We hear so much these days about “Patient Centered Care” but what does it really mean? Throughout written and even prehistory there have been therapeutic relationships between a patient and a health care provider (such as a shaman, curandero, complementary therapy provider, health care extender or physician). The basis for this relationship is the patient, who chooses to go to the provider for help, and the provider who willingly engages to provide knowledge and skills to achieve benefit. They establish mutually a unique relationship that transcends usual conventions and social mores. The patient shares his or hers deepest thoughts and feelings that might never be said to others, permits a very personal physical examination, and trusts the provider to administer expensive, sometimes painful and occasionally risky procedures. The provider in turn takes in all this information discretely and in confidence, serves as an advocate and advisor, and forever commits to the patient’s health and well being until such time as termination of the relationship, be it by death, moving away or dissatisfaction in the care.
Traditionally, at least in physician care this association has implied a hierarchy in the relationship where the physician allegedly has the power to make the clinical decisions, and the patient willfully accepts. In recent years and particularly in Western societies, this approach has fallen into disfavor, because it minimizes the role of the patient in the decision making. Important decisions that require patient input is choosing the advanced directive, deciding whether or not to undergo a major surgical procedure that the provider may think essential, or to make choices among many medications and procedures given their benefits and risks, and even to refuse them.
It’s not surprising that when patient and providers have strongly differing views, good communication between the two is needed in order to negotiate a mutually desirable response. I believe the best way to do this is to reduce the power differential between the two while maintaining mutual trust and confidence in the other’s role: the provider as the knowledgeable partner who offers ideas and recommendations and the patient who gathers this information and makes an informed decision. When a patient chooses not to take a medication, such as an antidepressant for pain, because of a fear of it leading to addiction or of altering the mind, I do my best to provide the scientific information to the contrary and the rationale for its use as a central nervous system pain modulator. If the patient still refuses, I have to respect that and consider other options to meet the patient’s interests. I also recall how difficult it was for me to withhold blood transfusions from an anemic patient with intestinal bleeding and who couldn’t accept transfusions for religious reasons so we looked at other options.. Conversely, the patient has the obligation to keep an open mind and listen to the provider’s explanations for any particular guidance. It goes both ways
The term Patient Centered Care went on the map in 2001 when the Institute of Medicine issued an important report, “Crossing the Quality Chasm: A New Health System for the 21st Century.” They stated that the health care system is deficient in meeting the needs of Americans and there is not just as a gap but a chasm between what exists and could exist. To improve on this, one important directive was to provide patient-centered care. This is care that is be respectful and responsive to patient preferences and needs, with the patient’s values guiding clinical decisions.
Some of the guidelines include:
- Care is based on continuous healing relationships
- Care is customized according to patient needs and values
- The patient is the source of control
- Knowledge is shared and information flows freely
- The (patient’s) needs are anticipated
This document has served as a template for later attempts to improve healthcare, and is essential when working with patients having complex functional GI Disorders (FGIDs). Unlike making simple and mutually agreeable decisions to take out an inflamed gall bladder, or a resectable tumor, patients with FGIDs may have several symptoms, impaired quality of life and work limitations that can’t be understood by x-ray or endoscopy; it requires active patient participation and decision making. Pain, bloating, nausea are examples of highly individualized experiences with possibly multiple determinants biopsychosocial determinants. Patients have the obligation to provide their total experience of illness both physical and psychosocial, and the provider must actively listen without judgment, offer information in the best interests of the patient’s needs and then work together toward the optimal solutions. In our increasingly compromised health care system, I believe this is one important solution to improving patient and physician satisfaction and reducing health care costs.
Dr. Douglas A,. Drossman
For further information on educational programs to teach patient centered care go to www.drossmancare.com
For information about Dr. Drossman’s patient practice go to www.drossmangastroenterology.com