Frankel, Richard M. PhD; Eddins-Folensbee, Florence MD; Inui, Thomas S. MD, ScM
In “Crossing the Quality Chasm,”1 a widely cited and influential 2001 report, the Institute of Medicine (IOM) asserted that patient-centered care is one of six domains of quality in medical care. The absence of patient-centeredness in the physician–patient relationship, the IOM stated, is associated with outcomes such as lower patient satisfaction, poorer adherence to medical recommendations, less well-controlled blood pressure, higher glycosylated hemoglobin A1c, and greater propensity to sue for medical malpractice in the face of an adverse event. Although definitions of “patient-centered care” vary, almost all indicate that patients should be partners in their care and that their values, attitudes, and preferences should be considered in making medical decisions.
In this article, we review the philosophical and scientific foundations of patient-centered and relationship-centered care and suggest that faculty development in three key areas—mindful practice, formation, and training in communication skills—is necessary to achieve patient- and relationship-centeredness. After providing concrete examples of teaching methods in these three areas, we offer five recommendations for faculty development. Finally, we examine the link between patient-centeredness and the medical education revolution prompted by Abraham Flexner more than a century ago.
In Flexner's day, the prevailing view was that physicians should remain detached from patients so as to maintain an “objective” stance. Current concepts of communication and quality challenge that physician-centered view of the patient as a specimen to be studied, and instead suggest that patients and physicians mutually influence one another during the context of giving and receiving care. Richard Glass,2 deputy editor of the Journal of the American Medical Association, captured well this shift in emphasis in his 1996 editorial introducing “The Patient–Physician Relationship” as a new section of the journal:
The patient–physician relationship is the center of medicine [italics added]. As described in the patient–physician covenant, it should be “a moral enterprise grounded in a covenant of trust.” This trust is threatened by the lack of empathy and compassion that often accompany an uncritical reliance on technology and pressing economic considerations.
Foundations of Patient- and Relationship-Centered Care
The contemporary use of the term “patient-centered care” has its roots in the work of Joseph Levenstein, a South African family physician interested in the effects of family, community, and culture on care processes and outcomes.3 Levenstein's ideas concerning the social and psychological factors affecting patient behavior were of particular interest to Ian McWhinney,4 whose 1986 essay “Are we on the brink of a major transformation of clinical method?” was influential in promoting a philosophy that expanded the physician's role to include dynamics such as “finding common ground” with patients as a fundamental precept for successful practice. McWhinney and his colleagues in the University of Western Ontario's Department of Family Medicine have since conducted a series of outcome-based studies documenting the effectiveness of the patient-centered clinical method.5,6
A more recent expansion of the patient-centered care model is the concept of relationship-centered care.7 Whereas patient-centered care focuses on patient behavior, relationship-centered care considers relationships to be vital to medical care, research, and education. It is based on four principles: (1) Relationships in health care ought to include not only the role but also the “personhood” of the participants, (2) affect and emotion are important components of these relationships, (3) these relationships occur in the context of reciprocal influence, and (4) the formation and maintenance of genuine relationships is morally valuable.8 By conceptualizing the relationship as the smallest unit of measure, relationship-centered care focuses on the communication and interactional processes through which patients' needs are established and addressed within the physician–patient relationship. In terms of medical education, relationship-centered care promotes curricula that build on self-awareness as well as on key relationships with patients, their family members, other health professionals, the community, and society.
The biopsychosocial model developed by George Engel, an internist with interests and training in psychiatry, is critical to understanding contemporary patient- and relationship-centered care models. Engel's influential 1977 article, “The need for a new medical model: A challenge for biomedicine”9 (and other publications10,11), set the stage for much contemporary thinking about the physician's expanded role as an active participant in, rather than a “detached observer” of, the medical encounter. Engel and his followers have documented the intricate sets of interrelationships that exist within the biopsychosocial framework and their effects on processes and outcomes of care—for example, the effects that stress at the societal or cultural level can have on immune response at the cellular level.12
Fostering Patient- and Relationship-Centeredness in Physician–Patient Interactions
Inherent in patient- and relationship-centered approaches is the idea that establishing and maintaining healing relationships is central to delivering high-quality health care and requires the physician to have a deep knowledge of self. Therefore, professional development of self-awareness skills is crucial to ensure that physicians provide patient- and relationship-centered care, whether they are responding empathetically to a patient's statement of suffering or considering their own sadness in delivering bad news to a patient. Researchers have shown that three educational approaches to self-awareness promote patient- and relationship-centeredness in physicians and trainees: mindful practice,13,14 formation,15 and training in communication skills.16,17 Below, we describe each of these approaches and provide an illustration of the way each can be taught.
