Blog | Tuesday, April 2, 2013

When does patient-centered communication not lead to patient-centered care?


How do we make patient centered care happen? One way is to ensure that both patient and doctor are using good communication practices on a foundation of a positive relationship. This is the subject of my book, Talking to Your Doctor.

But what if the doctor and the patient talk the right way, and get along, but somehow the plan of care does not end up focusing on what is really important to the patient, the subtle and overt ways in which her circumstances are different from the textbook or algorithm? Part of making the leap from checklist to patient is to maintain a resolute though polite and productive skepticism towards quality boosterism, another topic of my book.

We also need to ask a scientific, empirical question: does patient-centered communication always lead to patient-centered care? No, it doesn't, says our anecdote and intuition, but for the first time recently I saw a scientific study which helps to show this. Published in the Journal of General Internal Medicine, it's a study of physicians' reactions to unannounced standardized patients and their ability to "depart from the script" of how diseases are usually treated on the basis of widely accepted algorithms.

The study has many moving parts and is worth reading in full. In brief, though, the researchers trained the standardized patients to portray cases which would differ in important but various ways from a baseline case presentation. (By and large, doctors cannot distinguish between well-trained simulated patients and real-life equivalents.) For example, a woman could come to see her doctor for an evaluation before a hip replacement. Rather than going through the motions, the astute physician should notice the red flags that some simulated patients were told to portray. For example, she might have symptoms of hypothyroidism. Or, in a separate alternative portrayed by some simulated patients, there might be a troubling context for the surgery (e.g., the woman's desire is to have the surgery so that she can take sole care of her adult son with end-stage muscular dystrophy).

A widely used classification system was used to measure the patient-centeredness of the physicians' communication, and independent raters--doctors themselves--then evaluated, blinded to the communication ratings, whether the doctors had met the challenge of the simulated patients, caught the red flags, and completed a plan of care which acknowledged the complexity of the individual before them.

You can guess the punch line: there's no relationship between them, at least not found in this study. With the usual caveats – read the article to get the details – we come around to a basic question. If patient-centered communication does not inexorably lead to patient-centered care, should we be measuring something else? And does communication matter as much as we think it does?

No big surprise: I think it does matter, for ethical and psychological reasons as much as due to any possible impact (or lack thereof) on the plan of care. I'll touch on those reasons in future posts.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.