Sunday, January 23, 2011

How To Make The Patient The Center Of Patient-Centered Care

There is increasing attention being paid to the patient-centered medial home (PCMH) as a way to re-focus medical care on outcomes that matter to patients (such as sick days, hospitalizations, death) and less on surrogate outcomes (such as blood sugar control, cholesterol levels, etc).  The PCMH is also expected to allow physicians (especially primary care physicians) to spend more time with patients--time for counseling, care coordination, discussion and education surrounding medical problems, etc.  At this point, the National Committee for Quality Assurance (NCQA) is the organization that accredits medical practices as fulfilling the principles of the PCMH.  However, a review of their principles shows that in order to qualify as a PMCH a practice must meet a number of expectations, most of which involved new or improved technology (electronic health records, e-prescribing, patient registries and databases, etc).  Although there are other expectations, and the technology expectations themselves have understandable reasons for existence, there is no discrete description of what a patient's experience in a PCMH should be like.

This morning, I saw this article from the American Medical Association's Journal of Ethics Virtual Mentor website.  It is a few years old, and predates the current push for the PCMH, but is worth noting because the principles listed here are key to truly patient-centered care.  If health care providers follow these 10 rules, patients will get better care that is truly focused on their needs--patients will actually be the center of care.

The 10 points are:
  1. Be on time. If you aren’t, apologize. If you know you’ll be late, notify the patient. Doing so tells the patient that you respect his or her time.
  2. Find a way to touch your patient; the simplest way to do this is to shake hands when you enter the exam room. Look the patient in the eye when you shake hands. Maintaining eye contact throughout the visit conveys sincerity and honesty.
  3. Be interested in what your patient is saying—she can tell if you are faking it. Cultivate curiosity about how this patient is different from other patients.
  4. Communicate. Lack of communication is the most common complaint patients have about their physicians. This does not just mean talking—it also means listening. Being an active listener and responding to patients and their families is a vital skill. Effective communication includes explaining tests and diagnoses with patients in plain English.
  5. Learn to appear relaxed and not in a hurry. In situations of illness or crisis an aura of calmness goes a long way. It shows patients that, at the moment, their care is more important to you than the next patient.
  6. Never refer to a patient by a diagnosis. Patients are individuals, not loci or hosts for disease. Do not tolerate others’ use of such terms; such usage reinforces a service-oriented culture and makes the patient-physician relationship less personal.
  7. Convey a sense of warmth. This can’t be done without smiling. Endeavoring sincerely to establish rapport with patients helps put them at ease.
  8. Be mindful of how often you interrupt. Studies have shown that the physician usually interrupts the patient less than 20 seconds into the patient’s side of the dialogue.
  9. The needs of the patient must come first. This means you have to put aside your own prejudices and biases to help the patient. This clinical encounter is for the benefit of the patient—not the physician.
  10. The "platinum rule" of medicine is: treat every patient the way you would want a member of your family treated. A twist on the “golden rule,” it is one of the best ways to be aware of the needs and fears of our patients.
More than just good principles of patient-centered care, these 10 rules are key to effective and successful medical care, period.  They allow physicians and patients to develop therapeutic relationships that will address the patient's health care needs.

Ever since medical school, I have carried with me a list of ten key rules on how a physician should practice--something I have previously blogged about.  The ten rules listed in this Virtual Mentor article will be companions to those first ten.  They will remind me (and the students I teach) of the most important part of patient care: caring for the patient.


Vicky said...

I have 2 questions:

1) If a patient is homeless, can they sleep in the medical home?

2) How did something that started off to address health disparities become about EHR and being able to email your doc?

mark said...

I worry that the transition of patient-centered care to the PCMH parallels the underlying issues with our health care "system" as it exists: focus on high-tech interventions and approaches while losing sight of the personal, "high-touch" face-to-face care that most patients would like.

Shep said...

Hi Mark,

Definitely agree with the focus and push toward a "high-touch", personal doctor visit as a necessity for improving healthcare, and this was certainly a premise for us at ScriptPad (why we focused on mobile devices).

I wanted to propose point 11. for the docs: Work away from the computer terminal as much as possible. And, if you must work there during a patient visit, let the patient know what it is you're doing (even if mundane).

I think this ties into 4. with Communicate, but the fact is technology is only increasing within healthcare and often times doctors these days become "shackled" behind the terminal, away from the patient.

Great blog.