CPC Corner
The Heart of Permanente Culture
By Patricia K Fahy, MD, Ilene K Kasper, MS, Andrew M Lum, MD

Introduction

The many interrelated forms of patient advocacy--excellent medical care, smooth transitions in an integrated health care model, responsible stewardship of patients' resources, empathetic care--define Permanente Medicine and constitute a core value, even the heart, of our organization. The heart of Permanente Medicine thus resides in the professional and interpersonal transactions that occur in the examination room and at the patient's bedside.

Emerging From a Difficult Decade

The mid-1990s was a time when growth was the supreme goal. It was a time when health care planners were concerned with network model management, consultant-assisted "redesign," and bewildering competition. It was a time of HMO-bashing among the public, dissatisfaction among our office staff, and aggressive consumerism. Navigating that difficult terrain, the KP Colorado Region became unsure of its footing. The patient advocacy road became a path of increasing resistance: patients needed tenacious assistance with navigation through unfriendly systems staffed by discouraged personnel. Often, this assistance could be provided only on the imaginary margins of a physician's chaotic workday.

The KP Colorado Region with its Colorado Permanente Medical Group (CPMG) is reconfirming patient advocacy as a core organizational value. A crucially linked value is the importance of satisfying worklives for physicians. We are just beginning a journey to better understand, support, and enhance the careers of our physicians. This article reviews some elements of the cultural rejuvenation underway within CPMG and focuses on the Clinician-Patient Communication (CPC) training being given special attention as part of that rejuvenation.

CPMG Culture: Developing Better CPC

In 1999, Executive Medical Director-Elect Jack Cochran, MD, launched his term of office with a three-month facility tour, during which he met with all members of CPMG in small groups of two to six physicians. During this tour, Dr Cochran found morale to be "akin to the aftermath of the Yellowstone fire." As a result of the tour, DR Cochran developed his primary areas of concern, which have subsequently been dubbed "The Three Constants" (see Sidebar, The Three Constants). These areas focus on physician career development, patient advocacy, and improved systems and innovation in delivering care to our Health Plan members.

As one of the first initiatives dedicated to improving patient advocacy and physician careers, we developed a comprehensive approach to CPC. Acknowledging the essential roles of both the examination room interaction and the physician-patient relationship led to creation and implementation of a three-pronged CPC program.

Physician-Patient Interaction (PPI) Course
This eight-hour physician-patient interaction (PPI) course is based on the Four Habits Model¹ of patient interviewing and is offered to all new physicians joining CPMG. The course is offered as part of the initial orientation for new CPMG physicians and is also available to any other physician who might benefit. Offered in two four-hour segments, the course briefly outlines relevant literature on clinician communication, presents an in-depth review of the Four Habits Model, and spends approximately half the time conducting discussions and building skills with the participation of "typical" patients (portrayed by actors).

	The Three Constants:
	Preservation and enhancement of career Optimizing the medical care experience for patients Streamlining the process of delivering care

Video Vignettes
Six brief videos starring familiar CPMG personalities are used as a basis for discussing effective and not-so-effective techniques for communication with patients in the examination room. Unlike the PPI course, which uses a classroom format, the video vignettes are designed to spark conversation among members of a department. After providing a brief introduction to the Four Habits Model, the videos serve to stimulate problem solving and unearthing "best practices" among physicians within a department. Usually three, one-and-a-half- hour sessions are conducted at departmental or noon meetings and are facilitated by an Associate Medical Director or other physician along with a training specialist.

Direct Observation Tutorial
This direct observation tutorial (DOT) format offers more focused assessment and coaching of an individual physician's communication style and content in the examination room. A trained observer (who is a physician) monitors the physician in the examination room for a half-day session and provides structured feedback in the context of the Four Habits Model. A written report is provided to the observed physician in a follow-up meeting after the observation session has concluded.

Findings About CPC
Several findings emerged from implementation of the educational CPC programs:

Broad Implications for Permanente Practice and Culture

Although efforts to enhance CPC occupy a well-circumscribed, three-pronged training niche, these efforts actually have broad implications for reinforcing five important CPMG values:

Patient advocacy is the most obvious core value enhanced by CPC. We know that patients are more satisfied with their medical care when their physicians use certain communication approaches.

A segment of the PPI course focuses on developing more integrated, collegial relationships between primary care and specialty care practitioners. In this segment of the course, facilitators lead a discussion on how to positively shape expectations held by patients who are being referred to specialty care (and back to primary care). In addition, the specialty mix of physicians within the PPI class enhances relationships among CPMG physicians.

Improving physicians' careers is an explicit goal of all of our CPC courses. In this era of consumer-driven health care, physicians face enormous pressure to care for a full panel of patients (including an increasing population of patients served by Medicare), to integrate an overload of new products and literature, to navigate intermittent labor unrest among staff, and to accommodate many other demands. Studies² show that physicians who are able to incorporate specific techniques in their patient interview are more satisfied at the end of their day (and incur fewer lawsuits brought by dissatisfied patients). Although these communication approaches do not provide a comprehensive answer to workload issues for physicians, improved CPC is one component that may help.

The Permanente emphasis on delivering a consistently high quality of care is supported by an increasing number of articles in the medical literature showing that use of "patient-centered" interview techniques in the clinical setting improves adherence to treatment regimens and improves medical outcomes.¹ Moreover, quality of care is enhanced by use of the electronic medical record (EMR): during the PPI and video vignette sessions, specific communication strategies for using computers in the examination room are discussed (see Sidebar, Three Guidelines for Using Computer Information Systems).

Throughout the KP Regions, high value is placed on physician leadership in delivering medical care to our patients. Supporting the "In the Hands of Doctors" expectation held by our patients as well as by our organization is a common thread of all physician training within CPMG.

Conclusion

Training in effective CPC skills is one of many efforts within CPMG to transform our organizational culture to a fully engaged, well-integrated, dynamic, and stimulating environment for physicians and their staff in caring for patients. This key role of effective CPC in our culture is reinforced by the fact that two Associate Medical Directors are the primary facilitators and sponsors of the CPC programs. And because patient advocacy is the core value of Permanente Medicine, we believe that our CPC programs help support the heart of Permanente culture.

References

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