; a white coat; a formal suit; jeans and casual dress.
- The doctor is a part of a team. Pay attention to your staff. Train them. Give them responsibilities that are commensurate with their abilities. A patient comes to an office for the whole experience.
- Facilitate your patients use of the health care system. They expect it of you.
- Continuity of care is important. Once people see the same doctor over a two year period, their satisfaction with the entire care team goes up.
So, Doctor, you say, “Perkins is an idiot. If I do all this I will never get out of the office.” Here are a couple of tricks that the evidence shows will help you to get out of the office on time:
- Orient the patient – Make sure that the team is on the same page and the the patient is brought along as well. “The doctor will want to deal with your blood pressure today; is there anything else you are going to want to discuss?”
- Be mindful of the schedule – Nothing ticks off staff and patients alike more than a doctor (or other provider) who spends 30 minutes apiece with patients 1 and 2 then rushes through 3-15 to catch up.
- Make a list – Encourage patients to make a list them work on prioritization
- Make sure the patient is able to tell his or her own story – We are terrible at interrupting to ask clarifying questions before the full story is out. A little time on the front end will save time on the back end.
- Ask clarifying questions only after the patients story is told – See above
- Pay attention to body language – If the patient seems to not be satisfied, call his or her attention to it. On the other hand, if time is pressing, follow-up is better than cutting off. “I don’t feel like I’ve dealt with your fatigue as fully as I need to. Tell you what, let’s do some labs and have you do a symptom diary for the next two weeks then when you come back we can discuss it in more detail.”
- Confirm what is important to the patient – By restating what is important you will assure the patient that their concerns are paramount: “So, what I’m hearing is this chest pain is not as important as the toe fungus” you can often get buy-in for the rest of the treatment plan.
- Seek confirmation and commitment – By using statements like “we will take care of this” you assure the patient that their priorities are also your priorities.
By improving patient centeredness, a practice will improve patient satisfaction, have more folks using the practice for comprehensive care, and have fewer patients looking for alternatives as care delivery changes.