you

Report
Practical Approach to
Patient-Centered Medicine
Reid B. Blackwelder, M.D.
President, AAFP
[email protected]
Goals
• Remember Why You Went into Medicine!
• Describe Patient-Centered Care
• Challenge you to become and remain PatientCentered
• Review Patient-Centered Communication
• Emphasize Patient-Centered EBM
• Implement (or Prevent) Attitude Shifts
• Give you hope!
• Medical care is mainly Physician Centered
– Still in many ways despite transformation
• Access is on our terms
– Where we are
– When we are open
– Who (or what) you can talk with
– When you can be seen
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“Health Care System” (sic)
Physician-Centered Care
• Medical Care
– What we provide – services, call, hospital
– Our rules for visits, medications, CAM, etc.
– Our rules for loss of access to us
• Oversight Exists
– By very non-patient centered regulators
– State, Federal, Medicare, Insurance
– And Medical School (and Residency)!
Physician-Centered Care
• Taking “The History”
– Much less personal connection with our
patients
– Emphasis on only certain aspects of
information which we call the history
• Social Hx: ??
• Tobacco, alcohol, drugs…
– Lists and templates
The Patient History
• Semantics
– It is called “His or “Her” story for a reason.
• But we have lost the emphasis on obtaining
stories
– Instead we check boxes on templates.
– One of the dangers of EHR!
– Or you don’t even write notes!
The Patient History
• How much time do we allow patients to tell their
story before we interrupt and take control?
– 15 seconds!
– This shift is due to time pressure
• Fee for service/pay for volume
– Significant oversight of our documentation
● For billing, NOT for patient care
The Patient Interview
• Many purposes
• Important info about the medical issues
• Must learn and explore our patient’s health care
philosophies
• Generating and maintaining rapport
• Creating a relationship
– Immediate
– Long-term
Physician-Centered Care
• We also have de-emphasized our physical
exams, instead…
• Emphasizing labs and studies
• We have definitely moved toward high tech and
low touch
• Our entire relationship has changed
Current Reality
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Poor outcomes
Poor patient satisfaction
Poor provider satisfaction
High cost
Partisan politics preventing change
The Physician of “Now”
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Must be patient-centered
Must focus on Health!
Must be relationship-based
Must be team-based
Must balance technology with compassion
Starts with personal choices
Reframe!
• Create more Patient-centered processes
– In your practice
– In your style
• We will review a few of these
• This is an “Art” class
– We will consider your choice of media, color,
technique
– Time to create masterpieces!
Changing the Environment
• Sacred Space
• Personal Power and Symbols
• Internal Environment
Nurturing Environment
• Surround yourself with
– Meaningful relationships
• As best you can at work
• And at home
– Meaningful “Stuff”
• Photos
• Candles, fountains, icons
• Minimize stressful images
– “Humor”
Personal “Power”
• What kind of image are you presenting?
– How is it working for you?
– How will it work for your patients?
• Everything carries potential meaning
Personal Powerful Symbols
• Tools of the trade
– Coats
– Stethoscopes
– Smart phones
– Computers/tablets
• Clothes
• Jewelry and decorations
• Spiritual icons
• Colors
Be Attentive to…
• Your affect
– Perspective is key
– Half-empty or half-full?
– Impacts your life path tremendously
• Impacts patient care tremendously
– Become confident in your role
– Knowing your boundaries
– Enjoy caring for your patients!
– They can tell your mood!
Half-Full Warning!
• Remember you always have a choice
• Today is yours for a reason
• The “challenges” you face can be seen as
– Your teachers of the moment
• You chose this profession to help people
– They are rarely at their best when they need
it the most
• Laugh regularly and easily
Healing Effects (Placebo)
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All treatments can have a specific effect
All treatments have some healing effect
All encounters have potential effect
Good bedside manner!
Starts with communication skills
Basic Communication Skills
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Rapport
Facilitation
Agenda setting
Information management
Active listening
Negotiating common ground
Basic Communication Skills
• These are such important clinical skills!
– Actually Life skills!
– Little things are not little.
• They are not specialty specific!
• Engage completely!
• Be present
• Trick for focusing on each patient
Rapport
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First impression of office
First impression of your staff
First impression of you
How do you start your interview?
Scenario
• You have a new patient in your office, the nurse has
written “Chest pain” as the chief complaint
• Patient looks fine
• What do you ask first?
– How are you?
– What can I do for you, or variant?
– How long have you had the chest pain?
– Other closed ended questions.
Instead:
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“Tell me about your chest pain.”
“Tell me more.”
“Anything else?”
Amazing how much info you get!
Early use of close-ended questions
– Shuts your patient up
– Requires you to guess right!
– Takes more time!
Agenda Setting
• Clarify agenda
– Yours
– The patient’s
• Must put into the context of the time you have
available
• Limitations are real and more controllable than
one may think
Agenda Setting
• Clear agenda setting clarifies the common
ground that needs to be negotiated.
• Be prepared for surprises anyway…
– “By the way…”
And, the “Biggie”
• Recognize and respond to emotion!
– Without becoming defensive
– Or Angry
– Or clicking into didactic mode
• Information does not overcome emotion!
• You are not required to “fix” anything
– And you can’t fix anything!
• Emotion is okay and real and needs validation,
not fixing
Handling Emotion
• Recognize it and state it
– “You are…” angry/frustrated/sad/whatever
– Trust your intuition as to what it is
• Just listen
• Try not to say “I understand.”
• Or “Don’t be…”
• Be okay with saying “I’m sorry you have to deal with
this.”
What a bunch of Hooha!
• Is any of this actually supported by evidence?
• We are challenged to practice EBM
• We are also expected to have some common
sense!
– Good bedside manner seems like a good
idea!
• But, let’s look briefly at EBM…
Levels of Evidence
• Type Ia
– Meta-analyses of RCTs
– Accepted as strongest level of EBM
• Type IV
– Expert opinion
– Considered the weakest level
– JNC VII(I) and Hypertension protocols…
Levels of Evidence
• Even stronger…
–Level 0
–What you believe that others don’t!
• Even weaker
–Level V
–What others believe that you don’t!
EMB Caveat
• EBM helpful, but…
• Statisticians try to remove variable of the
individual response
• Practitioners are focusing on the individual
response
• “The Average Patient” is a statistical entity that
does not exist
Patient-Centered Reframe
• “I don’t have a treatment for metastatic
breast cancer…
• …but I have lots of things I can do for
you”
• “I don’t treat cholesterol…
• …I treat patients!”
EBM for New Model
• A patient-centered interview improves health
outcomes!
• Team-based care improves outcomes
• Patient-centered medical homes
– Change how care is delivered
– Change how care is paid for
• Challenge medical schools to serve:
– Meet their social responsibility
Truths and Goals
• For better outcomes patients need:
– Health Insurance coverage
– Routine source of comprehensive continuous care
– They need a relationship!
• Right Care
– in Right place
– from Right person
– at Right time
Make This Practical
• What will you do different?
• How will you become patient centered?
Make This Practical
• First and Foremost
– Remember that you Love What You Do!
– Answering the call to serve
• Nurture yourself – role model that love
– Nurturing, sacred environment for you
– Creates one for your patients
• Your actions and affect speak louder than words!
Make This Practical
• Consider your communication style
– Learn patient centered techniques
– Use them!
• Exercise caution with how you use and explore EBM
– Much is disease, not patient oriented
• Who is your team?
• How will you keep your heart in your art of medicine?

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