Patient-centered care is a common industry term that resonates deeply, yet truly successful implementation remains an enigma for most care environments.
The American Association for Physician Leadership has been involved with numerous external initiatives over the past few years as we develop our thought leadership portfolio. Three in particular have been especially critical in our association’s efforts to further strengthen the essential importance of the patient-physician relationship as health care evolves:
- Co-sponsorship with the Beryl Institute1 on development of a white paper that clarifies contemporary expectation differences for the relationship between patients and physicians.
- Participating in an initiative from National Quality Partners,2 a subgroup of National Quality Forum, that is focused on shared decision-making.
- As our association’s CEO, I have been privileged to serve as steering committee chair of the National Collaborative for Improving the Clinical Learning Environment.3 NCICLE recently hosted an invitation-only symposium oriented to establishing and developing guidelines for what constitutes successful structures and functioning of clinical learning and practice environments.
In each, patient-centered care as a concept was regularly brought to the foreground as the anchoring principle for all that should be done in health care today … and tomorrow.
Being somewhat of an idealist and altruistic individual, as a surgical trainee in Montreal at McGill University, I was highly influenced by a seemingly omnipresent influence of William Osler. The Osler Library is located at McGill University’s Medical School, and the auditorium where our surgical educational sessions were conducted had a large portrait of Osler hanging in constant view. Like many, I endeavored to emulate his teachings and to practice by those ideologies. I just couldn’t shake his stare from that portrait — you know, the type of portrait where the eyes are always following you.
Sir William Osler (1849-1919) was a Canadian physician who created the first residency program for specialty training of physicians, and he brought medical students out of the lecture hall for bedside clinical training. He frequently has been described as the “Father of Modern Medicine,” and his career traversed the universities of McGill (1874-84), Pennsylvania (1884-89), Johns Hopkins (1889-1905) and Oxford (1905-19).
A prolific writer, he once wrote in an essay titled Books and Men that “he who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” He also is credited for saying, “Listen to your patient; he is telling you the diagnosis,” emphasizing the need to take a good history.
In a similar vein of thought, who in medicine hasn’t heard of Florence Nightingale? Her influence on patient care has been omnipresent in our industry as well, primarily through her role in founding the modern nursing profession. Nightingale (1820-1910) rose to prominence managing nurses she trained during the Crimean War, where she organized the tending to wounded soldiers and gave nursing a highly favorable reputation. She became the iconic “Lady with the Lamp” while making rounds at night.
An English social reformer and statistician, Nightingale established a nursing school at London’s St. Thomas' Hospital in 1860. Now part of King’s College London, it was the world’s first secular nursing school. Also a prolific writer, she worked to improve health care for all sections of British society, advocate hunger relief in India, abolish prostitution laws that were overly harsh to women, and expand female employment. In partial recognition of her pioneering work, new nurses take the Nightingale Pledge. She helped set an example of compassion and commitment to patient care, as well as diligent and thoughtful hospital administration.
Indeed, patient-centered care actually has been a focus for roughly 150 years.
A Disruptive Future
Patient-centered care is taking on new meaning, however, while the primary focus on physicians being the dominant conduit for care and decision-making remains. Since the mid- to late 1800s, the complexities of health care delivery systems have escalated logarithmically. We all know, and feel, the diversity of influences (too many to list) that now encroach the core components of essential patient care — the patient-physician relationship and the patient-nurse relationship in a conducive environment for optimal care.
A portion of what is gradually occurring is the rapid adoption of technologies and the progressive implementation of not only expanded responsibilities for nonphysician providers but also an expanded number of nonphysician clinicians involved with patient care. Several components of a new paradox gradually are becoming clearer — the paradox between existing delivery systems oriented toward how altruistic physicians prefer to deliver care versus a renewed focus on patient-centered care that is trying to thrive in a highly complex set of evolving systems amid new types of providers not yet fully oriented to patients.
