The following
are excerpts from recent dialogues with members of Kaiser Permanente's
Interregional Clinician-Patient Communication Leadership Group and The
Permanente Medical Group's (TPMG) Communication Consultants. The focus
is the foundation of patient-centered care experience--effective clinician-patient
communication in the exam room. I believe our readers will find this
dialogue instructive as the participants suggest approaches that are
possible despite the limited time we have during office visits. --Lee
Jacobs, MD
Patient-Centered
Care in the Exam Room--Do we really have the time?
Lee
Jacobs, MD: Let's open by confronting the tension that our physician
readers may sense--Do I really have time to make this happen? Help us
out, panel: How can Permanente clinicians get any more patient-centered
than they are already, considering all the tasks that need to get done
in a brief interaction? Isn't being more "patient centered"
an unrealistic expectation?
Meg
Graue: Patient-centered care truly acknowledges the patient as an
individual. Because this is a real challenge for physicians when they're
seeing so many patients each day, it is important that they make a connection
quickly, acknowledge the patient as a person, and then commit to work
with them at their individual pace. The belief by the patient that they
are important to the physician, and not just one person among many on
an assembly line, is essential to providing care that is patient centered.
Terry
Stein, MD: I think there are enormous pressures on clinicians to
accomplish more and more in less time. So promoting a greater degree
of patient-centered care can feel like another imposition. The irony
is that using patient-centered approaches can relieve some of the pressures.
Dr
Jacobs: We're all interested in any approaches that might actually diminish
the pressure on the clinician. Tell us more, Dr Stein.
Dr
Stein: When we are on the "hamster wheel" seeing lots
of patients, we put out a lot and get depleted ourselves. Having a sense
of connection with our patients by noticing and acknowledging their
emotions sustains us, reduces conflict, and makes practice more fun.
I hear this over and over again from clinicians--even surgeons--who
change to a more patient-centered approach. Also, when we share some
control about decision making with our patients, we carry a lighter
burden.
Defining
Approaches to Patient-Centered Care
Dr
Jacobs: Helpful insight, Dr Stein. Realizing that both patient
and clinician benefit, let's identify some approaches available to the
clinician. Could you describe what patient-centered care might look
like in the exam room?
Ann
Eastman, MD: What it comes down to is being with the patient and
taking into consideration the whole human being.
Ilene
Kasper, MS: The specific skill that helps the physician acknowledge
the patient as an individual is empathy. Empathy is both an understanding
and an acknowledgment of the patient as a person as well as listening
to what the patient has to say.
Vivian
Nagy, PhD: Patient-centered care is care from the patient's perspective,
whether provided by primary or specialty care, outpatient or inpatient.
Patient-centered care covers not only communication between patients
and clinicians but also various aspects of the care experience.
Ms
Graue: To provide care that is patient centered, we must discover
what the patient expects and then make certain that the physicians'
and the patients' expectations are aligned. That is foundational for
patient-centered care.
Scott
Abramson, MD: Less doctor talk, more doctor listen.
Ms
Kasper: Perhaps a key component of patient-centered care is how
decisions are made. Patient-centered care focuses on what patients perceive
their needs to be, what their preferences for treatment are, and what
they are or are not willing to do. Good patient-centered care is really
a partnership between the clinician and the patient.
Importance
of Patient Participation in the Treatment Decision
Dr
Jacobs: Good point, Ilene. Providing patients with treatment options
and then supporting them in making decisions is essential if patients
are to be involved in their own care. In a recent JAMA article,1
David Mechanic chronicled the increasing level of patients' knowledge
about disease, since 1957, and the level to which patients today want
to be involved in selecting their treatment. Do you agree with his assessment?
Ms
Kasper: Yes. If physicians can appropriately inform patients of
treatment options, using evidence-based medicine when available, the
patient is in a better position to make a decision s/he will actually
follow.
Ms
Graue: We know that involving patients in decisions improves their
satisfaction as well as the outcomes. This is not surprising, because
by acknowledging and involving the patient, the treatment intervention
is more likely to be successful.
