News flash: care improves when doctors consider the whole person

15 May

by Carolyn Thomas  @HeartSisters

When I worked in hospice palliative care, I remember being gobsmacked one day while reading in a medical journal about Dr. Harvey Chochinov’s research on Dignity Therapy out of the Manitoba Palliative Care Research Unit.(1) His studies determined that – wait for it! – patients feel better when their doctors listen to them. This of course sounds like a no-brainer until it hits you upside the head that, apparently, not all doctors know this fact to be true unless it’s published in a peer-reviewed journal.

Is it actually possible, I wondered at the time, that doctors thumbing through journals madly take notes when they discover a surprisingly shocking news flash like this?

Recently, I ran across yet another fine example of the bleedin’ obvious that makes me crazy-go-nuts, as my Ukrainian relatives would say.

In this study(2), researchers out of the University of Chicago recorded interactions between physicians and patients to see how doctors respond to what patients tell them about what’s going on in their lives, and particularly if they would pick up on the patient’s life circumstances before coming up with acontextualized care plan” – also called patient-centered decision-making.

These researchers specifically looked for red flags such as patients having missed appointments or showing apparent worsening of a chronic illness.

Then they reviewed recordings of doctor-patient interviews to determine if patients get better care plans and decision-making outcomes if doctors pay attention to real life factors like financial or emotional difficulties, or lack of social support that may be influencing their health behaviours.

To the surprise of not one patient reading this, over 70% of patient-physician encounters that produced these “contextualized” plans for care led to a positive outcome, compared with only 46% of visits that disregarded patient life factors, according to lead author Dr. Saul J. Weiner.

In fact, patients with contextualized care plans were almost four times as likely to show improvements, as reported in the April 16 issue of the journal, Annals of Internal Medicine.  As the study authors explained to MedPage Today:

“Contextual errors can occur when clinicians overlook a relevant factor in assessing the patient.

“For instance, failure to recognize when a worsening chronic condition, such as diabetes, is due to progressive cognitive disability and deteriorating medication adherence rather than a need for intensified medication therapy is a contextual error.

“In addition, contextual red flags are clues that should prompt the physician to consider patient context to look for obstacles to treatment adherence.”

In the case of missed appointments, for instance, contextual factors that could be contributing were identified in almost 25%, yet were addressed in the care plan in only half of those.

Since surviving a heart attack, I’ve often observed that even the skilled specialists who are providing my most important ongoing care know very, very little about my life outside of these visits.

So I was struck during an appointment last week with my fairly new family doctor by her conversational questions about my home, my relationships with my grown children, my social life, my day-to-day physical limitations, etc.  What may have seemed at first blush to simply be two women chatting casually was actually an astute attempt on her part to accurately assess vital information about her patient’s life and support system at home.

In fact, she likely learned more about me in under five minutes than some of my other doctors have in years. And that’s how doctors can come up with a contextualized care plan specific to their patients.

One of the key factors identified in the Chicago study was that patient-centered care requires clinicians to constantly address the question:

“What is the best next thing for this patient at this time?”

And as Dr. Weiner and his colleagues concluded:

“Our findings suggest that when clinicians successfully answer the question, as reflected in their care plan, there is an associated benefit to the patient that is measurable and substantial.”

In an editorial that accompanied the study, Dr. Hanan J. Aboumatar and Dr. Lisa A. Cooper of Johns Hopkins University called for broader application of patient context to improve healthcare overall:

“To make substantial improvements in health outcomes and healthcare quality, healthcare professionals and organizations should:

  • move beyond traditional healthcare provision models
  • redefine their responsibilities to and partnerships with patients, families, and other community groups and institutions
  • build systems that couple elicitation of patients’ contexts with services and support structures that address their particular social determinants of health”

Allow me to translate this observation: when doctors treat their patients like whole persons who have a full and complex life outside of the hospital or the doctors’ waiting room, things get better.

When doctors actually listen to what their patients are telling them – and ask questions about what they aren’t – things get better.

When doctors take the time to find out more about what Dr. Victor Montori and his Mayo Clinic-based team describe as the “burden of treatment” that’s particularly common in those patients living with one or more chronic diagnoses, things get better.

Remember Dr. Harvey Chochinov working on the concept of Dignity Therapy?  Here’s what his team has to say about the most important question that health care providers can ask of their patients – the Patient Dignity Question:

“The PDQ is a simple, open-ended question:

“What do I need to know about you as a person to give you the best care possible?”

“Research has shown that this single question can identify issues and stressors that may be important to consider when planning and delivering someone’s care and treatment.

“The intent is to reveal the ‘invisible’ factors that might not otherwise come to light – and to identify these concerns early in the process.”

