Transcript you
Practical Approach to Patient-Centered Medicine
Reid B. Blackwelder, M.D.
President, AAFP [email protected]
Goals
• Remember Why You Went into Medicine!
• Describe Patient-Centered Care • Challenge you to become and remain Patient Centered • Review Patient-Centered Communication • Emphasize Patient-Centered EBM • Implement (or Prevent) Attitude Shifts • Give you hope!
● • Medical care is mainly Physician Centered – Still in many ways despite transformation • Access is on our terms – Where we are – When we are open – Who (or what) you can talk with – When you can be seen “Health Care System” (sic)
Physician
-Centered Care
• Medical Care – What we provide – services, call, hospital –
Our
rules for visits, medications, CAM, etc.
–
Our
rules for loss of access to us • Oversight Exists – By very non-patient centered regulators – State, Federal, Medicare, Insurance – And Medical School (and Residency)!
Physician
-Centered Care
• Taking “The History” – Much less personal connection with our patients – Emphasis on only certain aspects of information which we call the history • Social Hx: ??
• Tobacco, alcohol, drugs… – Lists and templates
The Patient History
• Semantics – It is called “His or “Her” story for a reason.
• But we have lost the emphasis on obtaining stories – Instead we check boxes on templates.
– One of the dangers of EHR!
– Or you don’t even write notes!
The Patient History
• How much time do we allow patients to tell their story before we interrupt and take control?
– 15 seconds!
– This shift is due to time pressure • Fee for service/pay for volume – Significant oversight of our documentation ● For billing, NOT for patient care
The Patient Interview
• Many purposes • Important info about the medical issues • Must learn and explore our patient’s health care philosophies • Generating and maintaining rapport • Creating a relationship – Immediate – Long-term
Physician
-Centered Care
• We also have de-emphasized our physical exams, instead… • Emphasizing labs and studies • We have definitely moved toward high tech and low touch • Our entire relationship has changed
Current Reality
• Poor outcomes • Poor patient satisfaction • Poor provider satisfaction • High cost • Partisan politics preventing change
The Physician of “Now
” • Must be patient-centered • Must focus on Health!
• Must be relationship-based • Must be team-based • Must balance technology with compassion • Starts with personal choices
Reframe!
• Create more Patient-centered processes – In your practice – In your style • We will review a few of these • This is an “Art” class – We will consider your choice of media, color, technique – Time to create masterpieces!
Changing the Environment
• Sacred Space • Personal Power and Symbols • Internal Environment
Nurturing Environment
• Surround yourself with – Meaningful relationships • As best you can at work • And at home – Meaningful “Stuff” • Photos • Candles, fountains, icons • Minimize stressful images – “Humor”
Personal “Power”
• What kind of image are you presenting?
– How is it working for you? – How will it work for your patients?
• Everything carries potential meaning
Personal Powerful Symbols
• Tools of the trade – Coats – Stethoscopes – Smart phones – Computers/tablets • Clothes • Jewelry and decorations • Spiritual icons • Colors
Be Attentive to…
• Your affect – Perspective is key – Half-empty or half-full?
– Impacts your life path tremendously • Impacts patient care tremendously – Become confident in your role – Knowing your boundaries – Enjoy caring for your patients!
– They can tell your mood!
Half-Full Warning!
• Remember you always have a choice • Today is yours for a reason • The “challenges” you face can be seen as – Your teachers of the moment • You chose this profession to help people – They are rarely at their best when they need it the most • Laugh regularly and easily
Healing Effects (Placebo)
• All treatments can have a specific effect • All treatments have some healing effect • All
encounters
have potential effect • Good bedside manner!
• Starts with communication skills
Basic Communication Skills
• Rapport • Facilitation • Agenda setting • Information management • Active listening • Negotiating common ground
Basic Communication Skills
• These are such important clinical skills!
– Actually • Be present
Life
skills!
– Little things are not little.
• They are not specialty specific!
• Engage completely!
• Trick for focusing on each patient
Rapport
• First impression of office • First impression of your staff • First impression of you • How do you start your interview?
Scenario
• You have a new patient in your office, the nurse has written “Chest pain” as the chief complaint • Patient looks fine • What do you ask first?
– How are you?
– What can I do for you, or variant?
– How long have you had the chest pain?
– Other closed ended questions.
Instead:
• “Tell me about your chest pain.” • “Tell me more.” • “Anything else?” • Amazing how much info you get!
• Early use of close-ended questions – Shuts your patient up – Requires you to guess right!
– Takes more time!
Agenda Setting
• Clarify agenda – Yours – The patient’s • Must put into the context of the time you have available • Limitations are real and more controllable than one may think
Agenda Setting
• Clear agenda setting clarifies the common ground that needs to be negotiated.
• Be prepared for surprises anyway… – “By the way…”
And, the “Biggie”
• Recognize and respond to emotion!
– Without becoming defensive – Or Angry – Or clicking into didactic mode • Information does not overcome emotion!
• You are not required to “fix” anything – And you can’t fix anything!
• Emotion is okay and real and needs validation, not fixing
Handling Emotion
• Recognize it and state it – “You are…” angry/frustrated/sad/whatever – Trust your intuition as to what it is • Just listen • Try not to say “I understand.” • Or “Don’t be…” • Be okay with saying “I’m sorry you have to deal with this.
”
What a bunch of Hooha!
• Is any of this actually supported by evidence?
• We are challenged to practice EBM • We are also expected to have some common sense!
– Good bedside manner seems like a good idea!
• But, let’s look briefly at EBM…
Levels of Evidence
• Type Ia – Meta-analyses of RCTs – Accepted as strongest level of EBM • Type IV – Expert opinion – Considered the weakest level – JNC VII(I) and Hypertension protocols…
Levels of Evidence
• Even stronger… –Level 0 –What you believe that others don’t!
• Even weaker –Level V –What others believe that you don’t!
EMB Caveat
• EBM helpful, but… • Statisticians try to remove variable of the individual response • Practitioners are focusing on the individual response • “The Average Patient” is a statistical entity that does not exist
Patient-Centered Reframe
• “I don’t have a treatment for metastatic breast cancer… • …but I have lots of things I can do for you ” • “I don’t treat cholesterol… • …I treat patients!”
EBM for New Model
• A patient-centered interview improves health outcomes!
• Team-based care improves outcomes • Patient-centered medical homes – Change how care is delivered – Change how care is paid for • Challenge medical schools to
serve
: – Meet their social responsibility
Truths and Goals
• For better outcomes patients need: – Health Insurance coverage – Routine source of comprehensive continuous care – They need a relationship!
• Right Care – in Right place – from Right person – at Right time
Make This Practical
• What will you do different?
• How will you become patient centered?
Make This Practical
• First and Foremost – Remember that you Love What You Do!
– Answering the call to serve • Nurture yourself – role model that love – Nurturing, sacred environment for you – Creates one for your patients • Your actions and affect speak louder than words!
Make This Practical
• Consider your communication style – Learn patient centered techniques – Use them!
• Exercise caution with how you use and explore EBM – Much is disease, not patient oriented • Who is your team?
• How will you keep your heart in your art of medicine?