Dr
Stein: I don't think we have figured out how to truly engage in
shared decision making, especially around complicated decisions, in
a 10- or 15-minute office visit. What we can do is find out the patient's
perspective and use collaborative instead of directive language when
we talk about the treatment plan.
Dr
Nagy: This is especially true in lifestyle changes, such as smoking
cessation and weight loss. Interventions that involve consideration
for patients' feelings about what might be especially difficult for
them, and what they might be able to achieve as a first step, is more
likely to lead to changes in behavior.
Michele
Knox, MD: It never ceases to amaze me when I talk with a patient
about going ahead with a particular surgical procedure, my assumption
about what the patient would choose often ends up being wrong.
Ms
Graue: So much can be learned from the patient by simply saying,
"I've got some ideas about what's going on, but I'd really like
to know what you think." I'm amazed when I observe visits, and
patients respond, "Oh really? You want to know what I think?"
We all know that if the patient doesn't agree with your approach, then
we shouldn't expect a high rate of adherence.
Dr
Nagy: It is important. Patients also have some ideas of what the
problem or illness could be and may have some unfounded fears based
on these theories. If the doctor doesn't address those fears, the patient
leaves still feeling troubled. The extent to which the physician brings
out these fears will add to the overall quality of the outcome.
Other
Suggestions for the Clinician
Dr
Jacobs: In addition to empathy and involving the patient in the decision-making
process, does anyone have any other suggestions to help clinicians quickly
develop a bond with patients remembering that we have limited time in
the exam room?
Ms
Graue: We encourage the physicians to get more specific about acknowledging
where the patient is at the moment. It is very effective when the physician
walks into the room and says, "It looks like you're in a lot of
pain right now" or "It sounds like a really scary experience."
To acknowledge where the patient is right now emotionally and physically
confirms that the clinician is aware of the patient's particular discomfort
or worry. When I observe the reaction of patients when physicians say
this, I can see the connection being made. The patient's viewpoint is
"You get it, you see me."
Ms
Kasper: To emphasize the value of investing in the beginning of
the interview, we encourage physicians to make one nonmedical statement
to the patient. If it's something that you know about them from a previous
visit, referring to it can help establish rapport. Something like, "I
remember you were going to your daughter's wedding in Hawaii."
Then, right up front, as Ms Nagy said, check in with how the symptom
or illness is affecting the patient's life and what worries the patient
most.
Dr
Nagy: Sometimes within the context of empathy or being in the moment,
what the patient may be expressing to us could be more than just a symptom.
It could be an important value they have. It could be an idea they have
about their illness, or it could be a belief they have. Unless we really
unearth those things by listening well, we haven't really made a good
connection with our patients.
Ms
Graue: I tell clinicians that once a relationship has been built
with the patient, it's time to listen. For many people, when the day
is running so fast, it's really difficult to sit back and allow the
patient to share without interruption.
Can
Physicians Actually Learn New Approaches?
Dr
Jacobs: As trainers, you have experienced clinicians who try these new
approaches and feel awkward. In your experience, can clinicians pick
up these skills?
Dr
Stein: Absolutely. After our training programs, I hear back from
people about what they are doing differently and how even simple changes
enrich their practice. And I just read a study documenting that physicians
who have been in practice for 20 years are able to improve their skills.
Ms
Graue: I agree. We teach these approaches on a regular basis as
part of our workshops based on the Four Habits model of clinician-patient
communication. Clinicians do acquire new skills.
Ms
Kasper: I've learned that physicians respond very positively to
these educational programs--especially to the scripting. When clinicians
try new ways of saying things and see that it works, they are more likely
to adopt the approach into their practice.
Dr
Jacobs: I want to thank the panel for an excellent discussion. I especially
appreciate your reminder that despite the time crunch we are all under,
basic communication skills in the exam room are the foundation for creating
an environment of patient-centered care. Patients as well as clinicians
can feel better about the experience. Your emphasis on the importance
of involving our patients in treatment options, a skill arena now being
referred to as "shared decision making," seems to be the most
important new skill for us to acquire as we strive to provide care that
is truly patient centered.
Again,
I want to thank all of our panel members for participating today.
Reference
- Mechanic
D. Physician discontent: challenges and opportunities. JAMA 2003 Aug
20;290(7):941-6.
