PFC 101: Introduction to Patient-Centered Care
Imagine you're a health care provider. A patient presents with a lump in her breast that she first noticed two years ago. When you ask about her medical history, she tells you that she has never seen a health care provider to examine the lump before. What would be the best thing for the provider to do in response to this information? (A) Say, "Why did you wait so long to come in? Breast cancer is more curable when it is diagnosed earlier." (B) Say, "I'm so glad you came to see me today. Can you help me understand why you weren't able to come in before?" (C) The provider shouldn't ask about her delay in seeking care because it's not relevant to the current conversation. (D) The provider shouldn't ask about her delay in seeking care because it may come off as judgmental.
Say, "I'm so glad you came to see me today. Can you help me understand why you weren't able to come in before?" The best answer is B. The provider should affirm the patient's effort to seek care and be careful not to use language that suggests the provider is accusing the patient of making a bad choice. The delay in care is may be relevant to the course of treatment because it's a sign that the patient may be facing some barrier to care. For example, the patient may not have the money to pay for care, the patient may not trust health care providers, or the patient may not feel that there is hope of a cure for a disease like cancer. It's important for the provider to understand the reasons that the patient hasn't sought care before so that together they can make the best plan of care in the future.
Which model of the patient-provider relationship is exhibited when the expert provider simply provides information to patients, who hold decision-making power? (A) Paternalistic (B) Informative (C) Interpretive (D) Deliberative
Informative The answer is B, informative. This model assumes that patients know what their values and interests are, and they just need facts about their medical care to decide what to do.
Shared decision making, pioneered by Dr. Victor Montori of the Mayo Clinic, best reflects which of the four models of the patient-provider relationship? (A) Paternalistic (B) Informative (C) Interpretive or deliberative (D) None of the above
Interpretive or deliberative The best answer is C. The interpretive and deliberative models of the patient-provider relationship suggest the provider's role is to elicit and understand the patient's values, preferences, and social context, and then make a plan of care in collaboration with the patient. In shared decision making, providers share their thought process for recommending treatment with patients so that patients can choose the options that work best for them.
Which of the following relationships best reflects the paternalistic model of the patient-provider relationship? (A) Parent-child (B) Teacher-student (C) Commanding officer-soldier (D) Hairstylist-client
Parent-child The correct answer is A, the parent-child relationship. In the paternalistic model, providers make decisions on behalf of patients with their best interests at heart — values such as extending life, decreasing pain, and curing disease. This model is well-suited for emergency situations, but it doesn't work as well when patients have different values and interests than the provider or when social conditions affect the patient's ability to follow a plan of care. In those situations, patients and providers need to work together in collaboration to make a plan of care that works for the patients.
Imagine you're a first-year resident enjoying a meal at a restaurant on your day off, and another customer starts choking. The customer's companion shouts, "Is there a doctor here?" in a panic. You rush over to assist the patient, who can't breathe. Which of the following patient-provider relationship would be most appropriate in this situation? (A) Interpretive (B) Deliberative (C) Informative (D) Paternalistic
Paternalistic The best answer is D, paternalistic. In an emergency situation where the patient is in immediate danger and incapacitated, the best thing to do is take control of the situation to save a life - performing the Heimlich maneuver to stop the choking, in this case. It's reasonable to assume that this intervention is in the patient's best interests, and it's unrealistic to expect the patient to be able to participate in a decision about their health when he can't speak.
Which of the following is the main reason why minority patients receive lower quality care and less intensive care than white patients in the US? (A) Studies show approximately 45% of providers hold overtly racist beliefs and purposefully mistreat minority patients. (B) Providers who grow up in societies with negative stereotypes about minority groups may have implicit biases that negatively affect care for those groups. (C) Minority patients are actually treated equally in the health care system, but have less access to high quality care. (D) Health care providers in the US are mostly white, and white people are susceptible to implicit bias.
Providers who grow up in societies with negative stereotypes about minority groups may have implicit biases that negatively affect care for those groups. The correct answer is B. The authors of the Institute of Medicine report Unequal Treatment found that implicit bias against minority patients is a major cause of the lower quality of care that they receive in the health care system. This pattern exists even when access to care is equal for white patients and minority patients. Implicit bias may affect all people who live in societies that hold negative stereotypes against people of color. It's not something that only affects white providers.
