Patient-Centered Communication:A Clinically Useful Review

Obesity: The Doctor-Patient ConversationBaltimore City Medical SocietyZackary Berger, MD, PhDJohns Hopkins School of MedicineDivision of General Internal Medicine; Berman Institute of Bioethicshttp://talkingtoyourdoctor.org

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IT’S ESSENTIALIT CAN HELP OUTCOMESIT CAN BE TAUGHT

PATIENT-CENTERED COMMUNICATION

Reasons to care about patient-centered communication• Ethics• Effectiveness• Efficiency• Equity• Emotions10/19/2022 3

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Evidence-Based MedicinePatient-Centered Care

MIND THE GAP

What is evidence-based medicine?

Evidence

synthesis

Decision-

makingPatient care

Sackett, British Medical Journal, 1996: “…[t]he conscientious, judicious and explicit use of current best evidence in making decisions about the care of the individual patient”

Logic of decision-makingT. Greenhalgh: “Logic of decision-making

versus the logic of care” (J Primary Health Care, 2013)

Logic of care

Stewart’s global definition of patient-centered care

Seeks integrated understanding of

patient’s world

Explores patient’s reason

for visit,

concerns

Finds common

ground on problem and

mutual agreed upon management

Enhances

prevention

Enhances patient-provider relations

hipStewart M. BMJ. 2001 Feb 24;322(7284):444-5.

Patient-centered communication: Ethics

Shared decision-making

Respect for

persons

Patient-centered care

Patient-centered communication

Patient-centered communication: Ethics (2)

• Respect for persons• …and shared decision-making

– “Nothing about me, without me”– Ask the patient what they prefer

• Physicians and patient preferences

• Patients and the status quo

Patient-centered communication: Effectiveness

• Why patient-centered communication should improve outcomes– Improving symptoms– Setting agenda– Avoiding unnecessary tests/procedures

– Decreasing diagnostic error– Tailoring treatment and improving compliance

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Patient-Centered COMMUNICATION:Six overlapping functions

Epstein MR and Street RL. Patient-centered communication in cancer care:Promoting healing and reducing suffering. NCI, NIH publication #07-6225, Bethesda MD, 2007 http://www.outcomes.cancer.gov/areas/pcc/communication

Slide by Richard Street

Clinician-Patient Communication Processes

Proximal Outcomes*understanding*satisfaction*clinician-patient agreement*trust*feeling ‘known’*patient feels involved*rapport*motivation

Intermediate Outcomes*access to care*quality medical decision*commitment to treatment*trust in system*social support*self-care skills*emotional management

Health outcomes*survival*cure/remission*less suffering*emotional well-being*pain control*functional ability*vitality

Indirect (mediated) path

Direct pathSlide by Richard Street

Patient-centered communication and effectiveness

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The evidence is mixed

Does it work or doesn’t it?

• Positive evidence – Symptoms in IBS (BMJ 2008;336:999)

– Expectancy instruction in acupuncture [none on pain but effect on satisfaction] (PEC 2012;89:245)

– A1C in diabetes* (Acad Med 2011;86:359)

– Common cold symptoms and duration (PEC 2011;85:390)

• Insufficient evidence– CVD (PEC 2014;96(3)

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Exploring emotional distress in the clinical encounter (Dean and Street, PEC 2014)

• Recognizing emotional distress– Mindfulness– Self-situational awareness– Active listening

• Exploration– Acknowledge/validate emotions– Provide empathy

• Managing– Provide information empathetically– Identify therapeutic resources– Referrals/interventions to lesssen distress

Doctor-patient communication: efficiency

• Ask-tell-ask intervention in ophthalmologists: before-after study– Visit times longer by ~1min– Greater proportion time with provider (Ophthalmology 2010;117:1339)

• Impact of EHR on relationship between patient-centered communication and time

Doctor-patient communication: equity

Potential Criticism

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Myths about patient-centered communication

• I have no time• I have no talent• I have no training• I have no/insufficient team support

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Small, realistic, teachable goals

• Agenda-setting, negotiation, prioritizing

• Asking about the patient’s concerns

• Responding to emotion• Asking for patient’s preferences

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Can patient-centered communication be taught?

• Medical students become less patient-centered

• Social desirability of “patient-centered” self-definition

• EHRs tend towards physician centrism

• Patient centrism does not equal consumer centrism10/19/2022 22

Where do we go from here?: Facilitating PCC and SDM

•Decision aids•“Blue button” and patient-centered EMRs•SDM as incentivized behavior•Payment reform10/19/2022 23

Zackary Berger, MD, PhD@ZackBergerMDPhD

http://talkingtoyourdoctor.org

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