Broadly speaking, mindfulness is a form of reflection that allows a practitioner to review or reexperience a situation and learn from it. According to Epstein,14
Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight.
Importantly, mindfulness incorporates a nonjudgmental stance, one of curiosity rather than evaluation. In this respect, mindful practice has much in common with the philosophical stance of phenomenology, which asks how we know what we know, not how we judge it.18 Schoen19 introduced an early application of the concept of reflection in professional practice based on his observations of how reflective practitioners in “performing fields” went about their work.
Mindfulness involves bracketing different types of knowledge that are relevant to professional practice. (Bracketing refers to suspending one's beliefs and judgments to understand their underlying presuppositions and assumptions.) These types of knowledge include explicit knowledge, which consists of facts and logical relationships, and tacit knowledge (what Polanyi20 referred to as “personal knowledge”), which consists of internal experiences, feelings, beliefs, know-how, and deeply held values. In an educational setting, explicit knowledge is what trainees learn formally in the classroom; it is easily translated into evidence-based practice guidelines, for example. Tacit or personal knowledge is what Hafferty and Franks21 referred to as the informal or “hidden” curriculum; it is learned from observing and modeling the behaviors of others outside the classroom. The mindful physician reflects and calls on both types of knowledge in promoting patient- and relationship-centered clinical practices.
Teaching mindful practice.
One model for teaching mindful practice is the five-day intensive course in medical interviewing skills that the American Academy on Communication in Healthcare (AACH) has offered for the past 25 years, sometimes referred to as the Lipkin model.22 The AACH course includes didactic lectures and workshops, individual and small-group practice sessions with feedback on bedside and clinic interviewing skills, personal awareness (PA) groups, and project groups. Personal journaling is encouraged. The goal of the skills component is to expose learners to patient- and relationship-centered interviewing techniques that have been shown to improve outcomes, such as opening and setting an agenda for the visit, eliciting the patient's perspective, demonstrating empathy, and testing for patient comprehension. Groups of four to six attendees work on these skills with two faculty facilitators who are trained in teaching communication skills, small-group dynamics, and giving effective feedback.
The PA groups operate in a Rogerian, nondirective style. The facilitator does not establish an explicit agenda but, rather, describes ground rules for confidentiality and the time at which the session will end. Two skills groups and their facilitators combine to form a PA group (8–10 participants, 4 facilitators) that remains the same throughout the week. PA groups meet daily, immediately before or after skills groups, for two to three hours. Typically, PA groups raise deep personal and interpersonal issues; some are related to the skills group sessions, and some focus on larger issues of clinical practice, burnout, balance, loss, and grief.
Insights from this method.
The AACH's method of pairing skills practice with PA and journaling to teach mindful practice can lead to dramatic insights.23 For example, a female physician who has difficulty interviewing a male alcoholic patient during a skills session may, during her PA group, describe growing up with an alcoholic father who was loving when he was sober but emotionally and sometimes physically abusive when he was not. Although a connection between these two experiences may not seem obvious to the participant, by reflecting in a small group and then journaling about the experience, she may gain the insight that her skills difficulty is a result of her projecting her own family experience onto her patient. Having made the connection, the participant can “process” it both in subsequent skills sessions and PA groups as well as through journaling. This process of increasing mindfulness and personal growth as experienced by participants in AACH courses has been described elsewhere.24 Further, a recent community-based trial of mindfulness training showed positive results with regard to physician burnout, empathy, and attitudes among primary care physicians.13
A number of authors have described the changes that take place as individuals move from novice to expert,25 or from trainee to professional.26 These stages as well as the processes of professional enculturation in nursing and medicine are well described in the literature.27,28 Less studied, but no less important, is the relationship between professional socialization and the quality of care that health care professionals deliver.