Which of the following is a reason why the paternalistic model is unsuitable for improving health outcomes? (A) Patients can choose whether or not to follow providers' medical advice. (B) Chronic disease is on the rise, and management of chronic disease requires patients to change their behavior. (C) Providers have more medical expertise than patients, so their decisions are more likely to promote health. (D) A and B
A and B The best answer is D. The paternalistic model assumes that providers can make decisions on behalf of patients to promote their health without their input. In reality, providers can make recommendations to patients, but they can rarely force them to actually follow a plan of care. Patients also have more control over their daily health habits, such as exercise and nutrition, than providers do. For that reason, a patient-provider partnership model is best suited to promote good health outcomes, because it encourages providers to understand their patients' health goals and constraints to make a plan of care with them, not for them.
Why do some patients from underserved minority groups sometimes mistrust health care institutions and health care providers? (A) Health care providers have betrayed the trust of patients before, such as in the Tuskegee syphilis study. (B) Underserved patients often have religious beliefs that teach them that health care providers are untrustworthy. (C) Patients may feel that health care systems that are difficult to understand and access do not want to provide them services. (D) A and C
A and C The best answer is D. As Dr. Bobby Baker explained, patients who have experienced racism in the medical field may not trust health care providers to advocate for their best interests, such as when health care providers conducted unethical scientific testing on African American patients. Health care systems generate more mistrust when they make it difficult for patients to receive the services they want or need. Patients' religious faith may be important to their care, but providers should not assume that religious belief means that patients will not trust health care systems.
Why is it important for providers to understand how patients may perceive them, including their race, class, gender, age, and educational status? (A) It's important that providers not mistakenly think that social characteristics influence patients' lives but not their own. (B) By understanding what assumptions others may make about them, providers may recognize that stereotypes based on social categories may not be accurate. (C) Understanding how others perceive them can help providers recognize the need to get to know patients as individuals, rather than only through social characteristics. (D) All of the above
All of the above The best answer is D. By recognizing how others may perceive them, providers are more likely to understand that all people have social characteristics that influence their lives, btu that they are nevertheless individuals with their own unique identities as well. Recognizing their own social characteristics and how others may perceive them can help providers become curious and ask questions to help them understand patients as individuals, rather than as representatives of a group.
Which of the following is the description of the term "non-compliance" that best reflects patient-provider partnerships? (A) Non-compliance describes patient behavior that doesn't align with the plan of care, for example, not taking medicines as prescribed. (B) Non-compliance is a term that comes from the paternalistic model of care, where provider's role is to decide on the plan of care and the patient's role is to follow it. (C) When patients don't follow a plan of care, it may be a sign that the health care system is "non-compliant" in meeting patients' needs or goals. (D) B and C
B and C The best answer is D. The term "non-compliance" suggests that patients' role is to follow doctor's orders. In patient-provider partnerships, the role of the provider is to work with the patient to craft a plan of care that works in the patient's life to help the patient meet his or her self-defined health goals. If the patient doesn't follow the plan of care, it may be a sign that the plan of care or the health care system is poorly suited to the patient's needs. For example, patients might not attend an appointment because they don't have money to pay for transportation, not because they don't want to go. The failure may reflect a need to design a system that works better for those patients, for example, offering services in their homes or offering transportation to the facility.
A nurse is talking with a patient about the plan for her care after discharge from the hospital. He concludes by saying, "We've just reviewed a lot of information about what happens when you leave the hospital. Did you understand everything OK?" Did he effectively use Teach Back? (A) Yes, because he asked the patient to confirm understanding (B) No, because he didn't ask the patient to repeat back what she understood (C) No, because he placed the responsibility of communication on the patient instead of on himself (D) B and C
B and C An effective teach-back question in this situation might be, "We've just reviewed a lot of information. Would you mind saying it back to me so I know if I was clear?" This question prompts the patient to summarize the information so that the provider can clear up any miscommunication. If the provider wants to get a high-level understanding of the conversation, he could ask something like, "We've just reviewed a lot of information. What would you tell your son about this conversation when he picks you up from the hospital?"
