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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 PatientCentered • 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 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?