“Wherever the art of medicine is loved, there is also a love of humanity.”
Hippocrates
By: Annamarie Fuchs, Creator. Partners in Health | Conversations
October 15, 2020.
Abstract
How do some Alberta physicians define person-centered care? What barriers to delivering person-centered care have they identified in their practices and what insights can they offer in context to how the health system responds? How do physicians and patients navigate Alberta’s health system with our population growth, the ups and downs of political cycles, and unreliable natural resource revenues? In this first in a series of three articles focusing on person-centered care, system defects, and potential solutions, we explore what a small but diverse group of Alberta physicians believe about the profession and how they approach person-centered care. Personal insights were gathered from four Alberta physicians who practice in a range of disciplines and settings across the province.
- A young physician in emergency practice at an urban hospital.
- A family physician who practices in a busy rural setting in northern Alberta.
- A mid career general surgeon transitioning out of full-time practice and…
- A recently retired family physician from a large metropolitan Primary Care Network.
This group of physicians were selected as a means to offer a representative voice of the population. Each physician was interviewed in person (one by phone) and provided with raw notes which allowed them to review and offer corrections and or edifying comments that would ensure their contributions and the author’s interpretations were accurately captured. Their reflections are blended throughout this article and italics are used wherever their verbatim insights are shared.
Introduction
We take so much for granted about the health professionals who serve us that we rarely consider the commitment and the sacrifices they make throughout their careers. And while we recognize that everyone who enters any of the health professions is deeply committed to caring for others, the physicians interviewed all agreed that the pursuit of medicine fundamentally changes how physicians view themselves at their most basic level. Medicine is not a job. It is a calling, a passion, and for some, an obsession.
“I believe that the humanity of physicians often gets lost in the conversation [with health system leaders and administrators] because almost every conversation seems to focus on who you serve. We forget, or perhaps many of us don’t even think about the fact that we truly give our lives for patients.”
“The prospect of a career in medicine honestly fused with the core of my personality. For me, it offered connection to the cerebral, tactile and conversational or relational aspects of who I believe myself to be while allowing me to make a living at the same time. There are certainly never-ending demands but most of the time I think of this career as having been a gift.”
“This career is truly the best way to be part of and contribute to a community’s overall wellness. I consider myself so privileged to play an integral role in my community by working as a physician. And I keep doing this work because every so often, I get to help someone and truly make an impact on their health. There is nothing more rewarding than that. Plus, I love being part of a team of other qualified colleagues and allied health professionals who are all working together to achieve this common goal ‘of caring for a community’.”
“There is nothing more satisfying than having a patient who was sick and now is well, walk out of the hospital. For me as a surgeon, the natural history of a patient’s disease is so much more overt than what internists and family physicians experience. This is what attracted me to surgery.”
“Truly, for me it’s about the relationships and the feeling of contributing positively in the lives of others, although that sounds slightly too much like I lifted it from a manual somewhere. I honestly feel that this is the best career choice I could have possibly made for myself.”
Context
In 2009, the province of Alberta launched Canada’s first integrated single health authority with oversight from one provincial governance board. In the preceding years the province had moved from 17 geographically based health authorities to 9 and finally to Alberta Health Services which was established in May of 2008. System redesign and transformation has been underway for more than 10 years as a joint effort between government, health authority leaders, and clinicians and laudable progress has been achieved. However, adaptation to widespread system transformation on the part of physicians has been difficult. Moreover, as the province continues to integrate services, and innovate, efforts to adapt workflow patterns accordingly while struggling to preserve the value of face-to-face interactions and long term relationships with patients while being asked to manage rising costs has resulted in confusion among both providers and patients. Physician demoralization and burn out is escalating and a sense that while delivering person-centered care is something they continue to aspire to, achieving it appears to be more and more arduous.
Some physicians believe there is far more value being placed on achieving objective system-oriented outcomes rather than acknowledging their efforts to meet the individualized needs of patients. That opinion is supported by Lateef (2011) who suggests that the drive to respond to technological innovations in medicine seems to be shifting some of the physicians’ attention away from focusing on attending to the personal care of patients.1. Young et al (2017) also speculate that misaligned quality metrics and other mandates have contributed to physician burnout and more importantly, many primary care physicians believe that some metrics may paradoxically encourage poor quality of care.2
Doktorchik, Manalili, et al, offer a definition of person-centered care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”3 Van Aerde (2015) added that “clinical interaction, the basic element of any health care system is a complex adaptive process… where the purpose of health care is to respond to the needs of the patient.”4 He goes on to suggest that the process cannot be understood from the physician’s or the patient’s individual perspective but requires an explicit focus on the relationship between the partners.
