The Value of Patient Centered Care
Transitioning from a system centered on physicians
Patient Centered Care
Far from being a set of vague platitudes or ideals, patient centered care is a group of measurable skills and a set of behaviors that physicians can employ to increase both their patients' satisfaction and their clinical outcomes. It is effective across disease types and can be employed by physicians working in any specialty. Physicians practicing patient centered care improve their patients' clinical outcomes and satisfaction rates by improving the quality of the doctor-patient relationship; utilization rates for expensive tests and procedures typically decline while outcomes improve with this type of care.
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. For 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 very important for any measurement tools, such as the Harris Hip Score, to be developed with substantial patient input to ensure that they accurately reflect the patient experience with a hip replacement or any other aspect of their medical care. 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 only the patient's view of his or her health care providers correlates with outcome or satisfaction.
This fundamental tenet of patient centered care was tested by Stewart, et.al. in 2000. Experts studied video taped doctor-patient interactions while patients also rated these same interactions. Expert opinion meant nothing, 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; physicians 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 the patient to "what matters" to the patient.
The second fundamental tenet of patient centered care concerns the relationship between health providers and their patients. In fact, the relationship between a patient and his/her doctor greatly determines both patient reported 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 empathy. Saultz and Lauchner have shown an association between patients who generally see the same doctor and better outcomes, better preventive care and fewer hospitalizations. The power of physician empathy has been demonstrated by Kim, et. al. (subscription needed to read full article). 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 physicians has also been correlated with improved outcomes such as better control of diabetes. One must surmise that when care givers communicate empathy, patients respond by working harder toward better compliance. I can't think of any field of medicine where this is not immensely important.
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, prescriptions, and referrals among doctors who are poor communicators. In addition to those studies linked above, Charles Vega, in his well named 2010 article, The Satisfied Patient, Overprescribed and Costly, reviews 2 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. The second study by Jackson and Kroenke studied 750 patients regarding their care 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 want good communication. In this study, patients felt their physicians were failing when they were not given adequate information, and effective communication led to reduced symptoms and better outcomes.
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. Please look at the chart below taken from Moore and Wasson. Not only can one see some of the metrics being studied, one can also visualize the power of patient centered care.
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. For 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 very important for any measurement tools, such as the Harris Hip Score, to be developed with substantial patient input to ensure that they accurately reflect the patient experience with a hip replacement or any other aspect of their medical care. 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 only the patient's view of his or her health care providers correlates with outcome or satisfaction.
This fundamental tenet of patient centered care was tested by Stewart, et.al. in 2000. Experts studied video taped doctor-patient interactions while patients also rated these same interactions. Expert opinion meant nothing, 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; physicians 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 the patient to "what matters" to the patient.
The second fundamental tenet of patient centered care concerns the relationship between health providers and their patients. In fact, the relationship between a patient and his/her doctor greatly determines both patient reported 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 empathy. Saultz and Lauchner have shown an association between patients who generally see the same doctor and better outcomes, better preventive care and fewer hospitalizations. The power of physician empathy has been demonstrated by Kim, et. al. (subscription needed to read full article). 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 physicians has also been correlated with improved outcomes such as better control of diabetes. One must surmise that when care givers communicate empathy, patients respond by working harder toward better compliance. I can't think of any field of medicine where this is not immensely important.
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, prescriptions, and referrals among doctors who are poor communicators. In addition to those studies linked above, Charles Vega, in his well named 2010 article, The Satisfied Patient, Overprescribed and Costly, reviews 2 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. The second study by Jackson and Kroenke studied 750 patients regarding their care 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 want good communication. In this study, patients felt their physicians were failing when they were not given adequate information, and effective communication led to reduced symptoms and better outcomes.
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. Please look at the chart below taken from Moore and Wasson. Not only can one see some of the metrics being studied, one can also visualize the power of patient centered care.
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 and to lessen patient symptoms. Doctors are able to help their patients become more compliant with treatment and active in the management of their diseases. This is all achieved while also reducing the need for expensive prescriptions, testing and hospitalizations. It is a low-tech humanistic approach to medicine with the option of using high tech medicines, testing, and procedures when necessary, but not as a substitute for the fundamental bond between patient and doctor. In this world of corporate medicine where physicians are judged and paid by their daily patient volumes, communication and empathy are often peripheral to care or even frowned upon if their use requires too much physician time. This is quite disturbing since communication and personal relationships with patients are proven to be among the most effective care techniques that doctors can employ. Reduced patient volumes allow more quality time with patients and improves the effectiveness of care and reduces unnecessary expenses. Unfortunately, almost all current payment models reward non-patient centered care, and, therefore, it is not yet the standard of care that patients can expect when they walk into any physician's office. We must advocate aggressively for reimbursement changes that improve access to this type of satisfying and effective care.