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Patient-Centered Communication: A Useful Clinical Review

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Patient-centered communication is important because of the 5 E's: ethics, emotions, efficiency, effectiveness, and equity. This talk was originally given October 1, 2014, at the Baltimore City Medical Society.

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Patient-Centered Communication: A Useful Clinical Review

  1. 1. Patient-Centered Communication: A Clinically Useful Review Obesity: The Doctor-Patient Conversation Baltimore City Medical Society Zackary Berger, MD, PhD Johns Hopkins School of Medicine Division of General Internal Medicine; Berman Institute of Bioethics http://talkingtoyourdoctor.org
  2. 2. 10/2/2014 2
  3. 3. Reasons to care about patient-centered communication • Ethics • Effectiveness • Efficiency • Equity • Emotions 10/2/2014 3
  4. 4. Patient-Centered MIND Evidence-Based Medicine THE GAP 10/2/2014 4
  5. 5. 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”
  6. 6. Logic of decision-making Logic of care T. Greenhalgh: “Logic of decision-making versus the logic of care” (J Primary Health Care, 2013)
  7. 7. 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.
  8. 8. Patient-centered communication: Ethics Shared decision-making Respect for persons Patient-centered care Patient-centered communication
  9. 9. 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
  10. 10. 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
  11. 11. 11 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
  12. 12. 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 path Slide by Richard Street
  13. 13. Patient-centered communication and effectiveness 10/2/2014 13
  14. 14. 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) 10/2/2014 14
  15. 15. 10/2/2014 15
  16. 16. 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
  17. 17. 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
  18. 18. Doctor-patient communication: equity
  19. 19. Potential Criticism 10/2/2014 19
  20. 20. Myths about patient-centered communication • I have no time • I have no talent • I have no training • I have no/insufficient team support 10/2/2014 20
  21. 21. Small, realistic, teachable goals • Agenda-setting, negotiation, prioritizing • Asking about the patient’s concerns • Responding to emotion • Asking for patient’s preferences 10/2/2014 21
  22. 22. 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 10/2/2014 22
  23. 23. Where do we go from here?: Facilitating PCC and SDM • Decision aids • “Blue button” and patient-centered EMRs • SDM as incentivized behavior • Payment reform 10/2/2014 23
  24. 24. Zackary Berger, MD, PhD @ZackBergerMDPhD http://talkingtoyourdoctor.org 10/2/2014 24

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