Patient-Oriented Real-Life Encounters

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By: Ami Schattner, MD, visiting scholar, Ethox Center, Oxford University, Oxford, England, and professor of medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel

During medical school, we were taught to go after the patient’s history. And now we teach our students to do that.

By the patient’s history, we usually mean disease-centered data, such as the symptoms, their character and duration. Any past medical history, family history, occupational or social history, and habits that may be relevant to proper diagnosis are sought. However, I have long found that this type of information collection is, in a sense, a dialogue of the deaf. Patients crave recognition not only as “diagnoses” but also as persons. Indeed, Osler’s famous dictum “It is more important to know what patient has a disease, than what disease the patient has.” may be an overstatement, but it should be interpreted as a call to reverse the trend for an utterly “scientific” but humanistically-deficient practice of medicine. Curiously, it is more relevant today than when it was first used over a hundred years ago. The Institute of Medicine emphasis on patient-centered care is directly related. [1] The patient’s history [His(s)tory…] in fact includes further inseparable components: his or her identity (country of origin, childhood, family, occupation, achievements, etc.) as well as non-biological disease outcomes (stress, anxiety, depression, coping, contextual factors, etc.). These are not only highly prevalent but also strongly affecting patients’ quality of life and survival. [2, 3]

Ideally, all must be acknowledged as they are highly important, and their acknowledgement improves patient trust, satisfaction, adherence, quality of life, and health outcomes. [4] The physician stands to gain as well (for example, more interest and less burnout). [5]

Our frequent ongoing disregard of many of these aspects had been demonstrated by many studies: evidence of cutting the patient short within seconds, overlooking patient’s clues, missing opportunities to understand contextual factors or respond to emotions, and redirecting to ‘biological’ issues. [6-9] All these deficiencies seem to be common to many settings.

Reflecting on all this, and drawing on personal experiences that keep teaching me a lot, I have derived a simple formula that aims to address prevalent deficiencies. Published in the Archives of Internal Medicine in 2009 [10], it involves 5 elements which can be summarized by the acronym CAPTURES: show Curiosity and interest in your patient’s personal aspects; find something to Admire/ appreciate; try to see things from your patient’s Point of view; Touch and Use other body language to convey caring; React and respond to the patient’s words and body language; and stress and Support any positive aspects to encourage hope.

My personal experience (but no study…) demonstrates that these techniques, more a matter of attitude than a matter of any learning, can be readily adopted, take very little time, and the mutual benefits are too numerous to recount.

Often, our daily routine is so tight that we allow ourselves little time for those personal aspects of our patients and for reflection. A recent personal experience served as a poignant reminder to me, and I wrote it up in a Teaching and Learning Moments essay in the March issue. I had suddenly discovered that one of my very old and debilitated patients had a life story and experiences that were unique. Being in Vienna, alone, away from home and with time to spare, allowed more reflection, intensified the experience, and led me to write it up. However, I am convinced that in one way or another, every patient is unique. Recognizing and acknowledging it is what clinicians need to do to make their excellent practice perfect. [11]

 

References

  1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
  2. Frasure-Smith N, Lesperance F, Habra M, et al. Elevated depression symptoms predict long-term cardiovascular mortality in patients with atrial fibrillation and heart failure. Circulation. 2009; 120:134-140.
  3. Ayerbe L, Ayis S, Crichton SL, Rudd AG, Wolfe CD. Explanatory factors for the increased mortality of stroke patients with depression. Neurology. 2014; 83:2007-2012.
  4. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care. 1989; 27:S110-S127.
  5. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009; 302:1284-1293.
  6. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda. Have we improved? JAMA. 1999; 281:283-287.
  7. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000; 284:1021-7.
  8. Weiner SJ, Schwartz A, Weaver F, et al. Contextual errors and failures in individualizing patient care: a multicenter study. Ann Intern Med. 2010;153:69-75.
  9. Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med. 2008;168:1853-1858.
  10. Schattner A. The silent dimension: expressing humanism in each medical encounter. Arch Intern Med. 2009;169:1095-1099.
  11. Schattner A. Being better clinicians: an acronym to excellence. QJM. 2013; 106:385-388.

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