Patient-Centered Communication: A Useful Clinical Review
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Patient-Centered Communication:A Clinically Useful Review
Obesity: The Doctor-Patient ConversationBaltimore City Medical SocietyZackary Berger, MD, PhD
Johns Hopkins School of Medicine
Division of General Internal Medicine; Berman Institute of Bioethics
http://talkingtoyourdoctor.org
04/10/2023 2
IT’S ESSENTIALIT CAN HELP OUTCOMES
IT CAN BE TAUGHT
PATIENT-CENTERED COMMUNICATION
Reasons to care about patient-centered communication
• Ethics• Effectiveness• Efficiency• Equity• Emotions
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Evidence-Based MedicinePatient-Centered Care
MIND THE GAP
What is evidence-based medicine?
Evidence synthesis
Decision-making Patient
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-making
T. 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
relationship
Stewart 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)04/10/2023 14
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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 preferences04/10/2023 21
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 centrism
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Where do we go from here?: Facilitating PCC and SDM
• Decision aids• “Blue button” and patient-centered EMRs
• SDM as incentivized behavior
• Payment reform04/10/2023 23
Zackary Berger, MD, PhD
@ZackBergerMDPhD
http://talkingtoyourdoctor.org
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