If people with the letters M.D. after their names have to learn about this reality by reading study results in a medical journal because they don’t already know how to ask this question intuitively, perhaps we need to go all the way back to medical school training to see where failed engagement begins.

(1)  Chochinov HM, Hack T, McClement S, et al: “Dignity in the terminally ill: An empirical model,” Soc Sci Med 2002, 54:433-443,
(2) Saul J. Weiner, “Patient-Centered Decision Making and Health Care Outcomes: An Observational Study,” Annals of Internal Medicine. 16 April 2013, Vol 158, No. 8

See also:

Q: How has patient-centered decision-making affected your health care?

11 Responses to “News flash: care improves when doctors consider the whole person”

  1. Joanne McIntosh June 29, 2013 at 9:57 am #

    One of my Internist’s questions,
    “Do you have pain that is heart-related?”
    My answer,
    “I don’t know..I’m not a doctor.”

    Unfortunately, many specialists appear to view their patients as “walking organs”, and they seem to be interested only in the organ/illness that they specialize in. To attempt to vocalize other symptoms, seems to be considered by many as trying to take advantage of them.

    Here in London Ontario there seems to be a very restrictive environment even with many family Doctors, in that they will discuss one problem and one problem only, per appointment. I have yet to meet one who takes the time to consider the whole person. I would imagine this may be a side-product of the Doctor-shortage in this country.

    Like

    • Carolyn Thomas June 29, 2013 at 10:25 am #

      Hello Joanne – “Do you have pain that is heart-related?” Really. Seriously. Let me just go to medical school for a decade or so before I can answer that important question for you, Doc . . .

      When I went to Mayo Clinic, cardiologists there told us flat out that cardios are very very good at dealing with this one small organ, and often forget that there’s a whole person attached to that organ. And an endocrinologist there added: “Medical practice guideline parameters have been designed on a disease-by-disease basis.”

      I’ve written frequently on this issue, including here and here.

      Thanks so much for your comment.

      Like

  2. Antonia May 30, 2013 at 6:40 pm #

    Hello Carolyn …. there are indeed extremes in how doctors treat patients. Some doctors are THE BEST at seeing each person as a whole human being … I’m lucky to have a GP like this!! … and others see that same person as merely the 4 o’clock sinus infection. Some doctors are so burned out (but won’t/can’t admit it) that it may be impossible for them to be compassionate anymore and thus they see most patients as “difficult” at best and “the problem” at worst.

    Like

    • Carolyn Thomas May 30, 2013 at 8:02 pm #

      Interesting viewpoints, Antonia. I really appreciate your opinions here.

      Like

  3. Anonymous May 27, 2013 at 4:03 am #

    My doctor friends will tell you that, quite simply, they don’t get paid to make small talk with every patient, which is, sadly, how many of them might describe having to consider the “whole person” and all the ups and downs of each patient’s life, stress level, worries, family, workplace, etc etc.

    They are taught starting in medical school to assess each health condition swiftly and accurately, determine the appropriate treatment plan, and then move on to the other patients who are waiting for their attention.

    Pity.

    Like

    • Carolyn Thomas May 27, 2013 at 11:15 am #

      Dear Anonymous,
      That is a pity indeed. What patient hasn’t had the experience of feeling rushed through a doctor’s visit in which we are mentally editing our questions/concerns because we are so aware of taking up too much of the doctor’s valuable time? Much of value is thus completely missed by physicians like this.

      Like

  4. HealthHealing May 20, 2013 at 6:48 am #

    Thank you for this, Carolyn. I’ve had many experiences with doctors/nurses who unfortunately did not know anything about patient-centered care. But when I was in hospital last year for major back surgery, I was very impressed with the kindness and compassion of truly caring staff. I believe such care made a big impact on my healing both emotionally and physically.

    Like

    • Carolyn Thomas May 20, 2013 at 7:47 pm #

      Thanks for your perspective here. Good point about the strong link between emotional and physical healing. Hope you continue to heal.

      Like

Trackbacks/Pingbacks

  1. Insert Life Here - June 7, 2013

    [….] have a scale if you can’t imagine it, let alone sympathise, let alone empathise? […. Heart Sisters]

    Like

  2. Inspirational Reads - May 19, 2013

    [….] When recordings of doctor-patient interviews were reviewed to determine if patients get better care plans and decision-making outcomes when doctors pay attention to factors like financial/emotional…[….]

    Like

  3. Berkeley Bev - May 19, 2013

    Reposted from HEART SISTERS http://www.myheartsisters.org: … most important question from Dr. Chochinov says it all. Forward this to your own primary care provider …

    Like

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