Over the last decade, accrediting bodies, educators, and policy makers have shown renewed interest in promoting and educating health care providers about professionalism and professional values.29 A variety of reasons have been put forward to explain this. Most scholars agree that a sizable number of physicians have become demoralized by the focus on medicine as a business, pressures on their time, and a general erosion of trust and respect for physicians; as a result, they desire a return to first principles of the profession.29,30 Additionally, unprofessional behavior during medical school has been identified as a “missing link” in predicting who will have disciplinary actions brought against them by state medical boards.31 All this adds up to a burgeoning literature on defining and assessing medical professionalism.32,33
How educating for professionalism might lead to greater patient- and relationship-centeredness is an interesting and complex question. From a pedagogical point of view, the challenge is how to teach professional values in relationships at multiple levels across the medical school curriculum and culture. As noted by a number of authors,34,35 much teaching and learning about professionalism and professional values occurs through the “hidden” and informal curriculum. As summarized by Inui and colleagues,36 learners typically move from
• being focused on the formal to being focused on the “informal curriculum” (from noting what we say to noting what we do);
• being open-minded and curious to being test-driven and minimalistic, focused only on what they need to know to pass examinations;
• being open-hearted and idealistic to being well defended and closed-minded;
• being altruistic to cynical, concluding that medicine is a field in which one must say one thing and do another;
• being empathic to being task-driven, focused less on the patient's experience and more on getting their own work done;
• being confident to being uncertain in their capacity for moral reasoning.
The extent to which patient- and relationship-centered interactions are manifest in the environment in which students are immersed is highly variable from one institution to another, suggesting that there are likely “best practices” that medical educators could harvest for teaching purposes.37
Strategies to teach trainees.
One of the best ways to teach trainees professional behavior and role recognition is by using what psychologists call parallel process to create and assess learning experiences.38,39 Doing so encourages learners to make connections among what they are learning, how they are learning it, and how it relates to what they see in day-to-day practice. For example, in teaching about respect and trust as professional values in patient care, the educator could design and employ a parallel trust-building exercise so that students experience in the classroom what it feels like to be respected and trusted as individuals. Facilitated learning would then proceed by moving back and forth between the students' experience of being cared for as individuals and their responsibility to care for others. In terms of teaching patient- or relationship-centeredness as an element of professional behavior, the educator could employ a learner-centered approach to model the behaviors students are expected to exhibit with their patients. Parallel processes can also be used to teach about ethical decision making in situations of cognitive dissonance. Classroom exercises and conversations that anticipate situations in which students witness their teachers acting unprofessionally may inoculate students against cynicism, preventing them from becoming disillusioned or dispirited.
Strategies to teach faculty.
It is also important to address the hidden curriculum by teaching faculty to recognize the complexities of their own roles as physicians and the culture of the organizations in which they work. This might include exploring issues such as maintaining a balance between home and work, setting aside time for oneself, and meeting the service demands of the profession. Parker Palmer,40 an educator and social scientist who has written extensively on this topic, referred to this as the challenge of “living an undivided life” and to the process of striving for wholeness as “formation,” a term borrowed from educating clergy. Like mindfulness, formation involves cycles of reflection on what it means to be a physician, to be in community, and to remain true to one's values and commitments in the face of competing demands. It is conceptualized as a continual process of becoming and is not thought of as instrumental (i.e., having an end goal in mind). Formation activities are particularly helpful in understanding and dealing with the spiritual dimensions of patient- and relationship-centered care.
A faculty development example.
The Center for Courage and Renewal has been offering programs in formation and formation facilitator training since 1997.41 Inspired by Palmer's work with primary and secondary school teachers, its “Courage to Teach” and “Circles of Trust” programs are designed to help participants look inward and identify the role of their subjective experience and spirituality in their work and personal lives. These programs have been expanded to include other professionals, such as physicians, lawyers, and clergy. A stated goal of this approach is to help participants achieve congruence between their inner experience and the call of service, thereby leading them to an “undivided life.”41 In recognition of Palmer's work in medicine, the Accreditation Council for Graduate Medical Education (AGGME) has given out 10 Parker J. Palmer Courage to Teach Awards each year since 2002.