Challenges: Creating effective encounters with patients
All four respondents agreed that person-centered care can be achieved when both system design and policy facilitate the ability of physicians and patients to take the time necessary to form and maintain a relationship where trust is established and information is reciprocal, enabling patients to contribute to decisions about their care. Systems should also be designed to anticipate the beliefs, backgrounds, cultural norms, and other influencers associated with responding to the social determinants of health.
While effective delivery of person-centered care indeed requires an individual physician’s commitment to come alongside patients to establish respectful relationships to respond to the needs of each patient, organizational and systemic components such as standardization should not be ignored. The respondents agreed that standardization may indeed have a role to play in the delivery of care however each emphasized that clinical acumen arises from knowing when to use a standardized approach and when to acknowledge a patient’s very specific needs.
“I’ll often tell a student; “We’re going to proceed this way because I saw this patient 5 years ago. I know her family and I know what happened last time. I’ve spent time with this patient and her family. I understand their context.” That’s what it means to deliver individualized person-centered care. And that is what cannot be easily measured.”
“Rather than institutions or systems anchoring the practice of healthcare, the notion of working together with patients and their families to deliver person-centered care should become the anchor. Everything should cascade from there including how we measure outcomes [and what we measure].”
“Person centered care is code for “I care a lot and I’m trying my best to serve you.” Sadly, in the current environment, it’s nothing more than a catch phrase that defends efforts on the part of administrators to continually re-design the system to grant access to the myriad of services that patients have come to expect. What complicates these decisions is the fact that [as physicians] we’d like to offer some services because we believe they are in the best interests of the patient while there are others that we know we either cannot or should not deliver.”
“It’s important to understand that physicians are repeatedly constrained by systems that seem impossibly fragmented, expensive, and inaccessible. But more importantly, as physicians, we haven’t asked patients themselves what that means to them! We don’t have the time to explain options to patients in ways that they can understand so they can make truly informed decisions. And the idea of person-centered care itself is something that has been redefined by decision makers to fit the system that’s been created and not by patients themselves. It is essential that the public creates a vision for health care in this province. Once we adopt that vision, we’ll not only have person-centered care, we’ll have the road map we need to deliver the right care. And with momentum which will invariably build, providers such as myself will come on side.”
“Care has always been person centered. It goes back to Hippocrates. But here we are. We are in 2020 and we think that we’re inventing something new. The big change in today’s world is finding new ways to create balance between paternalism (physician expertise) and patient autonomy. Creating an environment that supports greater patient autonomy is a good thing, but it still requires careful balance. In terms of patient autonomy, you have to be careful or you might shatter the cultural norms in a family in your effort to deliver patient centered / patient autonomous care.”
“Patient centered care can never be a ‘one size fits all’ concept. This is why the art of medicine is so much more important than the science. It takes experience to navigate through the complexities of relationships and to acknowledge the cultural implications. Some cultures will demand that ‘you cannot tell grandma she’s dying.’ And if you choose to plough ahead and tell her anyway (in your drive to preserve her personal autonomy above all else) you can shatter cultural stability and devastate a family. I think I’ve become very good at delivering the most horrible news while preserving some level of hope and thankfulness. To me, that’s person-centered care.”
Our informants agreed [and emphasized] that a shared objective to deliver excellence in care still must be the aspirational goal or providers will be compelled to cut corners. And in today’s world, cutting corners can be a means of survival where demand often outstrips capacity. The natural stimulus to do good as the fundamental driver for physician care has the potential to degrade quickly unless physicians and leaders work together to find a balance between efforts to improve patient outcomes and experience while managing resources in a world where the cost of delivering health care has become unsustainable.
