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Patient-Centered Care: What It Means And How To Get There



January 24th, 2012

At a recent symposium concerning both saving money and improving patient care, Health Affairs Editor-in Chief Susan Dentzer stated, “It is well established now that one can in fact improve the quality of health care and reduce the costs at the same time.”  This is exactly the principle behind the growing movement toward patient-centered care.  Physicians practicing patient-centered care improve their patients’ clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship, while at the same time decreasing the utilization of diagnostic testing, prescriptions, hospitalizations, and referrals.  Patient-centered practitioners focus on improving different aspects of the patient-physician interaction by employing measurable skills and behaviors. This type of care can be employed by physicians in any specialty, and it is effective across disease types.

Patient-centered care replaces our current physician centered system with one that revolves around the patient.  Effective care is generally defined by or in consultation with patients rather than by physician dependent tools or standards.  As an example, orthopedic surgeons employ the Harris Hip Score to judge the success of total hip replacements.  It was designed solely by physicians and does not even ask patients to rate their satisfaction with the procedure; it answers questions important to doctors and thought to be important to patients; however, it is unknown whether almost any physician derived tools, such as the Harris Hip Score, accurately reflect the patient experience with a hip replacement or other aspects of their medical care.

Determining What Matters To Patients

This tool, like most common measures of outcome, has never been studied to quantify how well it reflects overall patient satisfaction or outcome from the viewpoint of the patient.  I once cared for a young man who required revision of a total hip replacement due to an infection; a revision in this setting requires multiple staged procedures and results in months of repeat hospitalizations, disability, and pain.  When reviewing the previous surgeon’s records, I was surprised by the excellent result that had been scored on the Harris Hip Score. While the score seemed reasonably accurate, it, obviously, in no way correlated with the experience of this patient.  Therefore, one of the basic tenets of patient-centered care is the idea that patients know best how well their health providers are meeting their needs, and it is the patient’s view of his or her health care delivery that correlates with outcome or satisfaction.

This fundamental tenet of patient-centered care was tested by Stewart, et.al. in 2000.  Experts studied audio taped doctor-patient interactions while patients also rated these same interactions.  Expert opinion could not be correlated with positive results, but patient-perceived patient-centered care correlated with “better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals.” This same phenomenon can be seen when studying physician empathy.  Researchers at Thomas Jefferson University developed the Jefferson Scale to test physician empathy.  Physicians rated their own empathy, and the scale could not be correlated with improvements in patient care.  However, researchers then changed it to the Jefferson Scale of Patient’s Perceptions of Physician Empathy and administered it to patients.  Suddenly, the tool was useful for predicting patient outcomes.

Therefore, the first step in understanding patient-centered care is an understanding that patients must be asked to rate or judge their health care; providers often believe that we know everything about our patients and their care, but we are simply unable to accurately assess our patients’ perceptions of their care–what is important to them, how well we are delivering care, what factors in our patient care improve outcomes.  We need to attempt to move from “what’s the matter” with our patients to “what matters” to our patients.

What Patients Want From Their Physicians: A Personal Relationship, Communication, And Empathy

The second fundamental tenet of patient-centered care concerns the relationship between health providers and their patients.  A young well-educated, insured woman recently asked for my help in treating a metastatic lesion of her femur.  Her primary malignancy was lung cancer.  During the course of treatment, she related to me that she had, early on, seen a pulmonologist for her symptoms.  He had performed pulmonary function tests, prescribed inhalers, and told her to return if her symptoms did not improve.  She never went back, and the cancer was later found by her family doctor, by which time it was metastatic.

In such situations, patient advocates tend to blame the doctor for his treatment and inability to diagnose the problem while physicians and their advocates point to the patient’s not following up despite instructions.  However, the underlying problem in this tragic example is the lack of a relationship between the patient and her doctor.  This patient never felt any personal connection with her doctor; from her point of view, the visit was an expensive waste of time, and, therefore, she did not return for further treatment.  This lack of relationship significantly influenced her health decisions in the same way it impacts all patients.

In point of fact, the relationship between a patient and his/her doctor greatly determines both treatment outcomes and a patient’s satisfaction with his/her care.  Any attempt to ignore this relationship when measuring the effects of care is necessarily artificial and results in spurious results.  Patients want a personal relationship with their doctor, good communication and empathySaultz and Lauchner have shown an association between patients who generally see the same doctor and better outcomes, better preventive care and fewer hospitalizations.  Little et.al. demonstrated that a personal relationship between patient and doctor and a feeling of partnership led to patients who were more satisfied, more enabled, and had a lower symptom burden and lower rates of referral.

