His book is a thoughtful meditation on the evolution of medicine -- from the paternal doctor-patient model of the past to the current "informative" model, where doctors give aging and dying patients all the information they need to make their own decisions about treatments. But Gawande argues for a third model; here, doctors take the time to talk with their patients to determine what's most important to them. Then, doctors help patients make the best decisions so they can achieve their goals.
This morning, I picked up my Washington Post, which on Tuesday's has a special "Health & Science" section. Today, the front page of this section had two stories about doctors learning to lecture patients less and question them more about what they want.
Asking "How Can I Help?"
The first story was written by primary care doctor Mitch Kaminski about the lesson he learned when he met a patient suffering from congestive heart failure and renal failure. The patient had endured an endless cycle of medication adjustments prescribed by dueling specialists... punctuated by emergency room visits and hospitalizations.
After 30 years in practice, Kaminski knew that he couldn't possibly solve this man's medical problems. But he remembered a recent meeting at which a visiting palliative-care physician had said that in caring for the fragile elderly, "We forget to ask patients what they want from their care. What are their goals?"
So Dr. Kaminski asked the patient: "What are your goals for your care? How can I help you?"
He was surprised when the patient answered: "I would like to be able to walk without falling. Falling is horrible."
Kaminski realized he might be able to help this patient after all. He remembered what a geriatric nurse practitioner had told him once: "Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function."
The patient had rejected dialysis because he wanted to be at home, not in the hospital. So Kaminski arranged in-home physical therapy for him.
The doctor did not see the patient again. But over the next few months, he faxed order forms for the physical therapy to continue. Two months after the two first met, Kaminski completed the patient's death certificate.
Later, Dr. Kaminski reflected: He didn't go back to the hospital. He had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.
Several months later, the wife came to his office about her own maladies. She said she was grieving the loss of her husband, but she wasn't depressed. He had died peacefully at home, and it felt like the right thing for everyone.
She, too, was in her late 80s, frail, and suffering from fatigue and anemia. Six months earlier, she had stopped going for medical care, and Dr. Kaminski asked why.
"They were just doing more and more tests," she said. "And I wasn't getting any better."
Now, Dr. Kaminski writes, "I know what to do. I looked her in the eye and ask:"
What are your goals for your care and how can I help you.Source: What One Patient Taught a Physician
Doctors:Engage More, Lecture Less
The lead story in this morning's Health & Science section was about the burgeoning effort to teach doctors an essential but overlooked skill: clinical empathy.
Clinical empathy was once dismissively known as "good bedside manner" and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship. Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors.
Patient satisfaction scores are now being used to calculate Medicare reimbursement under the Affordable Care Act. And more than 70% of hospitals and health networks are using patient satisfaction scores in physician compensation decisions.
Interest is growing in empathy courses that are increasingly being offered in medical training of doctors. The article describes several programs currently being offered. While the curricula differ, most focus on self-monitoring by doctors to reduce defensiveness, improve listening skills (one study found that, on average, doctors interrupt patients within 18 seconds) and decode facial expressions and body language. Some programs use actors as simulated patients and provide feedback to individual doctors.
Researchers have found that some doctors don't respond with empathy because they are clueless when it comes to reading other people. Many others do recognize distress, but fear unleashing a flood of emotion in the patient, and sometimes in themselves.
The empathy courses can be explicitly prescriptive: make eye contact with the patient, not the computer. Don't stand over a hospitalize patient, pull up a chair. Don't conduct a monologue in offputting medicalease. Pay attention to tone of voice which can be more important than what is said. When delivering bad news, schedule the patient for the end of the day and do not allow interruptions.
And, getting back to the main theme of this post, doctors are advised to find out what the patient is most concerned about and figure out how best to address that.
Source: Teaching Doctors To Engage More, Lecture Less