This is part two in a series of posts on person centered care. You can read part one here. A version of this content recently appeared as a guest post: “The center of gravity in health care and the role of primary care” on KevinMD.com. A recently recorded podcast episode on the guest post is also available here.
The concept of patient-centeredness has now been embedded in healthcare policy frameworks and strategic plans worldwide. There has been a seismic shift in our collective clinical mental construct about patient-centeredness, reflected in changes to medical education which has transitioned to a model of shared decision-making, respect for patient privacy, and honoring of patient preferences, among other things. This is remarkable progress. Much of the emphasis on restoring patient-centeredness has been focused on the patient experience, and heroic work has been done to understand and unravel the threats. Numerous programs, policies, and processes have been implemented to improve (and measure) patient experience. However, too much responsibility has been placed on the shoulders of clinicians – to be more compassionate, more considerate, more patient; to be better listeners, better communicators, less in a rush. None of these efforts is “wrong”, but they still don’t get at the heart of patient-centeredness.
Turning the tide has been a gradual process of chipping away at tradition and introducing practices which incorporate patients and families in new ways, beginning with changes like the implementation of informed consent and advanced directives. These foundational developments were the start of a revolution in health care. Today, the ideal model of patient-centeredness falls on a spectrum, with involvement of the patient (and families) in medical decision-making at the low end, and empowering patients to take responsibility for their own health and treatment at the high end.
In the middle between these two ends of the spectrum, we find other worthy approaches to patient centeredness:
- Care that incorporates patients’ values and preferences, like language, religion, and cultural expectations.
- Increased diversity across physicians to be more representative of the community.
- Consideration of a patient’s abilities, like mobility limitations, cognitive impairment, and financial constraints.
- Coordination of care and patient advocacy, to help patients navigate health system complexity.
- Clear communication about one’s condition, prognosis, and treatment plan.
- Consideration of the patient’s physical comfort, ensuring that symptoms like pain, nausea, and thermal comfort are properly addressed.
- Accessibility of care, ensuring appointment availability, ease of scheduling, and adequate parking.
- Help understanding medical bills, identifying highest value services, and negotiating payment plans.
- Assessment of social determinants of health and connection to community resources.
- Providing trauma-informed care where appropriate.
But a truly patient centered healthcare system would be built on a sturdy foundation of high quality primary care. Patients want to know what they need to do – how to get the right care, at the right time, from the right person; how to identify and manage their signs and symptoms and when to ask for help; how to take their medications; how to make more informed decisions when faced with complex health quandaries or end of life decisions.
There is no one better positioned in the healthcare system than a patient’s primary care physician to help them navigate the convolution, explain and educate, advocate for timely care from the right sources, and partner with the patient in working toward their health goals. The healthcare system still has work to do to support what patients need to exercise more sovereignty over their own health, but primary care is the cornerstone.
The U.S. healthcare system won’t be truly patient-centered until we put power in the hands of the patients and give them a collaborator and advocate, in the form of a primary care provider (PCP). Unlike any other medical speciality, primary care approaches a patient’s care holistically, and serves as a quarterback to help patients increase both health care and health system literacy. The role of the PCP is uniquely suited to empower patients with education, navigation, coordination, and integration of healthcare complexities. Because of the exclusive, longitudinal, trusting relationship between a patient and their PCP, the PCP is the clinician best equipped to walk a patient through end of life planning, scary treatment decisions, and bad news. The PCP is also the antidote to patient consumerism – when my patient and I know each other and have developed trust, we can discuss their suggestions as partners, and there is no power struggle or fear contaminating our relationship.
If we want a more effective healthcare system, it needs to be re-engineered to revolve around the true center of gravity – the patient. We must involve patients early and often in the design of health policy, health technology, and health care ecosystems. We must reinvent health care payment models to tie incentives to what is of value to patients. And we must give every American access to a high-quality PCP.
Until we do this, we’ll continue to pay too much money for too little value, and we’ll all suffer in a system perfectly designed to keep getting the results it’s getting.