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Medical students must focus on patient-centered care

From the May ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Ching-Sheng Brian Lin

Sidebar: For more information

The relationship between physicians and patients is fundamental to the practice of medicine. Research has shown that the quality of this interaction affects patient satisfaction; compliance to prescribed regimens; patient knowledge, recall and trust; and health outcomes (Stewart et al., 1999; Clever et al., 2008). Ineffective communication and a disintegration of the physician-patient relationship often results in inconsistent care, doctor shopping, self-medication and an increase in patient demand for referrals and diagnostic tests (Safran et al., 1998).

In the current context of rising clinical demands, long waiting lists and shorter appointment times, it’s more important than ever to communicate effectively and foster a strong therapeutic relationship.

Medical students are not exempt from this responsibility. Indeed, it’s especially salient, as students have frequent and direct patient contact and are often the primary conduits of information between physicians and hospitalized patients. However, medical curricula rarely address the basic skills needed to establish a strong physician-patient relationship and the psychosocial aspects of patient care. Following are some things students, and their educators, should keep in mind.

Respect for patients’ values and preferences

While physicians view a patient’s condition physiologically, illness is experienced in a psychosocial context. We must recognize and respect that each patient has specific values, preferences and needs, and not assume we know how a patient may feel about acceptable risks to therapeutic interventions, side effects of medications or clinical outcome. Many experts have made practical recommendations to integrate the psychosocial and biomedical aspects of care (Kern et al, 2005; Botelho RJ, 1992). A few suggestions I’ve found effective in clinical encounters are to:

1. Explore the patient’s perspective with open-ended questions about his or her needs, understanding of the situation and concerns about the illness and its treatment.
2. Explain your perspective clearly, avoiding medical jargon. Be sure to communicate any benefits and shortcomings of the medical team’s recommendations.
3. Acknowledge any differences in opinion, create common ground, and settle on a mutually acceptable plan.
4. Acknowledge that the patient ultimately has the final decision in his or her health care.

By asking questions like “What can we do for you today?” and “What are your concerns?” and reassuring patients of their right to informed consent and control over decisions, we offer them an opportunity to actively participate in their own care. Such strategies promote patient empowerment and restore a sense of control that may have been lost during a person’s illness. The result is a long-lasting and successful therapeutic partnership.

Health care literacy and understanding

In the current health care environment, patients are increasingly expected to process complex medical information and seek out services needed to make appropriate medical decisions. All too often, physicians overestimate the health literacy skills of their patients. One study indicated that inadequate or marginal health literacy levels may be as prevalent as 54% in Spanish speakers and 40% in English speakers (Gazmararian et al, 1999).

I’ve found several interventions helpful in improving the quality of care of patients with limited literacy skills (Parker et al, 1999; Paasche-Orlow et al, 2006; Fernandez et al, 2009):

• Clarify job definitions and reporting structures in the different medical teams. The multiplicity of clinical professionals involved often negatively impacts the coordination of care and may lead the patient to believe there is a lack of communication between teams.
• Correct inaccurate perceptions and clearly explain the need for and benefits of any diagnostic tests and therapeutic procedures.
• Communicate clearly using simple language that is free of medical jargon, and confirm understanding by asking the patient to restate in her own words. Patients will often overestimate their level of competence and fail to voice pertinent concerns.
• Do not exceed three main concepts per patient interaction. A patient’s inpatient stay is often stressful and may not be the most conductive environment to remembering medical information and recommendations.
• Ensure that the discharge instructions and any other educational information are appropriate to the reading skills of the patient, and reinforce with oral instructions.

Emotional support

Medical illness not only inflicts a physical insult but also damages the psychological health of a patient. Often patients have unmet emotional needs and require emotional support, as well as alleviation of their fears and anxiety, however extreme or irrational the concerns may seem to a clinician. Many experts have called for a new integrative model that incorporates psychosocial issues into the traditional disease-oriented biomedical model of medicine (Lindau et al, 2003).

Medical students receive little training on the topic of dealing with patients’ emotions. Here are some steps I’ve found effective in addressing and managing patients’ emotions (Smith et al, 2009):

1. Name and label the emotion.
2. Understand and legitimize the emotion by stating that the reaction is understandable.
3. Respect the emotion by acknowledging how difficult things have been.
4. Support the emotion by saying that the medical team and other health professionals are willing to help alleviate the patient’s fears and anxiety.

Mastering these skills is critically important: Research suggests that addressing emotion leads to the strongest possible physician-patient relationships (Smith et al, 2002). In the darkest of times, a genuine expression of respect and concern by the medical team can mean a lot to a patient.

Mr. Lin is a student at Chicago Medical School at Rosalind Frank in North Chicago, Ill.

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For more information

• Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor communication. Cancer Prev Control. 1999;3(1):25-30.
• Clever SL, Jin L, Levinson W, et al. Does doctor-patient communication affect patient satisfaction with hospital care? Results of an analysis with a novel instrumental variable. Health Serv Res. 2008;43(5p1):1505-1519.
• Safran DG, Taira DA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47(3): 213-20.
• Kern DE, Branch WT Jr, Jackson JL, et al. Teaching the psychosocial aspects of care in the clinical setting: practical recommendations. Acad Med. 2005;80(1):8-20.
• Botelho RJ. A negotiation model for the doctor-patient relationship. Fam Pract. 1992;9:210-18.
• Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. Journal of the American Medical Association. 1999;281:545-51.
• Parker RM, Williams MV, Weiss BD, et al. Health Literacy: Report of the Council on Scientific Affairs. Journal of the American Medical Association. 1999;281 (6):552-7.
• Paasche-Orlow MK, Schillinger D, Greene SM, et al. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006;21(8):884-7.
• Fernandez L, Schillinger D. Literacy and patient care. Uptodate. 2009.
• Lindau ST, Laumann EO, Levinson W, et al Synthesis of scientific disciplines in pursuit of health: the Interactive Biopsychosocial Model. Perspect Biol Med. 2003 Summer;46(3 Suppl):S74-86.
• Smith RC, Dwamena FC, Fortin AH. Patient Centered Interviewing. Uptodate. 2009.
• Smith RC. Patient-Centered Interviewing: An Evidence-Based Method. Philadelphia: Lippincott Williams and Wilkins; 2002.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated