Patient-Centered Care and Communication: An Expert Interview With Tom Delbanco, MD

Interviewer: Randall F. White, MD

Disclosures

February 11, 2005

Editor's Note:
What is patient-centered care and what research demonstrates it is better for physicians as well as for patients? On behalf of Medscape, Randall F. White, MD, interviewed Tom Delbanco, MD, Professor, Harvard Medical School, Physician (Former Chief) Div General Medicine & Primary Care, Beth Israel Deaconess Medical Center; Boston, Mass.

Medscape: Can you define patient-centered care in the context of primary care and psychiatry?

Dr. Delbanco: I don't much like the phrase, "patient-centered care." I guess we were among the first to use it the mid-1980s when we developed an effort supported by the Commonwealth Fund to learn from patients. I never liked it. It offends everyone, because each health professional thinks he or she is patient-centered.

The basic notion to me is trying to see through the eyes of the patient and understand patients' expectations, perceptions, and experiences, rather than just seeing through our professional eyes. The expression has come to mean an awful lot of different things, as it's become shop talk. The minute that happens, words take on many different meanings.

Medscape: So you haven't come up with a better phrase to describe this?

Dr. Delbanco: I haven't really. People use "relationship-centered care," which sounds pompous. People talk about "shared decision making," certainly an important concept to talk about in this context. But the English language always gets in the way, and I don't have one phrase that covers it all.

Medscape: In the 1992 article in which you introduced this concept, you recommended that physicians solicit feedback from their patients in a "patient's review."[1] Can you give some specific suggestions on how busy clinicians in 2005 can accomplish that?

Dr. Delbanco: The first thing is that they can't do it all at once. On the other hand, if you get to know people over time, which psychiatrists do as well as primary care doctors, you can fill in the blanks and complete a rather organized review that gives a good picture of the patient above and beyond the purely biomedical or even psychosocial issues.

Medscape: Can you tell me how you accomplish this? How do you obtain and record these data?

Dr. Delbanco: I have an organized checklist in my head of things that I think are important to know about patients. They include the 3 biggest stresses in their life; I have found that a very useful question. One of my favorite questions is, "What do you want your doctor to be like?" I have learned never to anticipate the answer to that question. I may ask a captain of industry who's highly educated that question, and she may answer, "I just want the doctor to tell me what to do." I may get a school dropout, and the answer may be, "I want the doctor to give me his best bet on what is right, and then I want to get 3 other opinions, and I'll look it up on the Internet."

I've learned not to predict what people want their doctor to be like. Some of them want me to be warm and cuddly; others want me to be stern and distant. Some want to use a first name and some a second name. I always negotiate that with a new patient.

I like to know about hobbies; how they feel about their living circumstance; how they feel about their work or lack of work; about their important relationships; and their views about their health: their fears, their worries, their patterns of healthcare. When people get a sore throat, half will ignore it, the other half will go see the doctor. Different people have such a wide spectrum of needs, and that applies, I think, equally to the psychiatric world.

Medscape: How do you organize this information?

Dr. Delbanco: I've tended not to have a formatted sheet to use to fill in the blanks. I think that will happen increasingly in the future as we use more electronic communication with patients and electronic medical records.

I organize it in notes. I try to dictate my notes in front of my patients and negotiate the notes with them. I like to give the patient a copy of that interchange. I think in the future, with recording devices and voice recognition, our interviews, including psychiatric interviews, will be transcribed automatically and rapidly, and the patient will go home with a copy to reflect on.

Medscape: What is the one thing every physician can do to make his or her practice more, for lack of a better term, patient-centered?

Dr. Delbanco: I think that if there's one single answer to your question, it is to work hard to see through the patient's eyes. I have found this a very good guide for life. I have found that if I try to see through my wife's eyes, my assistant's eyes, my patient's eyes, I'm a much better listener, I'm better at responding, and I'm better at what I do.

Medscape: You call this a creative activity that can involve patients in improving care and bring doctors and patients closer. Can you give an example from your own practice of how this has unfolded?

Dr. Delbanco: I had a patient once who had blood pressure that was hard to control and some job dissatisfaction, and in talking with him, I got a history of his drinking "a few beers off and on." I also, as I did my patient's review, learned that he got mad at his kids very often, that his sex life could be better with his wife, and that his job as a printer was something he was thinking about stopping. It struck me that all these little signals might be a proxy for alcohol abuse.

This was back in the paper-and-pencil days of medical records, and I realized that he could read what I was writing, because in those days printers could read upside down. I stopped and I said, "I'm wondering whether I should write, as part of our understanding of each other, 'alcohol abuse.' If you don't see it as a problem, there's no point in writing it. On the other hand, if you think it is, we should write it down, agree on it, and work on it."

