David Sandman
Another tough election cycle is behind us. In this polarized climate, there is a lot more talking (shouting?) than listening.
We often talk past each other, rather than engage with each other. We retreat to our corners, to our echo chambers, rather than try to find common ground and understanding. The result is noise. Politics is politics, and some of that dynamic is unavoidable.
But we need something else when it comes to health care and the relationship between providers and patients. There’s a lot of lip service paid to patient-centered care, patient and family engagement, patients engaging as partners with their health care providers, and patients and providers making shared decisions. But is it just more talk? Given the power differential, can patients and providers truly be partners?
Yes. I know it’s possible, because I’ve seen that partnership in action. At a recent conference, I listened to some patients and physicians describe how they had formed teams to co-create care plans. They were partners navigating through the scary contours of serious illness. But that doesn’t mean they were equals, or that they had the same role to play. As one physician put it, “We are teammates, but I’m the captain. And she has to trust me to keep her safe and be her doctor.”
It may seem obvious that it’s important for health care providers to listen to patients and their family members, but let me spell out a few reasons why:
1. Health happens outside of the exam room. How healthy we are is determined by much more than what our bloodwork shows. To get a clear and complete picture of a patient’s health, a clinician needs to understand what’s going on in a patient’s life. Does she smoke? Get regular exercise? Live alone? Does he have family and social support? Is the patient in an abusive situation at home? Does the family have electricity at home? Is the patient depressed and isolated? Do they have adequate food to eat?
It takes time and trust to have honest conversations about those kinds of personal topics that affect our health. But it’s worth it. Sometimes a conversation can be more revealing and more valuable than a lab test or a prescription.
2. Patients are more than an illness. When facing a medical procedure or a health crisis, we don’t all respond in the same way. Different people have different values and priorities when it comes to their lives and their treatment plans. Patients getting chemotherapy may want to have a flexible treatment schedule to accommodate work or family obligations, or even a vacation. A middle-aged athlete will likely have different goals than an elderly grandfather following knee surgery.
Discussing these different needs and preferences is a critical part of high-quality, patient-centered health care. At that same conference, Dr. Eric Manheimer—formerly medical director at Bellvue Hospital and now a producer of the TV show New Amersterdam—shared a lot of good advice. He reminded us what a skilled listener does: doctors also need to listen to what’s unsaid, to the unanswered questions and to the spaces between the words. That’s sometimes where the most important answers are.
3. Patients have valuable insights into the health care experience. Institutions, not just individual providers, can also listen to patients and act on what they hear. Research has shown that patient-generated Yelp ratings of health care are reasonable proxies for traditional quality measures. And a number of hospitals have established—and give real power to—patient and family advisory councils (PFACs). PFACs help guide decision-making and governance (in Massachusetts, state law actually requires that hospitals have a PFAC). At one New York hospital, family advisors and clinicians on the PFAC co-designed easy-to-understand patient and family education materials about safe central line care. At another hospital, the PFAC helped with content design of a tablet that enables patients to view their personal clinical information, in a patient-centered, user-friendly format, at the bedside. Patients’ voices and perspectives can be incredibly useful to health care provider organizations, sparking innovative ideas and meaningful change.
There are barriers to meaningful conversations between patients and providers, to shared decision-making, to genuine patient engagement. A lack of time, a lack of preparation, and a lack of will are hurdles. Every provider I know laments the ever-shrinking office visit and the need to meet productivity targets. Health care providers feel pressed for time and pressured to focus on the bottom line. The business of medicine is, in fact, a business. How do you sit down and have a genuine heart-to-heart conversation when you have three other patients waiting for you down the corridor? Listening isn’t necessarily taught or valued. My physician friends tell me that medical education doesn’t pay much attention to the “soft skills” of listening, communicating, and empathizing. And, let’s face it, not every provider wants that kind of dynamic. There are some who would prefer to be the boss and have their orders followed without question. Personally, I’d find someone else.
More takeaways emerged from that conference when speakers were asked a lightning-round question: what’s a radical innovation that would make health care more patient-centered? There were creative and perhaps viable responses: Get rid of waiting rooms. Get rid of 60% of the paperwork.
But the most provocative response? Appoint a patient co-CEO of every hospital, as a constant reminder of what health care should be about. I don’t know if that is going to happen, but it sure would make people listen.
By David Sandman, President and CEO, New York Health Foundation
Published in Medium on November 15, 2018