The power of physician empathy has been demonstrated by Kim, et. al. By studying several hundred patients’ care, they concluded that patient-perceived physician empathy was correlated with a perception of physician expertise, trust, and information exchange, and that such empathy was associated with improved levels of patient satisfaction and compliance. Treatment by empathic and communicative physicians has also been correlated with improved outcomes such as better control of diabetes.  No new expensive oral antiglycemics or new sophisticated monitoring devices are required for this improvement; rather, it appears that when given a better relationship with their care givers, patients responded with better compliance, and, hence, better diabetes control.

Doctors not engaged in patient-centered care often order expensive tests or referrals as a poor substitute for connecting well with their patients. Several studies document higher utilization rates for diagnostic tests, hospitalizations, prescriptions, and referrals among doctors who are poor communicators.  This phenomenon has been explicitly studied in a randomized study of over 500 patients, and patient-centered care correlated with fewer hospitalizations, fewer diagnostic tests and specialty referrals, and lower overall medical costs.

In addition, Charles Vega, in his well named 2010 article, The Satisfied Patient, Overprescribed and Costly, reviews two studies that both show the power of good patient-physician communication.  The first, by Paterniti, et. al. concluded that effective communication “may be used to communicate appropriate care plans, to reduce provision of medically inappropriate services, and to preserve the physician-patient relationship.”  These researchers were looking at strategies to tell patients “no” to inappropriate medicines—a skill very useful in our era of direct-to-patient pharmaceutical marketing.  The second study by Jackson and Kroenke examined 750 patients and concluded:

But tests and prescription medications were not the most common expectations; instead, patients were more interested in information on their diagnosis and prognosis. In fact, failure of physicians to address diagnosis and prognosis was the most common cause of unmet patient expectations, and patients who received adequate information on diagnosis and prognosis experienced better symptom relief and functional outcomes.”

In point of fact, patients most want good communication, and they report reduced symptoms and better outcomes when they receive it.

Finally, Doctors practicing patient-centered care have systems in place to continually measure patient perceptions.  On-line tools are often used and questions are related to patient satisfaction and other care parameters.  Moore and Wasson, in their study, The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship, document improved patient satisfaction and education using a simple on-line tool. It is important to remember that patient-centered care revolves around continually questioning patients to assess their needs and the effectiveness of the care they are receiving.

In summary, patient-centered care is a method of care that relies upon effective communication, empathy, and a feeling of partnership between doctor and patient to improve patient care outcomes and satisfaction, to lessen patient symptoms, and to reduce unnecessary costs.  Doctors are able to help their patients become more compliant with treatment and active in the management of their diseases.  Patients also feel more satisfied with the care that they are receiving.  This is all achieved while reducing the need for expensive prescriptions, testing, referrals, and hospitalizations.  It is a low-tech humanistic approach to medicine with the option of using high tech medicine when necessary, but not as a substitute for the fundamental bond between patient and doctor.  In many ways, it is the cure for what ails our health care system.

Obstacles To Patient-Centered Care

Unfortunately, current reimbursement and physician practice models limit the availability of patient-centered care.  First, primary care physicians are paid relatively poorly per patient encounter; certainly, their reimbursement is in no way correlated to the importance of the relationships and care they give their patients.  This usually drives private practice PCPs to increase their patient volumes, reducing the time they can spend with individual patients, and, thereby, degrading the patient experience.  Hurried and stressed physicians order tests or referrals and prescribe medicines in an attempt to appease and give the illusion of high quality care.

Second, primary care physicians who join multispecialty groups or are employed by hospitals or other entities are prized for the patients that they bring to the enterprise, rather than for the actual care that they give their patients.  Even among the best providers, the quality of actual care such doctors provide is usually secondary to the volume of patients seen and the resulting referrals they generate, lab tests they order, or sophisticated imaging studies they prescribe.  These are the criteria that organizations use to derive the financial benefit that they accrue from employing PCPs and, ultimately, these benchmarks determine primary care salaries. Again, by rewarding higher volume, this payment model incentivizes shorter, less interactive patient-physician, encounters reducing the quality of the patient experience while the institutions are, ironically, financially rewarded by the resulting higher rates of referrals, lab tests, and sophisticated imaging that result from lower quality care.

Third, entities often hire generalists to provide care for patients with goals that run contrary to patient centrism.  A good example of this phenomenon is the growing use of hospitalists.  Hospitalists have no long term relationship with the patients for whom they are caring, and they provide this care during critical times in patients’ lives.  In addition to the fragmentation which hospitalists bring to patient care, one of the reasons hospitals hire them is for the express purpose of reducing patient days per admission.  While this may be a worthy goal, and it is certainly financially beneficial to hospitals, it may or may not improve the care which patients receive, and it is antithetical to patient centrism, which puts patient concerns at its center.  It may in fact be a step not toward patient-centered care from our current physician-centered system, but instead toward a hospital- or health care system-centered approach that puts institutional needs above those of the patients for whom such systems exist.

