Original Publication
Open Access

Keeping the Patient at the Center: Teaching About Elements of Patient-Centered Care

Published: November 11, 2016 | 10.15766/mep_2374-8265.10500

Appendices

  • Patient-Centered Care.mp4
  • Patient-Centered Care Facilitator Guide.doc
  • Saks Excerpts.doc
  • Sample Admission Note.pdf

All appendices are peer reviewed as integral parts of the Original Publication.

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.


Abstract

Introduction: There is growing interest in delivering patient-centered care in all areas of medical practice, yet acquiring the requisite attitudes, skills, and behaviors simply by observing or participating in current systems of care that employ a medical or physician-centric model is challenging. Patient centeredness involves an understanding of patients’ perspectives on their illness and treatment, the impact that health and illness have on the lives of patients, and the values and goals patients have for themselves, while also encouraging patients and health care professionals to engage in a shared decision-making model of health care. That model aspires to result in increased trust between providers and patients, as well as better patient outcomes. Methods: This 90-minute workshop utilizes three different approaches to help the learner develop patient-centered care and communication skills in a mental health setting: a video of a patient sharing her experience with the mental health system, a narrative model of appreciating patient experience (first-person memoir), and an exercise using patient-centered language in a medical record documentation. Results: This workshop was presented at the American Association of Psychiatric Directors of Residency Training (AADPRT) Annual Meeting in March 2016. Approximately 21 people attended. Feedback was received from 11 participants and demonstrated a high degree of agreement (4.5 out of 5) with the following statements: the speakers met the stated educational objectives; the content was educationally useful; the information in this presentation will inform my educational practices; the presentation advanced my knowledge of the subject. Discussion: While these three pedagogical exercises do not cover the entirety of the skills required for patient-centered care and communication, they do provide a useful starting point for hearing and appreciating the experience of the patient. Despite the focus on mental health settings and treatment, other medical specialties could derive useful ideas from this workshop format or adapt the materials to their own needs.


Educational Objectives

By the end of this session, learners will be able to:

  1. Identify ways in which current practices in mental health care lack a patient-centered approach.
  2. Appreciate the impact of forms of patient communication and interactions with patients that have a patient-centered quality.
  3. Value a patient’s perspective in communicating and developing treatment plans.
  4. Compare the US and UK systems of care as presented in the memoir by Elyn R. Saks.

Introduction

Patient-centered care has been identified by the Institute of Medicine as one of the six main elements of high-quality care.1 Communication skills that are central and fundamental to the provision of patient-centered care include fostering healing relationships, exchanging information about what patients want and need, responding to patients’ emotions, engaging in informed and collaborative decision making, and enabling patient self-management.2 Interestingly, this is likely to be the way health care is reimbursed going forward, with quality indicators such as patient satisfaction being linked to payment for services. In addition, new models of care delivery, such as accountable care organizations and health homes, direct increased attention towards and drive training in patient-centered communication. Studies clearly show that patient-centered care provides cost savings, better care, better outcomes, and greater satisfaction for both the health care professional and the patient.3-6

Patient-centered care and communication start by listening to the patient. In this workshop, two of the three exercises are focused on hearing the patients and their experiences, one through a patient interview in a video, the other through excerpts from a written memoir of illness. Information gleaned from both of these methods allows the workshop participant to see common themes described by the individuals, appreciate the ways that health care professionals communicate through both what they say and the way they behave, and learn important insights from patients about how care could be delivered in a more patient-centered way. The third exercise looks at the way language is used in medical records, presenting the chief complaint and history of present illness in a sample admission note. The way we write about patients in the health record can set the tone for both how we perceive patients and the judgments we make about them. Even common parlance in medical records refers to the patient admitting or denying symptoms or parts of the history, which conveys an adversarial or judgmental attitude.

This workshop is best suited for use with a mental health audience at any level (from medical students to residents and fellows to faculty and practicing clinicians) but can also be utilized with other medical specialties, as the concepts of patient centeredness are universal. Health care providers in other specialties, however, may choose to use different examples of patient experience and a medical record note that is more specific to the types of patients with whom they would be working.

Methods

This educational intervention facilitates learning about patient-centered communication with three pedagogical tools: a video of a patient interview, excerpts from a first-person memoir of mental illness, and an exercise in writing an admission note in a mental health setting.

This workshop is designed to be a 90-minute session as follows:

  • Opening (10 minutes): presenter introduction and check-in with participants regarding their goals and reasons for attending. Presenters ask participants to offer their own definition of the term patient-centered care.
  • Video presentation/discussion (20 minutes): Participants view a 9-minute video (Appendix A) of an interview with a person who has experience with the mental health system. A follow-up discussion focuses on highlighting some of the concepts raised by this individual about care that was not helpful or patient centered, suggestions made by the individual that could be incorporated into the participants’ practice of care, and things this individual found helpful. A facilitator’s guide (Appendix B) is provided to help direct this discussion.
  • Narrative excerpt from memoir (20 minutes): Participants are assigned sections of excerpts from Elyn R. Saks’ memoir, The Center Cannot Hold: My Journey Through Madness7 (Appendix C), to read aloud. Professor Saks is a legal scholar and mental health advocate and has had her own experiences with mental illness. This part of the workshop first utilizes small groups to discuss their reactions to the reading. Following the small-group discussion, the large group comes back together to share thoughts and consider other questions (included in this Appendix).
  • Medical record note (15-20 minutes): Small groups are utilized again for this section of the workshop in which an admission note including a chief complaint and history of present illness is presented (Appendix D). The task for the groups is to recognize the stigmatizing language and to rewrite the note using more patient-centered language. The groups are given about 12 minutes to rewrite the note and then are asked to share what they have written.
  • Closing (20 minutes): In the large group, participants process the experience of the workshop and discuss potential opportunities as well as obstacles to implementing patient-centered care in their institutions. Participants are allowed to give examples of things they have found useful and incorporated into their own practices that are patient centered.

