19 July 2019

How being patient-centred can be real and concrete

General Practice Patients

When tension is high, calm focus is a gift.

Picture this. My patient was in hospital having responded appropriately to the red flag of reduced fetal movements. Tests had been run. Expert consensus was that both mother and baby were healthy, but now was the time for a caesarean. A theatre was available; obstetrician and team were waiting.

The problem was one person was missing from that consensus: the mother. The mother could feel the baby moving again and wanted to wait another 24 hours to see if life within the womb would return to normal.

The family got me on the phone. The information I needed to communicate was complex. It included: this is your first time; these folk deal with this situation all the time; no-one can guarantee that a caesar now will result in the outcome most hoped for but that, on balance, action now is most likely to result in a good outcome.

All this needed to be conveyed in a way that respected the mother’s autonomy, with no hint of resorting to guilt as a motivator.

The decision was made. The caesar went ahead. And 10 weeks down the track, the result has been marvellous.

But now, my point.

When I got to the hospital I was told about the attending midwife who was contributing to the pre-op conversations. I was told how her contribution protected the mother from a system that tended to value theatre-time above patient-centeredness. Her approach respected the complexity of the mother’s situation and created a safe space that ensured she did not feel bullied into a decision.

The performance of this midwife made my heart sing. More than all the others gathered around the bed, that midwife was the one who recognised the pressure inadvertently being put on the woman to get consent and to get it quickly.

My delight was not only in the midwife’s patient-centred focus but also, it appeared, in the fact that the midwife had been supported as a professional within this healthcare system to be patient-centred.

My motivation to tell this story arose during a recent strategic planning day.

Our Primary Health Network was joined by consumers, senior clinicians and administrators from the local health district. On days like this most PowerPoint slides mention “patient-centredness”. Diagrams show the patient in the centre of health system ecologies.

So common is this that the audience starts to wonder what patient-centred actually means – or if it has just become part of the jargon.

But don’t get wearied by the talk. Patient-centeredness is concrete, therapeutic and measurable.

However, if clinicians are to sustain patient-centred work, they need more than their personal professional aspiration. They need the support and autonomy that comes from working in a patient-centred healthcare system.

The story of my mother-to-be and proposed caesarean delivery demonstrates that patient-centredness is a value that drives the maternity unit at the Nepean Hospital, Penrith, in NSW.

The patient-centred clinical method was conceptualised over a decade or so in the Department of Family Medicine, University of Western Ontario, Canada under the inspirational leadership of Ian McWhinney. This work culminated in the publication of Patient-Centred Medicine: Transforming the Clinical Method, by Moira Stewart and colleagues, in 1995.1

The method assumes and does not devalue biomedical knowledge and skills. In fact, it is built on the biomedical platform.

The method distinguishes “disease” (the pathological process) from “illness” (this patient’s unique experience of feeling unwell).

It seeks to “understand patients within their social and developmental context”.

A crucial aim of the method is to find “common ground” with the patient. A critical skill is managing the discomfort that may arise in “relinquishing power to patients”.

In my opinion, this discomfort is experienced not only by individual clinicians but also by health systems.

Patient-centredness may have implications for the budget.

Stewart and colleagues explore the six components of the method.

  • Explore both the disease and the illness experience
  • Understand the whole person
  • Find common ground
  • Incorporate prevention and health promotion
  • Enhance the patient-doctor relationship
  • Be realistic

Patient-centredness is not jargon. It is a well-described clinical method. Its implementation is crucial to the pursuit of the first and fourth elements of the Quaternary Aim:

  • Improve the patient experience
  • Improve the health of the population
  • Achieve both of these cost-effectively
  • Increase the joy of health professionals in their work

Another story demonstrates how truly valuing patient-centredness drives constructive change.

The Head of Nephrology at Westmead Hospital in NSW, Professor Jeremy Chapman, observed that the sooner patients present with problems after a transplant or while on dialysis the better the outcome.

Patients who delay turning up are, perhaps all too often, labelled as unmotivated, lacking responsibility for participating in their own care, poor compliers, and so on.

 But Professor Chapman took a different approach. He found, that in many cases failure of prompt and appropriate attendance for medical care arose because of barriers that had inadvertently emerged in the system. These included overtaxed emergency departments and overbooked clinics.

System reform was instigated.

Rather than having to run the gauntlet of outpatient appointments, referrals or ED presentations, patients were able to access their renal team directly: “Just turn up to clinic – no phone calls, no booking, just come.”

This patient-centred change reduced costs to the system by treating emerging problems early, demonstrably reducing the need for admission to hospital. It improved patient health and wellbeing and, perhaps counterintuitively, it increased the renal team’s professional satisfaction in their work.

That ticks off three elements of the Quaternary Aim and, by my guess, all four.

When an audience becomes jaded about “patient-centred care” it is time to tell stories.

Reference:

1. Patient-Centered Medicine: Transforming the Clinical Method. Moira Stewart et al. SAGE Publications, California, 1995. (Note, a 3rd Edition was published in 2014)

Dr Michael Fasher is Adjunct Associate Professor at the University of Sydney and Conjoint Associate Professor at Western Sydney University