Courage to Lead facilitator training programs typically involve quarterly 1.5-day workshops that are structured around the seasons of the year, which provide metaphors for reflection and dialogue. Courage work is not skills based in the conventional sense of the term. As noted above, its goal is not instrumental—like pairing PA with clinical skills instruction—but, rather, to create opportunities for individual reflection and sharing in small groups. A typical exercise in courage work is to use a “third thing” (typically poetry, art, or music) as an object for reflection and meaning making. For example, in one exercise, participants in a large group are asked to read the poem “The Way It Is,” by contemporary American poet William Stafford,42 then they are invited to reflect on and journal about a few questions (see Box 1). After journaling, they return to the large group for an open-ended discussion of what the process brought up for them.
In a real-life example, one of us (R.M.F.) was facilitating a Courage to Lead training exercise when a general internist shared that he had recently received a major promotion that forced him to live several hundred miles away from his family, and he could see them only on weekends. The internist stated that reflecting on the poem made him realize that his first commitment was to his family. As a result of this insight, he said was planning to resign his new position to rejoin them full-time (and he subsequently did). Summing up his experience with the exercise to his group, he said, “I will likely have many jobs in my lifetime but only one family!”
The link between this type of faculty development exercise and patient- and relationship-centered care is the parallel between being congruent with one's values—the importance of family, for example—and recognizing competing demands that might challenge or compromise those values. When viewed as a model of change, formation is a particularly powerful tool that faculty can use to help trainees understand and balance personal and professional values.
Training in communication skills
If trust, respect, and connectedness are among the most desirable outcomes of patient- and relationship-centered care, then effective communication skills are the means by which these outcomes are realized. Recent scholarship has linked specific communication skills, like agenda setting and use of empathy, with specific outcomes of care such as adherence, propensity to sue for medical malpractice, and satisfaction with care.43,44 The landmark IOM report “To Err Is Human”45 made clear that communication breakdowns play a major role in as much as 80% of adverse events.
In terms of medical education, consensus statements describing effective patient- and relationship-centered communication skills, such as finding common ground, being nonjudgmental, and active listening, have been published.17,46 Valid and reliable systems for assessing such communication skills have been developed as well.47–49 Also, systematic reviews of the literature have shown that communication interventions can improve patient- or relationship-centered care.16,50 And, importantly, medical education research has shown that these communication skills can be taught, learned, and put into practice by trainees and physicians.51–53
Teaching communication skills.
Medical educators have used a variety of techniques for teaching communication skills, including simulation with feedback to improve performance; clinical skills demonstration, in which an expert models a behavior and then learners practice the skills; skills intensives, in which groups of physicians meet for one to five days (typically off-site) to learn and practice skills in small groups; peer coaching, in which on-site faculty work with peers to help them improve skills; interviewing rounds, in which a team of clinicians goes to the bedside, interviews an inpatient, and “debriefs” the encounter; and stop–action videotape review, in which a facilitator offers concrete and specific feedback on an individual's videotaped interviewing performance.54 The goal of these approaches is to help clinicians become more patient- and relationship-centered by gaining a better understanding of their own verbal and nonverbal behavior and becoming more adept at reading their patients' cues, thereby improving communication and relationships.
An example of communication skills teaching.