Disruption of our industry is at the core of this paradox. Learning to manage it effectively will be a challenge for physician leadership — and everyone oriented toward truly successful patient-centered care.
Are We Communicating Property?
Communication, communication, communication … we all know it’s an essential component of health care. When things go incredibly well, communication, caring and compassion are most often at the core of success. Equally, however, when things go horribly wrong in health care, communication problems are usually at the core.
Among many examples, electronic health records gradually have gained acceptance in health care. Cloud-based data warehousing and assertive efforts with data analytics are common practices. Push messaging that results from the analytics is now prevalent. Social media channels are generally accepted, and expected, forms of communication. But what is less clear is the collective and eventual impact on health care delivery — especially when patient expectations are higher than provider willingness.
Furthermore, the effect of digital communication hosted on a plethora of devices has transformed human interaction. Millennials (those born between the early 1980s and the early 2000s) now make up more than half of the U.S. workforce. They are the largest generation by nearly 15 million, and they own an average of 7.7 connected devices, research shows.
Our personal lives have been pervasively affected — and relatively quickly — by technology as all generations are now seemingly dependent on digital devices for in-formation, and a new form of addictive dependency apparently is evolving. Interpersonal communication and the types of relationships being formed are in unprecedented transition. A new type of patient-physician relationship is developing gradually, but is not yet formalized.
The internet is propelling clinicians into new ethical and legal territory, raising questions about the accuracy of online information, patients’ right to privacy, and doctors’ liability regarding their patients’ online behavior.
Liliya Gershengoren, a psychiatrist and professor with Weill Cornell Medicine, recently concluded from a survey she conducted that an overwhelming majority of psychiatrists and residents at one U.S. academic hospital had Googled a patient at some point in their careers. These survey results were presented at the American Psychiatric Association’s 2017 annual meeting.
Of 48 staff doctors and 34 residents who responded anonymously, 93 percent of staff and 94 percent of residents reported researching a patient online at least once. She found that 17 percent of staff and 40 percent of residents Googled their patients on a frequent or semiregular basis in the ER (compared to 5 percent of staff and 15 percent of residents in inpatient settings).
And then there are external risks — malevolent forces that continually try to create chaos by penetrating our organizational technology with the intention of stealing patient data, or holding patient care networks for ransom, or even doing harm to patients.
As physicians, we must continually seek how to optimize patient-centered care in the face of ever-increasing change and complexity. We must also continue to seek how our role as the natural, intended leaders in the health care system (and the dominant focus of patient care) can be further optimized. Increased personal awareness in both these areas will be essential for achieving improved outcomes on both fronts. Managing any paradox is not about “yes” or “no” decisions — it is a process of finding, then managing, the balance for both the individuals and organizations we influence within it. Positive outcomes often result from disruption.
I encourage all of us to continue seeking deeper levels of understanding. As physician leaders, let us get more engaged, stay engaged and help others to become engaged. Creating a broader level of positive change in health care — and society — is within our reach. Proactively helping others, as physician leaders, to better manage the disruptive paradox of true patient-centered care is a critical component of our professional responsibility — in fact, it has been a professional responsibility since our beginnings.
- The Beryl Institute is dedicated to improving the patient experience through collaboration and shared knowledge. Patient experience is defined as the sum of all interactions, shaped by an organization's culture, that influence patient perceptions across the continuum of care. Its primary cause is to change health care by advancing an unwavering commitment to the human experience.
- National Quality Partners brings together thought leaders and experts from the public and private sectors to address the nation’s highest-priority health care issues. NQP leads practical, action-oriented initiatives to drive meaningful and lasting change in health and health care.
- The National Collaborative for Improving the Clinical Learning Environment provides a forum for organizations committed to improving the educational experience and patient care outcomes within clinical learning environments. NCICLE simultaneously seeks to improve the quality of learning and patient care within CLEs through shared learning and collaborative practice among its member organizations.