The Potential Of Accountable Care Organizations To Promote Patient-Centered Care

One increasingly likely answer to the problem of encouraging more patient-centered care is the formation of ACOs.  While there have been, and will continue to be, growing pains in their development, ACOs, by their nature, hold the promise of encouraging patient-centered care and further developing the patient-centered care model.  For this reason alone, Medicare and other insurers should be doing everything possible to push the formation of workable ACOs, and patient advocates should be clamoring for their implementation.  After all, doesn’t every patient deserve empathic, trusted doctors with whom they feel they have a personal relationship, and who are working hard for no reason other than the care of the patient at hand?

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1 Trackback for “Patient-Centered Care: What It Means And How To Get There”

  1. Medical Professionalism - Recommeded Reading | The Medical Professionalism Blog
    February 3rd, 2012 at 10:04 am

5 Responses to “Patient-Centered Care: What It Means And How To Get There”

  1. JP McMenamin Says:

    Well-done.

    The same factors that tend to make it harder to build a therapeutic relationship with patients also tend to increase the risk that, if the outcome is less than perfect, someone will seek his remedy at law. So, anything that helps to improve the doctor-patient relationship ought to be seen in a favorable light by the doctor’s liability insurance carrier. Some carriers’ premium structures reflect steps the insureds take to mitigate risk. Has anyone ever tried to negotiate a better premium on the basis of steps taken in the context of bolstering the MD/pt relationship?

  2. Alex Berland Says:

    Good article, thank you. It is worth noting the dated but still relevant ancestor of modern patient-centered approaches, “Through the patients eyes” Gerteis et al (review http://www.nejm.org/doi/full/10.1056/NEJM199403243301225 ). This book is based on research conducted by the Picker/Commonwealth Program for Patient-Centered Care–including a US survey of over 6,000 hospital patients. I have used this extensively in talking with care providers about what matters to patients and their families.

  3. John Troidl Says:

    This is a terrific article which I plan to share with both my Patient Advocacy students and fellow consultants who work with Community Health Centers in their efforts to become patient centered health homes. I appreciate Dr. Rickert’s concern about agency issues for hospitalists whose job, it would seem, is to streamline the inpatient stay for the purpose of reducing hospital LOS, but my anecdotal experience with two hospitalists who helped take care of my Mother this Fall at El Camino Hospital were just the opposite. The two hospitalists were clearly focused on my Mother’s needs, did a super job of coordinating both inpatient and outpatient services, and provided an unsurpassed level of communication with our family, which is not always easy. :) This personal story is not research, but I did learn from personal experience that hospitalist care CAN work in a patient centered world. Let’s take a further look into this issue because it is so important as we “engineer” the transition to true patient centered care throughout our health care system.

  4. Jean Antonucci Says:

    Actually Brad, as one of the physicians in the Ideal MedicalPraciices study that Jim quotes , the questions we asked were (interestingly) “how confident are you that you know how to manage your care/when t o call?’
    and “do you know who is in charge?”(becasue so many people have multiple docs )
    These answers were huge in connecting to ER use and hospital readmits. I still measure these.When folks can access someone they know in a timely fashion and when they have confidence, we reduce unnecessary ER use and hospital readmits. Jean

  5. Bradley Flansbaum Says:

    James
    Before I cite my exception to your piece, overall, it is well done.

    My issue is with your incredibly broad, and incorrect assertion re: hospitalists. The abstract you link to is dated by hospital medicine standards. Regardless, it demonstrates that hospitalists had a shorter LOS–hardly the last word on why institutions hire them. That would require a far deeper look and a paper qualitative in nature.

    However, positing that hospitalists provide less patient-centered care in the acute setting is a leap, and one you will have to substantiate with data. Please browse SHM’s site: hospitalmedicine.org and get a feel for the tenets of our organization and what we stand for. Project BOOST is but one example, and note the heft, number of locales, and federal, state endorsements associated with this program. Its reasons for being resides in patient focused care– and long before regulatory bodies demanded it.

    Lastly, while I cannot refute the merits of a long-term physician/patient relationship, asking a patient an open ended question such as, “tell me how you feel,” how you want to live the rest of your life,” or “what makes you smile,” requires a decades long contract. Caring and sympathy go a long way–and I must say, a lot of what my colleagues provide, both nationally and locally, may be more comprehensive and informed than what transpires in the community.

    Anyway, thanks for a generally excellent post.

    Brad

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