Results

This workshop was presented at the American Association of Psychiatric Directors of Residency Training (AADPRT) Annual Meeting in March 2016. The participants were training directors, associate training directors, or coordinators in psychiatry residency programs from the US and Canada. Objectives for this group included having the participants both learn about patient-centered care and gain exposure to workshop/teaching resources to help their own learners in residency programs. Approximately 21 people attended. Feedback was received from 11 participants and demonstrated a high degree of agreement (4.5 out of 5) with the following statements:

  • The speakers met the stated educational objectives.
  • The content was educationally useful.
  • The information in this presentation will inform my educational practices.
  • The presentation advanced my knowledge of the subject.

All the respondents also indicated that there was no evidence of commercial bias.

The objectives for this MedEdPORTAL module have been modified slightly from those used at the AADPRT session due to differences in expected audiences. The first objective in this module focuses on raising awareness of ways in which our current system of care is not patient centered. This was done in an effort to look at systems and practices so as to potentially change them to be more patient centered. The video and the narrative exercises provide the mechanism to discuss these issues. The second objective relates to communications and interactions with patients that are more patient centered. All three exercises can support this objective in that they all highlight various ways mental health providers provide a framework for positive (or negative) patient centeredness, either through speaking/interacting with patients or writing about them. The third objective emphasizes taking an individual patient’s perspective, circumstances, and/or values into account in caring for him or her. Margaret, in the video interview, tells us what worked for her and what did not, while Saks describes one system of care in the UK that provided a more therapeutic climate that could be emulated in other settings. The fourth objective allows learners to compare similar clinical circumstances that Saks encountered in the US and UK mental health systems and discuss possible reasons for these differences, as well as considerations for how the US system might be able to incorporate approaches used in the UK.

In the AADPRT session, the participants appeared very engaged in all three exercises as learners (as opposed to educators). There was lively discussion, and participants offered strategies being utilized in their various settings to incorporate a more patient-centered focus. The participants found that both the video/interview and the narrative/memoir offered thought-provoking content that could inspire change in their practices as well as their educational interventions. The note-writing exercise, while seemingly obvious, was taken seriously by the participants, and the groups were able to recognize and transform non-patient-centered language into a thoughtful note that represented the clinical information in a less judgmental way.

Discussion

While these three pedagogical exercises do not cover the entirety of the skills required for patient-centered care and communication, they do provide a useful starting point for hearing and appreciating the experience of the patient. They explore in depth the aspects of patient care that are and are not patient centered and demonstrate the effect these experiences have on the patients involved. Hearing these experiences through a videotaped interview and from a first-person memoir allows the learner to reflect both on how patient interactions are perceived and on ways that communication and care plans could be modified to provide a more patient-centered approach. Scrutinizing a mock medical record note provides an opportunity to look at the way health professionals convey information about patients in medical records and how using patient-centered language can set the tone for respectful approaches to the patient.

The workshop may be modified or improved by using a standardized patient encounter so that learners can practice communication skills and get direct feedback from the patient about various elements of patient-centered care and communication. The exercise involving the mock admission note could be replaced by using an actual, deidentified note from a patient record whose language or descriptions could be changed to illustrate how the use of medical record language can set the tone for the way that patients are viewed by health professionals.


Author Information

  • Susan Stagno, MD: Director of Education, Department of Psychiatry, University Hospitals Case Medical Center; Professor of Psychiatry and Bioethics, Case Western Reserve University School of Medicine
  • Kathleen Crapanzano, MD: Assistant Professor of Clinical Psychiatry, LSU-Our Lady of the Lake; Training Director, Psychiatry Residency Program, LSU-Our Lady of the Lake
  • Ann Schwartz, MD: Director of Psychiatry Residency Education, Emory University School of Medicine; Associate Professor of Psychiatry and Behavioral Sciences, Emory University School of Medicine

Disclosures
None to report.

Funding/Support
None to report.

Ethical Approval
Reported as not applicable.


References

  1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2000.
  2. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff (Millwood). 2010;29(7):1310-1318 http://dx.doi.org/10.1377/hlthaff.2009.0450
  3. Freeman TR. Patient-centred approach is the way. Can Fam Physician. 2014;60(12):1081.
  4. Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. Ann Fam Med. 2005;3(5);415-421. http://dx.doi.org/10.1370/afm.348
  5. Stewart M, Ryan BL, Bodea C. Is patient-centred care associated with lower diagnostic costs? Healthc Policy. 2011;6(4):27-31. http://dx.doi.org/10.12927/hcpol.2011.22393
  6. Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013:158(8):573-579. http://dx.doi.org/10.7326/0003-4819-158-8-201304160-00001
  7. Saks ER. The Center Cannot Hold: My Journey Through Madness. New York, NY: Hyperion Books; 2007.


Citation

Stagno S, Crapanzano K, Schwartz A. Keeping the patient at the center: teaching about elements of patient-centered care. MedEdPORTAL. 2016;12:10500. https://doi.org/10.15766/mep_2374-8265.10500

Received: July 5, 2016

Accepted: September 29, 2016