One informant emphasized that success cannot and should not be measured by how quickly we process patients or whether we can reduce or eliminate variability. Shorter lengths of stay do not always result in better outcomes. And patients are not widgets. In fact, it comes down to the old saying which underscores the fact that “not everything that can be counted counts, and not everything that counts can be counted.”5 Trust, for example, is known to influence patient experience and to some extent objective health outcomes6 but measuring the effects of trust beyond its influence with patient reported satisfaction is difficult. Birkhauer, Gaab et al (2017) found only a small to moderate correlation between trust and health outcomes but a large correlation between trust and patient reported satisfaction with the association between trust and objective measures of health outcomes varying widely across individual studies.7
At the end of the day, all four informants agreed that what they hear from patients over and over is that they expect two things: time and trust, both of which can only be gained through the establishment of relationships. One respondent explained that if patients are given the time they need in order to feel heard, they will immediately believe they’ve been cared for and they are seen as part of an equal relationship with the provider. Yet while the literature tells us that a trusting relationship doesn’t necessarily translate to the best outcomes8 it is essential that leaders facilitate the identification and measurement of the right experiences and outcomes, ultimately creating a balance between the performance the system expects, the experiences that patients seek, and the ability of physicians to enable positive outcomes.
When Albertans enter the healthcare system, they should expect to be treated as partners, but it is also essential that they able to benefit from the counsel of the experts who provide for their care. However, achieving balance between supporting individual autonomy alongside clinical expertise can be difficult to achieve given time constraints that all physicians face. “Patient literacy is a huge factor in whether we can delivery person-centered care”, explained one respondent who went on to say that physicians often find that patients have difficulty participating in a truly person-centered experience because they don’t understand the system or the options available to them. For example, people don’t generally understand the definition of an emergency or what to expect in an emergency department. “People generally have little insight into the severity of their illnesses. A patient with a runny nose and no other symptoms will come to an emergency department while another 50 + year old man with multiple risk factors for heart attack and with a 6-hour history of chest pain will go to his family physician’s office. What’s undeniable is that it’s not only the patients who are fuzzy on the concept of what an emergency is designed to deliver in the health system, physicians also struggle. If the system’s approach to emergency services is inconsistent and/or dysfunctional, how is the public supposed to respond?”
Failure on the part of both physicians and patients to communicate expectations and coordinate solutions can have devastating consequences. Taking enough time to respond to the questions and concerns of patients is one way in which those consequences can be mitigated. One respondent illustrated a typical conversation that highlights the value of time when assisting a patient or his/her family to arrive at a decision around the “goals of care”9 designation.
“In my opinion, a 93-year-old with multiple comorbid conditions should not be an ‘R1’ and yet it happens! These designations are complicated for us as physicians to navigate and trying to help patients or family members understand what’s best for them in context to their current experience, is even tougher. That said, when I can take the time I need to sit with a patient and his/her family members, we may be able to arrive at a decision that reflects their values and what I believe is best for them from a clinical standpoint. What’s even more important though, is that for the most part, these types of conversations should not be happening in emergency departments with the frequency that they do. Family physicians need to be given the resources (time and remuneration) that they need to work through these complex discussions before patients present to emergency departments where they are forced to make time sensitive and frightening decisions.”
When physicians are consistently able to take the time necessary (while being reasonably compensated) to deliver the right information to patients so that they can indeed work together to make informed decisions, we will have made progress toward creating a culture of person-centered care.
Choices: Reflection on insights from informants
There is undoubtedly tension between how health systems are designed and the response to that design on the part of both physicians and patients. At times it appears that we are attempting to push a square peg into a round hole. One informant suggested that delivering person-centered care should fundamentally be the anchor from which all system design should cascade including how and what we measure in terms of performance toward meeting expected outcomes.
Designing and delivering health services requires an astonishing degree of insight and collaboration between business leaders, scientists, providers and patients. And the challenges faced by leaders in preserving the physician-patient relationship and acknowledging the role of patients in decision making about their own care were not lost on all four informants. Moreover, they acknowledged that Alberta’s health system leaders understand that when organizational practices align around the mechanisms that will enable physicians to meet their lifelong duty of care and commitment to excellence, outcomes will undoubtedly improve. Achieving that alignment is the challenge.
If current performance measures, lack of time to establish trusted relationships, and an inadequate compensation model are indeed hampering the efforts of physicians to deliver quality person-centered care, Young10 et al suggests that the right quality measures can promote accountable performance and boost motivation on the part of physicians when they are rewarded for managing complexity, solving problems, and thinking creatively while addressing the unique circumstances of each patient. For example, the Royal College of Physicians and Surgeons of Canada CanMEDS framework expects physicians as communicators to enable therapeutic communications, actively listen to the patient’s experience and explore the patient’s perspective. The physician then integrates this knowledge with the appropriate context and facilitates shared decision making that is informed by evidence, expertise, and guidelines.11 System design must recognize the time and commitment needed for physicians to consistently achieve this expectation. Otherwise the result will be inconsistent and transactional approaches that are misinterpreted as person centeredness rather than transformational where leaders enable all players to participate in a shared vision.
