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 at 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 a “contextualized 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
NOTE FROM CAROLYN: I wrote much more about doctor-patient communication in my book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for this book at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 20% off the list price when you order).
Q: How has patient-centered decision-making affected your health care?