patient centered medicine: enhancing healthcare delivery

Carl Rogers

introduced person-centred approach

• empathy

Michael and Edin Balint

coined the term patient-centered-medicine

• examining the whole person in order to form overall diagnosis

bio-psycho-social model x pearson-centered medicine

encompasses the patient’s experience of disease

What is patient centered communication?

involves focusing on patients psychological needs, values and wishes 

• improved patient trust and satisfaction,

• more appropriate prescribing

• more efficient practice

principles of patient centered medicine

• Respect for patients' values and preferences

• Collaboration and shared decision-making

• Compassion and empathy

• Information sharing and transparency

• Involvement of family and caregivers

medical model

patient: passive, recipient of the treatment

physician: dominates the conversation

care is disease-centered

patient-centered model

patient: active, a partner in the treatment plan

physician: collaborates with patient, listen more 

care is quality of life centered 

→ patient is more likely to adhere to treatment plan 

benefits of patient-centered care

• Improved patient satisfaction.

• Better health outcomes.

• Enhanced adherence to treatment plans.

• Increased trust and confidence in healthcare providers.

strenghts of disease centered model

• simplicity

• predictivity

• clarity of clinical method

• verificability

• teachability

weaknesses of disease centered model

• reductionism 

• dehumanization 

Frequent Deficiencies and Errors in the Doctor-Patient Consultation

• interrupting the patient

• lack of structure of the conversation

• suggestive/closed questions

• not responding to emotional remarks

• unclear and misleading explanations of examination findings, disease diagnoses, and therapeutic recommendations

• vertical communication

Eliciting and prioritizing concerns

1. Ask "Is there something else you're concerned about?" until the patient answers, "No."

2. Prioritize by asking the patient, "Which of these issues would you like to start with today?" and then negotiating a reasonable agenda for the visit

patient centered interviews

• don’t interrupt 

• open-ended questions 

• pause 

• encourage the patient to continue talking 

• pharaprasing 

• summarizing 

• reflect the patients emotions 

defensive medicine

clinical practice aimed at minimizing legal risks rather than optimizing care, is one of the factors maintaining a disease-centered approach

• rigid adherence to guidelines (depersonalization, simplification)

• overprescription of tests or medications (← not enough attention)

patients barriers

• 12% patients have adequate health literacy

• underreporting symptoms or pain (cultural norms)

• power imbalance - patients anxiety (authority of clinicians)

• withholding info due to shame

patients role - communication

• involve family members 

• ask open-ended questions

• request clarification 

• express goals/values/preferences 

• reflect back

environmental barriers

• physical

  • architectural

  • use of computer

  • space

• organizational

  • patient-therapist ratio

  • continuity of clinicians

  • coordination among teams

specific environmental factors

• busy room/lack of privacy

• interruptions (phone)

• time constraints

active listening

• concentrating on the question of what contents are relevant for the patient

• signaling active listening

open-ended questions

providing space and signaling interest in patients point of view

pause

• lowers the inhibition threshold for speaking about psychosocial matters

• may express thoughts he/she had hesitated to address

• may mention something he/she has forgotten 

echoing

individual words are taken up and repeated literally

→ to encourage further speaking

transparency of content

provide information about the treatment steps that you have planned for this appointment and the necessary technical information

transparency of the environment 

point out potential difficulties and timeline of the interview 

transparency of interview phases

• make it clear if you expect from your patient long explanations or short answers

• indicate transitions between a patient-centered and a doctor-centered interview

• announce the end of the interview well in advance

four elements of interruption

• direct interruption

• summarizing

• repeat interview goal

• obtain agreement

shared decision making

• respect for patient autonomy

• information sharing

• informed consent

• collaboration

process of shared decision-making 

• identify the issue

• provide information (about treatment) 

• discuss preferences

• explore pros and cons 

• make the decision (together) 

barrier to shared decision-making

• time constraints

• lack of necessary skills

• hierarchical traditions (culture)

breaking through the barriers

• training and education for healthcare providers

• development of tools and resources

• changes in healthcare policies

evidence about cost savings and reductions in service use related to person-centred care activities

• better informed patients: choosing less invasive less expensive treatments 

• managing your own health → less likely to use emergency services 

• sticking with the treatment (shared decision making) 

• life style changes