Douglas A. Drossman, MD
President Emeritus and COO, Rome Foundation, Professor Emeritus of Medicine and Psychiatry, Center for Functional GI and Motility Disorders, University of North Carolina and Drossman Gastroenterology
Medical information on diagnosis and treatment is often taught without attention to the process of care that can effectively improve clinical outcomes. This involves learning proper skills to engage and collaborate with the patient.
At the heart of an effective collaboration is the practice of patient-centered care. As originally defined by the Institute of Medicine almost 20 years ago, patient-centered care is respectful of and responsive to patient preferences, needs, and values to help guide clinical decisions. This term may be misunderstood by some who believe that the clinician might give up control to the patient. Several of us in the field have considered a change in the terminology to “relationship-centered care” which clarifies the collaborative nature of the clinical interaction.
There are several components to establishing patient-centered care: respect for the patient’s knowledge and perspective, providing physical comfort and emotional support, offering education and reassurance, being accessible and collaborative, and making decisions based on patient preferences. To accomplish this, the clinician uses effective communication strategies to understand the full nature of the patient’s symptoms and their illness experience in addition to their needs, perceptions, concerns, and impact on their life.
There are 10 specific components that help optimize the patient-provider relationship:
1. Listen actively
Don’t jump in with questions unless you’ve made the effort to understand the patient’s perspective, then base any additional questions on the information obtained.
2. Understand the patient’s agenda
Patients are not always given the opportunity or may be reluctant to bring up the items that are important to them, so they often need to be asked. There may be concerns that relate to the impact of the illness on their life, fears about cancer or other serious disease, worries about future consequences, and many more. When such issues are discussed, patients feel heard and more satisfied. These issues can be explored using four important questions on the first visit:
- What brought you here today?
- What do you think you have?
- What worries or concerns do you have?
- What do you feel I can do to help?
Use empathic language like, “I can see how difficult it is been to manage with your pain.” Empathy incorporates four components:
- Perspective taking: Seeing the world as other see it.
- Being non-judgmental.
- Recognizing the emotions and understanding the patient’s feelings.
- Communicating that understanding to the patient.
4. Validate thoughts and feelings
Validating the patient’s thoughts and feelings legitimizes them. Even if clinicians don’t necessarily agree with the patient’s view, they can still acknowledge and accept their perspective. For example, if a patient feels stigmatized by others who say that their problem is due to stress, use a validating statement such as, “I can see you are upset when people say this is due to stress and you know it’s real.” This statement also opens the door to further dialogue about the role of stress in illness.
5. Set realistic goals
Patients with chronic illness may seek a rapid diagnosis, but the clinician may need to focus on ongoing management with realistic expectations. This difference in perspective needs to be reconciled. Here, the clinician can say, “I can understand how much you want these symptoms to go away, but since they are longstanding, we need to reset our expectations. Would it help if we could work together to reduce your symptoms by 30 percent over the next several months?”
Education does not just mean giving a brochure or showing a video. It is an iterative process that includes several elements:
- Elicit the patient’s understanding.
- Address misunderstandings.
- Provide information consistent with the patient’s understanding.
- Check the patient’s understanding of what was discussed.
Reassurance is also a collaborative process and requires the following:
- Identify the patient’s worries and concerns.
- Acknowledging and validating them.
- Respond to the specific concerns.
- Avoid false reassurances such as, “Don’t worry about it,” that may diminish what the patient views as important.
Patient-centered care requires agreement on diagnostic and treatment options. After eliciting the patient’s personal experience, understanding and interests in various treatments, the doctor offers choices, rather than directives, that are consistent with the patient’s beliefs. IOM guidelines require that the patient makes the final decision.
9. Help the patient take responsibility
Patients with chronic illness should be encouraged to take responsibility for their care. Rather than asking the patient how their pain is doing, the clinician might ask how they are managing their pain. This encourages the patient, rather than the clinician, to take responsibility over management. It is wise to offer several treatment approaches with a discussion of their risks and benefits, so the patient can make the choice.
10. Be there
Provide support and a listening ear. Sometimes patients disclose personally meaningful and sensitive issues where there may not be simple solutions. Here, patients are seeking reassurance that they are being heard, understood, and supported.
Even though we are talking about a mutual collaboration, there are some features unique to patient and providers. Providers need to understand that their patients need to know that you care about them, feel respected, and not judged. This will allow patients to be more willing to share personal thoughts and feelings.
Providers also need to keep an open mind about their patient’s ideas and beliefs related to their medical condition and within that context communicate the diagnosis and treatment plan. They need to be able to communicate when they don’t know something and then seek out the proper information for the patient. Finally, they need to be fully committed to the patient care and be able to communicate to the patient that they won’t be abandoned.
Patients need to understand the important of engaging with the provider as a partner. In this regard as a patient you have the following rights:
- Your role in the care process and your health are worth fighting for. Don’t shrink from asserting your ideas and needs
- Share personal thoughts and feelings about your care, and demand that they are heard.
- Ask questions and receive educational materials to understand your diagnosis and treatment
- Refuse treatment or seek another opinion if your needs are not met.
Douglas A. Drossman, MD, President Emeritus and COO, Rome Foundation, Professor Emeritus of Medicine and Psychiatry, Center for Functional GI and Motility Disorders, University of North Carolina, [email protected]