Since 1996, Kaiser Permanente has been using an approach to teaching and evaluating patient- and relationship-centered communication skills called “The Four Habits of Highly Effective Clinicians”55,56 which is based on a comprehensive review of the evidence linking specific elements of clinical communication with processes and outcomes of care. The approach consists of 23 discrete skills that are organized around four habits of practice: opening and organizing the beginning of the visit; eliciting the patient's perspective; demonstrating empathy; and sharing diagnostic information and ensuring patient comprehension at the end of the visit. The approach attempts to model the stream of communication that typically occurs during a visit, recognizing that the skills that make up each habit do not exist in isolation but, rather, build on one another. A valid and reliable coding scheme for the Four Habits has been developed49 and has been used to assess physician skills in a number of different contexts and countries.57–61
At Kaiser Permanente, the Four Habits approach has been used to train more than 10,000 physicians and serves as the foundation for an array of education programs. Sustained improvement in patient satisfaction scores has been demonstrated, especially for physicians whose technical skills may be excellent but whose communication is judged by patients to be poor.55 Figure 1 shows the gain scores of physicians with low patient satisfaction scores who took part in a five-day “communication skills intensive” based on the Four Habits approach during 1998–2003.55
Communication skills training is especially useful for practicing physicians: Unless they graduated from medical school relatively recently, they are unlikely to have received formal training in delivering bad news, using empathy as an efficient and satisfying clinical tool, and developing functional partnerships with patients. As with most clinical skills, there is usually a steep learning curve. It is therefore important to recognize and anticipate the time and commitment necessary for physicians to learn new communication (or any other) skills and reach proficiency. The success of the Four Habits approach at Kaiser Permanente suggests that, with organizational “buy-in,” it is possible to achieve significant improvement in quality by investing in communication and relationship skills training.
Recommendations for Professional and Faculty Development
Many positive changes have taken place in medical education over the past 100 years, not the least of which is the recognition and increasing acceptance of the importance of the “noncognitive” aspects of becoming and being a doctor. For example, interpersonal and communication skills, practice-based learning, and professionalism have gone from being suggested to required competencies that resident physicians must demonstrate prior to licensure.62 Likewise, medical school faculty are increasingly being held accountable for the context and culture in which education takes place. The Liaison Committee on Medical Education standard MS-31-A, for example, states that medical schools must provide the appropriate context for the development of expected professional attitudes and values.63 Finally, the Joint Commission recently published new guidelines (LD 3.15) that require hospitals and other health care organizations to have programs in place to identify and deal with disruptive behavior exhibited by practicing physicians.64
In essence, oversight organizations are calling for a cultural shift, recognizing that asking trainees to do as we say and not as we do compromises the quality of medical education and, ultimately, undermines their ability to practice patient- and relationship-centered care. Whether these changes are the result of a paradigm shift in conceptions of what counts as science or the distressing statistics about patient safety and satisfaction is a topic for academic debate and discussion. In the meantime, we are witnessing many calls for change from within and many challenges from those outside the profession.
Following are five recommendations for faculty and professional development related to patient- and relationship-centered care:
1. Establish patient- and relationship-centered care as a central competency across the health care continuum.
One place to start is with the admissions process, which selects the individuals who will train in our institutions. It seems reasonable to ask whether there are admissions processes and practices with a high probability of identifying applicants who are likely to develop into physicians with superb patient- and relationship-centered skills. McMaster University and the majority of the other Canadian medical schools have expanded their admissions processes beyond the traditional (face-to-face) interview format to include mini-OSCE stations for applicants to complete.65 This and other techniques for assessing applicants' values and attitudes toward patient- and relationship-centeredness should continue to be developed, evaluated, and put into practice. Unlike most European medical schools, which rely entirely on paper performance, schools in the United States and Canada have the opportunity to assess applicants before they enter training. We should take maximum advantage of this opportunity, as well as faculty development opportunities, to find ways to educate students in a broad range of intellectual and noncognitive competencies.
2. Develop a national curriculum framework with input from patients, health professionals, and other stakeholders.
To train students in a patient- and relationship-centered care competency, there must be faculty who are fully familiar and trained in the requisite skills that trainees should embody. This will require development of a national faculty development curriculum, with input from a broad range of stakeholders, including patients, trainees, and practicing physicians.
3. Require performance metrics in different domains of education.
Linking elements of professional development in patient- and relationship-centered care across the educational continuum (UME, GME, and CME) will be important to ensure quality and consistency. Developing assessment metrics for maintenance of certification, accreditation, and licensure will provide external incentives for achieving and maintaining national standards for performance in a defined area of quality.
4. Form partnerships among health care systems, academic institutions, and professional organizations to disseminate and create incentives for adopting the curriculum (i.e., train-the-trainer model).