There was a long pause, and he said, "Doc, I think you should write it down." And that was the key to opening an aggressive intervention with his drinking and his life. I got a social worker involved. We got his wife involved, and that was a turn around in his life.

Medscape: What you describe is the forging of a consensus between patient and practitioner.

Dr. Delbanco: That's right. Shared decision making is an interesting notion. It's also a popular phrase these days. It sounds heavy, but the basic idea is simple. The patient brings into the office a unique understanding about his or her own personal and health issues. No one knows about it more than he or she does. The doctor brings into the office a carefully developed body of expert knowledge. The basic notion is that the two get together with their own expertise and negotiate a shared plan and understanding.

Angela Coulter, who runs the Picker Institute Europe in Oxford, England, wrote a wonderful book that explicates this very clearly, called The Autonomous Patient .[2]

Medscape: Has anyone done empirical studies on how this approach might affect patient outcomes?

Dr. Delbanco: I don't think anyone has taken what I've described and run a randomized controlled trial on it. There is a literature on doctor-patient communication and its impact on outcome and management. The classic studies are by Kaplan and Greenfield. They took patients with diabetes and ulcer disease and taught them to be aggressive with doctors, to push doctors to communicate more openly and fully with them.[3] They showed that patients they taught had better outcomes than those who were the usual passive recipients of care.

Medscape: What are the medicolegal implications of patient-centered care?

Dr. Delbanco: The data are pretty clear that the doctors least apt to be sued are those whom patients trust and have close interaction with, even if they make a serious mistake. The malpractice rates I pay as a primary care doctor are much lower than other specialties, and it's not just because I don't cut people up. It's because they're much less apt to sue me than they are someone they know less well. So, in our litigious society, the medico-legal implications will likely be positive, rather than negative.

Medscape: In a 1996 study published in Annals of Internal Medicine , you and several coinvestigators examined how differently physicians and patients ranked elements of care.[4] Can you discuss those findings?

Dr. Delbanco: This turned out to be a paper that got a lot of attention. We did something very simple. We went to 80 office-based general internists around the country and asked the doctors, "If you were a patient, what would you rank, from 1 to 100, as most to least important in your office practice?" We asked the physicians to give us the names of their patients, and we asked 10 of each of their patients picked at random, 800 in all, the same questions. We found a very interesting dissonance.

Medscape: You asked the physicians, "If you were a patient, not as a physician, how would you rank these elements?"

Dr. Delbanco: We asked them to see through the patients' eyes, and we found that both doctors and patients agreed that the most important thing by far was technical clinical competence; for instance, what is the difference between Prozac and Valium ? But then there was an enormous divergence. Doctors, for example, thought it was very important that privacy be honored, and patients put it very low on their list. In contrast, patients thought it very important that doctors explain the potential side effects of medicine they were prescribing, and doctors put that very low on their list. Overall, when you categorize these many questions we asked, the bottom line was that patients put communication and education as a strong number 2, whereas doctors had that rather low on their list.

Medscape: You wrote in that paper, "Our data indicate that physicians may underappreciate that information exchange is extremely important to patients," and that this receives little emphasis in medical training. Are you aware of any progress in this?

Dr. Delbanco: I am, actually. We did the study in 1990-1991. I think that medical schools spend a lot more time teaching that [now]. Whether that sticks is a different question. What you're ready to learn at the time is important. If you're an intern and your greatest fear is that you're going to kill the first patient you encounter, you're probably going to be spending more attention on the right dose of medicine A or B than you are on how you're going to address psychosocial issues with a patient. The time to teach this is maybe when someone is ready to go out into practice. That's when you get more receptive ears. Then, on the other hand, it may be too late.

Medscape: How did you become interested in patient-centered care?

Dr. Delbanco: The Commonwealth Fund in New York and the Jean and Harvey Picker Foundation decided they wanted to make healthcare more humane. They called a group of people together to try to figure out the approach to take that they would fund generously. At that meeting, I suggested that the first step would be to understand what patients experience, what's on their minds, and to gather data. I pointed out that we're probably second only to lawyers as the service industry least likely to seek customer feedback. Doctors think they know what their patients experience and feel, but they never bother to ask.

That was the first step. Once you understand the patient's experience better, the question is what to do about it. My conviction is you need doctors to team with patients and other health professionals to fix what's broken. And my real fascination is working with patients in getting things to work better. I think that pertains to psychiatry just as well as it does to general medicine. That will be the salvation of doctors, I think, if we can turn to those we serve and work with them to improve things.

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