Conclusion
Physicians in Alberta today are experiencing compassion fatigue in escalating numbers. And without sensitive and insightful decision making that enables true collaboration between leaders, clinicians, and patients, the physicians who serve us will continue to grapple with balancing demands of a fragmented system where moral injury, fatigue, and burnout is too often the outcome.
In our next article, we will explore system defects and discuss opportunities that may allow all participants in the health system to work together in new ways to reshape healthcare in Alberta. Final comments are preserved for our physician respondents who offered words of advice for individuals who may be contemplating whether to enter the profession.
“It’s a fantastic career if you really want it but terrible if you discover that you don’t; it really requires thinking about how you see yourself fitting into the role of ‘caring’ in the broad context of society.”
“It’s a wonderful profession, incredibly difficult but wonderful, nonetheless. You have to ask yourself how badly you want it because it’s a 10-15-year road of continual sacrifice. You sacrifice every part of your life to achieve this dream. There are competitive exams, constant study, applications, residency matches, exhaustion, relocation, hundreds of thousands of dollars in debt, delayed earning potential, delays starting a family, and no guarantees.”
“Don’t go into medicine unless you really want to do it. I can’t think of anything worse for a career if I found myself not wanting to go to work. There will be days when things will go badly, and you’ll beat yourself up. If you can’t let go of the bad feelings, the career will burn you out. But if you can find a way to let go of those feelings, you’ll love the profession. I love what I do! I find it exciting, intellectually interesting, and it’s provided me with a lifetime of curiosity for how I can care for people. There’s nothing better than that. When I leave medicine, I know that I will miss walking into my hospital and recognizing my community. And it’s such a great community!”
“We lost a friend and a colleague last week. It breaks my heart. I would tell a young person not to choose family medicine. In fact, unless you’re Mother Theresa, don’t choose medicine. It’s too painful, too difficult. I hope we can turn the ship around one day.”
Author’s Note:
The interviews for this article were completed early in 2020 shortly before the world began to experience COVID-19. It was during that time [February, 2020] that a beloved family physician passed away suddenly and that loss was recognized by one of the informants in their final comments. Recent challenges being faced across all health systems in managing COVID-19 have also not been contemplated in this article and we may consider gathering insights from physicians and other health professionals about the current environment in a subsequent article.
References
- Lateef, F. Patient expectations and the paradigm shift of care in emergency medicine. Journal of Emergencies, Trauma and Shock. 2011 Apr-Jun; 4(2): 163-167. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132352/#__ffn_sectitle
- Young, R., Roberts, R.G., & Holden, R.J. The Challenges of Measuring, Improving, and Reporting Quality in Primary Care. Annals of Family Medicine, Vol 15, No. 2, March/April 2017. annafammed.org
- Doktorchik, C., Manalili, K., Jolley, R., Gibbons, E., Lu, M., Quan, H., Santans, M.J. Identifying Canadian Patient-Centered Care Measurement Practices and Quality Indicators: A survey. 2018 Canadian Medical Association Journal, Joule. 6(4) E643. http://cmajopen.ca/content/6/4/E643.full.pdf+html
- Van Aerde, J. Relationship Centered Care: Toward real health system reform. The Canadian Journal of Physician Leadership. Winter 2015, pages 3 – 6. https://cjpl.ca/assets/cjplwinter_2015.pdf
- Cameron, I.A. Dr. Willian Osler: Humour and wonderment. Canadian Family Physician, December 2014 Vol 60, page 1134 – 1136 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264811/pdf/0601134.pdf (accessed 05 Feb. 2020)
- Birkhauer, J., Gaab, J., Kossowsky, J., Hasler, S., Krummenacher, P., Werner, C., & Heike, G. Trust in the health care professional and health outcome: A meta analysis. 2017 PLoS ONE 12(2): e01 70988. Page 1 – 13.
- Ibid
- Ibid
- AHS Goals of Care (GCD) Designation Order. https://www.albertahealthservices.ca/frm-103547.pdf
- Young, R., Roberts, R.G., & Holden, R.J. The Challenges of Measuring, Improving, and Reporting Quality in Primary Care. Annals of Family Medicine, Vol 15, No. 2, March/April 2017. annafammed.org
- Royal College of Physicians and Surgeons of Canada. CanMEDs Framework. http://www.royalcollege.ca/rcsite/canmeds/canmeds-framework-e
