Practical Approach to
Patient-Centered Medicine
Reid B. Blackwelder, M.D.
President, AAFP
[email protected]
• 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
“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
– 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
– 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
• 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
Poor outcomes
Poor patient satisfaction
Poor provider satisfaction
High cost
Partisan politics preventing change
The Physician of “Now”
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
• 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,
– 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)
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
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
First impression of office
First impression of your staff
First impression of you
How do you start your interview?
• 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.
“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
• 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
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
– Good bedside manner seems like a good
• 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
• “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
• “I don’t treat cholesterol…
• …I treat patients!”
EBM for New Model
• A patient-centered interview improves health
• 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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