Taking action in patient-centred care

Nacho Vallejo

 

Frame of the series New Amsterdam

Talking about patient-centred care in our healthcare organizations may sound hollow or a tradition of good intentions. There are very attractive topics such as "patients first". In any case, putting patients first, abandoning traditional medical paternalism, has at times become an excuse to configure a variety of intentions that risk being left in symbolic speeches. I believe that one of the reasons that don't allow progress in this task is the need to specify it in actions that the ordinary professional can understand and carry out, checking its benefits and its results.

Shared Decision Making on the Roadmap to Patient-Centred Care

Víctor Montori is a professor of Medicine, a diabetes expert at the Mayo Clinic and an international benchmark in this field. He is also responsible for the foundation of The Patient Revolution, whose objective is precisely to make patient-centred care a reality. Understanding what shared decision-making translates in healthcare is an important challenge that must be thanked, and very much, Jordi Varela for the interesting and highly recommended reading entries that he has dedicated to him on this blog.

I had the opportunity to meet Professor Montori a few years ago during a visit he made to our country on the occasion of the National Congress of the Society of Internal Medicine. It's fair to value not only his professional career but also his extraordinary human quality. During his intervention in this meeting, he spoke about the health care we provide today and how it appears diffuse, blurred and prevents a clear view of its main actors, the patient and the health professional. Factors present in the clinicians' agenda, such as indicators, objectives, or healthcare pressure, sometimes interfere with the quality of the doctor-patient interaction. In these times of a pandemic, I also add that the necessary security measures aimed at preserving the health of all have revealed a somewhat "colder" outlook if possible. A healthcare system, as the internist Abraar Karan says, that "continues to be determined that we see people as patients when in reality patients are people."

Put patients' needs first

Recurring themes on this blog such as fragmented healthcare, overdiagnosis or overtreatment are responsible for increasing the burden of treatment in terms of unnecessary effort and dedication to the disease not only for patients but also for caregivers and family members. These are factors that can make it difficult for professionals to understand what people's needs are. Addressing these needs is nothing more nor less than understanding that people want to live their lives in the best possible way, at all times and according to what is most important to them. It doesn't seem like an easy task these days. The problem is that most of the tools that professionals have to help people (control objectives, clinical practice guidelines, processes) do not always contribute to this mission. And they do not do it because they are probably "useful for the group of patients like the one in front of us, but they do not necessarily respond to the needs of the specific patient in front of us."

To implement shared decision making, it's a good idea to provide unhurried conversations, which doesn't always mean more time with the patient. It's about dispensing with those aspects of our agenda that may be interfering with the care of the person and being able to see them, as Montori explains, in "high definition", better understanding their circumstances and her experience. Change the verbs inform, train and educate to learn to listen, understand and share, and arrive together at a solution to the problem that has an intellectual meaning (which contributes to the professional experience and scientific evidence), an emotional one (which serves in life patient) and a practical one (that we can execute the decision and make it a reality).

Some examples

How to deal with this can be complex. I recommend as a practical exercise viewing the American fiction and television series New Amsterdam. Inspired by the memoirs of Dr Eric Manheimer (Twelve Patients: Life and Death at Bellevue Hospital), it has its centre in the figure of a new director of a public hospital. A person deeply involved in his work and who is capable of breaking the rules that are necessary to help patients and hospital workers. In addition to being an interesting example of leadership strategies in the management of these health institutions, it highlights in each episode the importance of the conversation between professional and patient, being an excellent practical manual of the scope and value of the shared decision making.

And what is the role of the healthcare institution?

Since events do not always depend on the professional or the patient, it's convenient, at this point, to make a call of attention to the health organization. Integrating shared decision-making into care should also be a strategy of the institution. We have very interesting examples of this approach, such as hospital Bernhoven, in the Netherlands: "Can patient-centred care plus shared decision making equal lower costs?". This is an interesting publication from The British Medical Journal that addresses this experience. Finding in the entrance hall of this hospital a sign with large letters where you can read "Better health care begins with a good conversation. In this hospital we decide together" is already a declaration of intentions. This article offers some compelling proposals and organizational changes implemented in that hospital. It's worth reading the reflections of its managers, who approach the experience from an interesting perspective: not to insist that the professionals change care towards a more patient-centred approach, but rather to generate the working conditions in which that is possible.

We need a cultural change that promotes the quality of the relationship between the patient and the healthcare professional, as a pillar on the path to people-centred healthcare. Talking "without rushing", taking into account people's needs and turning the model towards shared decision making are useful elements that should be taken into account in the roadmap. Patients, professionals and health institutions must abandon rhetoric and work together to promote a healthcare system that guarantees supportive, careful, friendly assistance that takes into account the needs of each one and the care of the patients in front of us (not only of patients "like the one in front of us").

Other additional references:

First of all, the Catalan Society for Health Management includes an inspiring conference delivered in 2017 by Víctor Montori.

Another engaging article, Patient-centred diagnosis: sharing diagnostic decisions with patients in clinical practice, was published in November 2017 in The British Medical Journal. It addresses shared decision making in the diagnostic phase. Xavier Bayona performs the analysis of the article in this other reading of this blog.