Beyond the platitudes: Thorny challenges in delivering patient-centered care.

Blog post by Dr. Michael Fisch

The phrase “patient-centered care” is ubiquitous in discussions of healthcare delivery. There are innumerable conceptual models for patient-centered care and even a research institute named the “Patient Centered Outcomes Research Institute (PCORI, www.pcori.org)” authorized by Congress to conduct research to provide information about the best available evidence to help patients and their health care providers make more informed decisions. The idea, not surprisingly, is central to the profession of medicine. As a medical student, I received a small booklet with a reprint of the classic essay (JAMA 1927;88:877-882), taken from a speech to medical students by Francis Weld Peabody, which included this iconic line:

…the secret of the care of the patient is in caring for the patient.

The hard part about patient-centered care, however, is simply this: that it is patient-centered. Beyond the platitudes, there are daily challenges in actually accomplishing this goal. There are challenges both at the level of individual choices and behaviors, as well as organizational choices and policies. To use a sports metaphor, proficiency in delivering patient-centered care is challenging in the way that hitting a baseball is challenging. Success requires more than just desire and “keeping your eye on the ball.” It requires a certain measure of courage and sacrifice, willingness to be creative, and a set of physical, cognitive, and emotional skills that requires some ability and a great deal of practice and training.

Here are 7 scenarios that illustrate how the challenges roll out at “game speed” in healthcare. Each situation is a patient-centered care vignette framed from a providers perspective. Imagine each vignette, also, from the perspective of a patient or family caregiver.

1. As a consulting physician you entered a room to assess a hospitalized patient and bring a portable stool (a folding chair) so that you can sit down to talk with the patient and spouse about the goals of care.
2. A new patient is seen in consultation and she asks: “Do you have a card?” You say “I don’t have one with me…I’m only covering for the weekend.”
3. You have 15 minutes before “conference” and one more patient to see on rounds. Do you see the patient now, keep the visit short, or come back later?
4. You are struggling through a clinic day and your next patient is Spanish speaking…but speaks some English. It will be 15 minutes or more for the Spanish translator to arrive. You can get by with your patient in English, wait for the translator, or use telephone translation. The nurse tells you that the patient’s 15 year old granddaughter is also there and could help with translation if needed.
5. You got delayed in traffic and you are walking quickly to your morning report or rounds. As you zoom down the hallway, you can see that an older couple is looking lost and trying to read signs. You think of stopping, but…you are also not sure if they speak English. You do….what?
6. You want to demonstrate the value of a new clinical service, so you ask the hospital patient to complete a 25 item questionnaire about current symptoms and functional status before the consultation. Your patient, referred for symptom control, returns the forms to you with all items rating at 0 (using a 0-10 numerical rating scale).
7. During a talk you hear a colleague explain: “This is an example of the ‘bedside to bench and back’ approach to integrating research into patient care.”

Join #hcldr on Tuesday April 29th at 8:30pm Eastern (click here for your local time zone) for a tweetchat on the following topics:

• T1: What are specific examples of thorny challenges that you see in striving for the realistic ideal in the delivery of “patient-centered care.”
• T2: How might we make structural changes or organizational adjustments to enable sustained improvements in patient-centered care?
• T3: Can you describe strikingly creative individual or organizational behaviors that produced truly elegant, effective patient and family centered care.
• CT: What’s one thing you learned tonight that you can use to help a patient tomorrow?

Biographical sketch – Michael J. Fisch, MD, MPH, FACP, FAAHPM

Dr. Fisch, is Professor and Chair of the Department of General Oncology in the Division of Cancer Medicine at the University of Texas MD Anderson Cancer Center in Houston, TX. He earned his MD from the University of Virginia School of Medicine and his master’s in Public Health from Indiana University in Bloomington, IN. He completed a residency in Internal Medicine at University of Virginia and fellowships in Hematology/Oncology and general internal medicine (Health Services Research) at Indiana University. He is board certified in Medical Oncology, and Hospice and Palliative Medicine. Dr. Fisch is a fellow of both the American College of Physicians and the American Academy of Hospice and Palliative Medicine.

Dr. Fisch’s research interests include palliative care, symptom management, and health care disparities. He has been published in the Journal of Clinical Oncology, the Journal of the National Cancer Institute, and numerous other peer-reviewed journals. He has also authored or co-authored several book chapters and books. He is an active blogger for the American Society of Clinical Oncology (ASCO) and for MD Anderson, and he is active on twitter as @fischmd. Dr. Fisch is currently the Principal Investigator of the MD Anderson Community Clinical Oncology Program Research Base, Chair of the Symptom Management Subcommittee of ECOG-ACRIN and Co-Chair of the Symptom Management and Quality of Life Steering Committee for the National Cancer Institute.

Tags: caring, challenge, encounter, patient centered, patient experience, patients, pcori, physicians, rounds, visit