A Patient-Centered Hospital - Part III: Where Everyone Knows Your Name
Rounding with a medical team at an academic institution can sometimes feel like a trip to the zoo. The patient, caged up in their room, is talked about as if they aren’t there. They are then poked and prodded in their most intimate locations, often without explanation, by a gaggle of strangers. And then everyone leaves the patient to endure his or her ailments alone. Even in non-academic centers, patients are often treated as objects rather than human beings.
There is an argument that objectiveness is what allows providers to make the best decisions; emotion muddles things. But is this really true? Doesn’t emotional connection also add something to patient interactions? According to abundant research, it does. A literature review, over a decade old now, sums up this idea nicely: “…one relatively consistent finding is that physicians who adopt a warm, friendly, and reassuring manner are more effective… (Di Biasi, et al., 2001).”
I think to connect with patients you first have to know them beyond their diagnosis. Hippocrates said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” I have learned the truth to statement during my time on the wards and I attempt to gather this information in my medical interviews. I try to ask myself, “Who is this man?” “What did this woman do before being sick?” To me these are vital questions.
However, anyone who has participated in medical rounds realizes how little this type of personal information is captured, and further, how little this type of curiosity about patients is rewarded. In the equations of efficiency, productivity, and profits there is little room for questioning the patient experience. Further, modern medicine places a lot of emphasis on evidence-based care, which seems to preclude personal relationships. Because we are awash in data points and expert guidelines, the patient’s chart gets magnificent care. The patient, however, is left as a placeholder – a physical representation of those digital numbers. As one patient stated, "you cease being a person and become 'the carcinoma in Room B-2,' (Carey, 2005)."
“But wait,” you might say, “hasn’t that been fixed with the ACA, MACRA, and the new emphasis on patient satisfaction metrics?”
In my experience the result of such efforts has been the creation of entire departments that focus on appeasing patients, not improving the overall experience. Plastered on many hospital walls are new signs that say, “If you cannot give us top marks in satisfaction, please call 1-800-LETUSKISSYOURASS.” Some data suggests the problem gets worse as hospitals consolidate into ever-larger organizations, a persistent trend in modern U.S. health care. The larger a hospital is, the lower it’s satisfaction scores are (Mcfarland et al., 2015). Obviously correlation is not causation, but it does beg some interesting questions.
The upside of these realizations is that many hospitals are attempting to re-engineer the provider-patient relationship. For example, Johns Hopkins and other institutions are now collecting personal patient data with the belief that truly knowing the patient improves the patient experience and creates a more responsible attitude on the part of the provider (Sun, 2015). This is wonderful and extremely sad – why do we have to create a workflow for caring about someone on a personal level? Shouldn’t that be part of the job?
Regardless of how we accomplish it, proper patient care has a strong evidence base for improving outcomes. Take for instance a recent Consumer Reports’ study, which reported that patients who felt rarely respected by medical staff were 2.5 times as likely to experience a medical error (2014). As care becomes more complex, we cannot afford to let attitudes become a malignancy that prevents positive outcomes.
Many physicians lament the use of patient satisfaction metrics. But here is a telling quote from a nurse turned patient and her experience: "There's this overwhelming sense being a patient of having no boundaries, no privacy, no control over anything, and you feel so awful you can't do anything about it. (Carey, 2005)." Is it any wonder that patients who feel cared for do better? Whether you argue physiology (stress hormones and their impact on healing) or psychological factors (patient’s motivation to get better), it seems obvious why patients might do better in a supportive environment.
Obviously there are barriers to being able to spend adequate time with each patient and their story. Hospitals are often over census and understaffed. Administrators favor profits and efficiency over quality and satisfaction. But each provider can make small changes. Try to lead with empathy in each interaction. Imagine how you would treat each patient if they were your mom, dad, sister, or brother. This can change your entire interaction, even with the curmudgeonliest patients. Realize that patients are at their most vulnerable when they are in your care. In true Maslow fashion, they are looking to have their most basic needs of security and safety fulfilled. Finally, call patients by their name. Just remembering they are a human being and not an illness is perhaps the easiest way to restore some dignity.
To summarize, I will end with another quote from a giant of our field.
The good physician treats the disease; the great physician treats the patient who has the disease.
Citations/Further Reading
Carey, B. (2005, August 16). In the Hospital, a Degrading Shift From Person to Patient. The New York Times. Retrieved from http://www.nytimes.com/2005/08/16/health/in-the-hospital-a-degrading-shift-from-person-to-patient.html
Di blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357(9258):757-62.
L. P. Casalino, M. F. Pesko, A. M. Ryan et al., “Small Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions,” Health Affairs Web First, published online Aug. 13, 2014.
Mcfarland DC, Ornstein KA, Holcombe RF. Demographic factors and hospital size predict patient satisfaction variance-implications for hospital value-based purchasing. J Hosp Med. 2015; Epub ahead of print: 4 May 2015. DOI: 10.1002/jhm.2371
Sun, L. H. (2015, April 8). Meet the cancer patient in Room 52: His name is Joseph, but call him Joe. The Washington Post. Retrieved from http://www.washingtonpost.com/national/health-science/effort-to-reduce-harm-in-hospitals-centers-on-seeing-patient-as-a-person/2015/04/08/13c7a814-da16-11e4-b3f2-607bd612aeac_story.html
The surprising way to stay safe in the hospital (2014, December). In Consumer Reports. Retrieved May 23, 2015, from http://www.consumerreports.org/cro/magazine/2015/02/the-surprising-way-to-stay-safe-in-the-hospital/index.htm
