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Posted by Ishani Ganguli November 2, 2011 07:00 AM
Patient-centered care: Like most health policy wonk-speak, the term is both obvious and perplexing. (What kind of health care ISNíT patient-centered? Who else would doctors and nurses care for?, a reader recently asked me. Itís a fair point.)
In Sundayís Boston Globe magazine, I took a stab at understanding what it means to practice patient-centered care through my story on training doctors in this elusive art. A day later, Lisa Rosenbaum, M.D. wrote in The New York Times about the pitfalls of training doctors to be nice to patients (more on this in a bit).
Hereís how I understand patient-centered medicine: it means keeping the individual patient at the forefront of, and actively involved in, decisions about his or her care. It is a principle that seems to help us take better care of patients and may even lower health care costs. Though it seems intuitive, many doctors arenít good at doing this, and researchers find that bad habits start early in medical training.
As a student at Harvard Medical School, Iíd heard about an unorthodox approach to teaching patient-centered care within our own walls. Through the community hospital-based Cambridge Integrated Clerkship*, a handful of students spend their third years following patients through inpatient stays and outpatient appointments. Their learning is structured around their patientsí medical problems, not divided into discrete blocks of disciplines like surgery or pediatrics as in traditional third year curricula. Thereís some evidence that Cambridge students do the same or better on tests of clinical knowledge while retaining empathy towards patients and the ability to involve patients in their decision-making better than those in traditional programs.
Just a year after completing a traditional third year at another Harvard hospital, I put on my journalistís hat and got to know some of the students in the Cambridge program, tagging along with them as they helped tend to patients in the hospital and visited patients in their homes.
I did this reporting in my final year of medical school - close enough to my own third year clinical experience to compare this with my observations, but far enough away to have gained some perspective on becoming a doctor. I was impressed with what I saw. The students were invested in their patients in an educational model that made it easy for them to know the patients as people. They readily understood how a choice of medication or a plan for surgery would fit into one of their patientís lives, and could use this knowledge to communicate with them and help tailor their care. Itís hard to tease out the relative contribution of nature versus nurture here, but I was convinced the program brought out the best in these students.
I opened the Globe magazine piece with an anecdote from my own third year in medical school. I was at a standstill with a patient who was set on getting antibiotics that he did not need for his head cold. The upshot of that story didnít make into the final version, but here it is: midway through the visit, I broke for a strategy session with the supervising doctor. He encouraged me to hold firm on my data-driven judgment that the patient did not need antibiotics, tease out his reasons for wanting them, and use my sense of him and his preferences to lead him to what, in this case, was a clear right answer. I marched back into the exam room to execute. Iíd just met this young man, but at the end of the conversation that followed, Iíd like to think he understood that the antibiotics would do more harm than good and that we came to a mutual understanding about a better plan to fight his cold.
This is an approach Iíve tried to carry with me through medical school and now residency, both for patients Iíve had the luxury of knowing well and those I meet for the first time, and both in the rare scenarios when there is one right answer and the multitude of others when there is not. Communication skills in medicine may be a fad, as Rosenbaum argues, but theyíre awfully useful.
Rosenbaum worries that the pendulum will swing too far in the wrong directionóthat medicine and medical training will favor charm over cunning. Is it too much to ask that we have both? I believe that the combination is both critical and achievable, and programs like the one in Cambridge are a fantastic way to help us get there.
*The original post referred to the Cambridge Integrated Curriculum. This version has been changed to reflect the correct name of the program.
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