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Practical Approach to Patient-Centered Medicine. Reid B. Blackwelder , M.D. President, AAFP blackwel@etsu.edu. Goals. Remember Why You Went into Medicine! Describe Patient-Centered Care Challenge you to become and remain Patient-Centered Review Patient-Centered Communication
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Practical Approach to Patient-Centered Medicine Reid B. Blackwelder, M.D. President, AAFP blackwel@etsu.edu
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 “Hisor “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 Life skills! Little things are not little. They are not specialty specific! Engage completely! Be present 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?