The changes we propose will require health care organizations to form partnerships to promote patient- and relationship-centered care principles. Innovative approaches to disseminating patient- and relationship-centered curricula at Kaiser Permanente have shown promising results and may be useful as models.55 Additional large-scale dissemination experiments, tied to quality outcomes, need to be designed and tested.
5. Create a patient- and relationship-centered educational experience that is interactive and occurs face-to-face over the long term.
Although medical education has begun to take advantage of digital technology and “virtual” education, some aspects of training—including mindfulness, formation, and learning communication skills—will continue to require the development of long-term relationships based on face-to-face interaction between learners and instructors.
More than a century ago, Abraham Flexner placed mastery of the content and methods of the physical and biological sciences as the highest ideal in medical education. Today, we would do well to consider how much has changed since then in society and in our conceptions of science. Whereas diseases such as polio, typhus, and yellow fever now are virtually unknown in the United States and Canada and are highly treatable when they do occur elsewhere, at the turn of the 20th century the ravages of disease were everywhere and physicians were limited in what they could do to cure their afflicted patients. It is not surprising, therefore, that Flexner and others concentrated on the biomedical aspects of medical education, stressing a focus on the etiology and treatment of disease. In this regard, the Flexnerian revolution has been a spectacular success.
One of the consequences of such unqualified success in the biomedical domain over the past century, and something that Flexner could not have foreseen, is the (relatively) recent emergence of the patient's experience as a significant dimension in medical care. Engel9 made an important distinction between disease—a pathological breakdown of a biological state—and illness—a social and psychological response to disease. It is possible to have illness without disease (e.g., everyday worry and stress), and disease without illness (e.g., asymptomatic hypertension). However, the interplay between disease and illness has produced fields such as psychoneuroimmunology as well as patient- and relationship-centered approaches to care. While research and evidence continue to grow, these approaches are not yet a staple of medical education.
Part of the distress apparent in medicine today likely has to do with the fact that patients, who have never enjoyed a higher standard of general health, are demanding more of their physicians than to be diagnosed and sent on their way. They want to have meaningful relationships with their medical providers that allow for discussion of why one treatment is better than another or what to do when cure is no longer possible.
It may be painful for medical educators to learn that our products and we, by extension, do not enjoy the same status and acceptance we once did and that physicians already in the profession are demoralized by this state of affairs, as illustrated by their being less willing than ever before to recommend that their children follow in their footsteps.66 The good news in this otherwise discouraging scenario is that we are beginning to ask important questions, as the IOM and others have done, in trying to define quality of medical care and what it means to be professional. By beginning with the outcomes we most desire and asking which methods will best help us to achieve them, we are doing what Flexner did more than a century ago. Faced with the practical problem of educating physicians who varied greatly in their values, abilities, and approaches, he insisted that physicians be trained to act in similar ways using similar methods according to the scientific evidence before them. Given the increasing pressures on medical educators to cover more information in less time, and the parallel challenge for practicing physicians to see more patients in less time, some may wonder whether there is room in the curriculum and whether we can afford the expense of teaching a whole range of additional patient- and relationship-centered skills that integrate mind, body, and spirit. In response, we would ask, given what happens when patient- and relationship-centered skills are absent, can we afford not to?
The authors wish to acknowledge the assistance of their collaborators in developing the five recommendations that appear in this article, including Clarence Braddock III, MD, Stanford University; Malcolm Cox, MD, Veteran's Health Administration and Harvard Medical School; Anne Gill, DrPH, Baylor College of Medicine; Martin Hernandez Torre, MD, Monterrey School of Medicine, Monterrey, Mexico; Carol Hodgson, PhD, University of Colorado Denver School of Medicine; Michael Howe, Howe Associates; Lynne Kirk, MD, University of Texas Southwestern Medical School; and LuAnn Wilkerson, David Geffen School of Medicine at UCLA.
This work was supported by a writing conference funded by the Medallion Fund and the Josiah Macy Jr. Foundation. The conference was entitled “A 2020 Vision of Faculty Development Across the Medical Education Continuum” and was held at Baylor College of Medicine on February 26–28, 2010.
This manuscript was originally presented at the conference mentioned above.
The opinions expressed in this article are those of the authors alone.
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