In my role as AARP president, I talk with members around the country, and they often express a similar concern about health care. In general, people like their doctors and appreciate the scientific wonders of modern medicine, yet they feel a sense of powerlessness and even dread when they enter the health care system. It is hard enough for any of us to contend with illness and all the uncertainties it may prompt. It is much harder when people worry that their personal wishes may be overlooked or their individuality not respected when they need care.
This consumer perspective points the way to a critical goal for health care reform: Person-centered care, in which an individual patient’s goals and preferences are treated as paramount, should be the standard throughout the nation. Achieving this ideal will require a change in the culture of health care, and medical schools can play a vital role in helping achieve it.
Honoring Patients’ Individuality
Anecdotally, we know that many dedicated doctors try to practice patient-centered care, and thoughtful professors try to give their students an awareness of the diverse, individual needs of the many individuals they will try to help in their careers. Nonetheless, in the vast industry of health care, person-centered care remains very much the exception. Lack of communication, uncoordinated services, and dealings with sometimes-aloof clinicians and staff on matters as simple as scheduling a test all can increase stress and undermine a person’s sense of well-being. Members of my own family have waited more than two hours for a scheduled appointment—and then gotten just a few minutes of time with their doctor. These kinds of things should not happen, and in a person-centered system they would be much less common. The shift starts with the idea of “engaging the consumer” rather than “treating the patient.”
Part of engaging the consumer is honoring individuality. The doctor may have a certain way of doing things. But people vary enormously in their values and priorities. They have different goals, different thresholds of pain, different anxieties, different needs for support, different backgrounds, and different resources to draw on. Individuals should feel empowered, aware of their choices, and connected to their health care providers through meaningful communication and understanding. They deserve to feel that their personal dignity and their wishes are a top priority. They should be made to feel that they, along with their caregivers, are members of the care team.
Following an exam, a physician may view the job as attaining a measurable, physical change, such as getting blood sugar or cholesterol down to a particular level. Yet the individual may have a different goal in mind, such as attending her granddaughter’s graduation or participating in the family’s annual beach vacation. In person-centered care, these connections are made clear.
The Role of Technology in Person-Centered Care
Increasingly, individuals arrive at their doctors’ offices eager to discuss information they have found on the Internet. An emerging industry of health technologies is further arming people with data on their own bodily processes, from sleep patterns to blood sugar levels, which they may wish to go over with their physicians. Others, however, have little motivation or ability to explore their personal data or try to research their own symptoms online. These two groups require different kinds of support, and raise different challenges for busy physicians.
Advances in medical technology may potentially extend life, but at an enormous cost in suffering. Individuals who face such trade-offs differ greatly in what they want. For many, preserving the best possible quality of life for as long as they can is their top priority. That is why there is growing interest in palliative care, which places great importance on easing of suffering and preserving an individual’s sense of comfort and security—paramount values that too often are overlooked. Medical schools can prioritize these values by training their students to respond meaningfully to patients’ fundamental wishes and imparting skills that facilitate person-centered judgments.
Communication Is Key
Communication is one of the skills that has the potential to promote person-centered care. Although this may sound straightforward, effective communication about health issues is anything but simple. Physicians must be good explainers and engaged listeners. They should avoid jargon. They should clarify the pros and cons of treatment options and engage individuals in decisions. They should create an atmosphere in which people feel their questions are welcome and never feel rushed. People can be shy about revealing information that may be important.
Good communication helps doctors do a better job and helps individuals make better decisions, because they will better understand risks, trade-offs, and choices. Communication is not just between the individual and the doctor. Person-centered care is a group enterprise, which may include not only a primary care doctor and specialists but also nurses, nutrition experts, social workers, and other professionals. Physicians should communicate effectively with the whole care team, including the patient. They should place a priority on collaboration, sharing of information, and recognizing the challenges that patients may face at transition points in their care.
Working together, the care team can replace a potentially bewildering—at its worst dehumanizing—health care experience with one that is affirming and coordinated. In addition, teamwork is a way to promote health and wellness rather than passively waiting for problems to arise and then providing treatment. Team-based care lends itself to a more holistic view of the individual. Are there needs for nutrition, recreation, or long-term services and supports that are not being addressed? Is the person isolated? Is the person depressed?
Each member of the care team plays an important role in treating the patient holistically. But physicians should be leaders in building a system that meets individual needs and supports wellness more reliably. Those who work collaboratively, communicate effectively, and respond carefully to individual differences can contribute greatly.
How Is Health Care Reform Promoting Person-Centered Care?
The Affordable Care Act has taken encouraging steps to elevate the needs of individuals in the health care system, and we want to see them expanded. Yet these patient-centered aims of health care reform are often overlooked in the general media, as is the complementary relationship between such care and cost containment. The Centers for Medicare and Medicaid Services (CMS) offers grants for models such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), along with other approaches that make a high priority of consumer needs. The Department of Health and Human Services (HHS) has authority to expand promising initiatives, and it should do so.
HHS also has announced the goal of allocating half of Medicare payments to person-centered practice models such as ACOs and PCMHs by the end of 20181 rather than through the traditional payment system of fee for service. Because of Medicare’s vast influence, the success of this effort could prove enormously influential throughout the entire health care system.
Ramping up efforts to make care more person centered is a key to achieving health care reform’s ultimate objective of improving quality and increasing value. Nobody wants to go through unnecessary tests, avoidable readmissions, or other forms of waste that burden their lives while achieving no health benefit.
And evidence is mounting that the financial incentives for person-centered care may ultimately improve the system’s financial outlook. In August, for example, CMS announced that 353 ACOs had saved $411 million in 2014, while making improvements in an array of quality measures.2 Earlier in the year, CMS cited more than $25 million in savings from a demonstration project that provided quality, home-based care to people with chronic illnesses.3 (Benefits included reduced hospital readmissions and less use of inpatient and emergency room services for a range of conditions, including diabetes, high blood pressure, asthma, pneumonia, and urinary tract infections.) In another context, Atul Gawande4 has chronicled the work of Jeffrey Brenner, a physician whose efforts to provide better, individualized care for a low-income clientele in Camden, New Jersey, also saved money.
Person-Centered Care Is Better for Patients and for Doctors
Creating a health care system that makes a central priority of meeting the needs of individuals and caregivers will require efforts from all stakeholders, including providers, payers, purchasers, and policy makers. But the support of doctors is absolutely crucial. By taking a more holistic view of individual needs, doctors can lead the system in a direction that is more effective, efficient, and humane. Medical schools can help create and broaden that support by providing a new generation of clinicians with the awareness and skill set needed to build a person-centered health care system.
Although I have been speaking for the consumer in this Commentary, I believe that doctors also will gain a great deal from a more person-centered approach. They will benefit from more insight into the individuals they serve, and their interactions with consumers and caregivers will be more positive. There also is research to suggest that outcomes may improve, including longer survival for some who are terminally ill.5,6
A greater educational focus on person-centered care will make tomorrow’s physicians the best possible healers and help them more easily achieve the noble goals of their profession.