You're a hospitalist in a large referral hospital, and you have just discharged a patient who suffered a stroke due to high blood pressure. You've used many strategies, such as Ask-Tell-Ask, shared decision making, and brief action planning with the patient. The patient's primary care doctor says he will follow up with the patient. Two weeks later, the patient is back in the hospital, and you find out the primary care doctor never followed up. What's the best thing to do next? (A) Call the primary care doctor to learn more about the miscommunication and how to avoid it in the future. If necessary, conduct a quality improvement project to improve the referral process. (B) Avoid referring patients to the primary care doctor in the future. (C) Make a note in the patient's record that she was non-compliant in completing the follow-up care plan (D) A and B
Call the primary care doctor to learn more about the miscommunication and how to avoid it in the future. If necessary, conduct a quality improvement project to improve the referral process. The best answer is A. The skills in this course have focused on what providers can do in their limited clinical encounters with patients to promote health through supportive patient-provider partnerships. But even excellent partnerships cannot guarantee good health outcomes, especially when health care systems are not designed to support patients' health outcomes or when they don't have reliable processes to ensure good quality care. Providers can be leaders of system change by using quality improvement methods and redesigning care delivery to better meet patients' needs.
Which of the following is NOT a step in brief action planning? (A) Asking patients if they have any health goals they want to work on in the next week or two (B) Telling patients what they need to work on to achieve their health goals (C) Asking if patients want to hear ideas about how other people are working on their health goals (D) Asking the patients to assess their confidence level in completing their plan
Telling patients what they need to work on to achieve their health goals The correct answer is B. In brief action planning, providers act as coaches who ask questions to help their patients or clients define their own health goals. Providers may ask patients if they would like suggestions based on how other patients have worked on similar health goals, but they do not tell patients what they should work on. As you saw in the example video in this lesson, when patients don't want to work on a particular behavior, the provider doesn't pressure them to do so. In this way, providers honor the patient's autonomy to choose how they promote their own health.
A cardiac surgeon is informing a patient and his wife about the risks and benefits of a coronary bypass surgery to treat the man's acute heart disease. The surgeon wants to take a collaborative approach in which the patient ultimately decides about the treatment, with the support of the provider. Which of the following behaviors would undermine such a partnership? (A) The surgeon takes a seat when talking to the patient and his wife. (B) The surgeon asks, "What matters most to you about your health and your treatment?" (C) The surgeon describes the risks and benefits of the surgery, being careful not to share her opinion that the surgery is the best option for long-term heart health. (D) The surgeon recognizes the patient's emotion and reflects back the understanding with a comment like, "I understand that you're scared about the surgery."
The surgeon describes the risks and benefits of the surgery, being careful not to share her opinion that the surgery is the best option for long-term heart health. The best answer is C. Sitting down, asking the patient about his health goals, and recognizing and acknowledging emotion are all part of practicing empathy and collaborative decision-making. In a true partnership, providers can also share their professional opinion about the best course of action for a given health goal. Oftentimes, patients want to know what the provider would do in their situation because they want access to the experience and expertise the provider has. It's important for providers to avoid pressuring patients to choose the option they think is best, but they should be transparent in explaining to the patient their thinking and recommendations.
Maureen Bisognano, IHI Senior Fellow and President Emerita, has helped popularize the idea of asking patients, "What matters to you?" in addition to, "What's the matter?" This question helps providers do which of the following? (A) Make a more accurate diagnosis (B) Record their patients' end-of-life care wishes (C) Understand patients' health goals and priorities (D) Decide on the best treatment option
Understand patients' health goals and priorities The best answer is C. The simple re-framing of the typical question in health care settings, "What's the matter?" to "What matters to you?" creates a very different conversation. Instead of hearing only patients' immediate health complaints, providers hear about patients' health goals. With this information, health care providers are better positioned to help patients work on their long-term goals for quality of life, which is especially important in managing chronic disease. It also changes the conversation from being only about health care — things such as diagnosis and treatment — and more about health, including the life circumstances that are affecting the patient's health.
Which of the following is one of the four components of empathy, as outlined by nurse scholar Theresa Wiseman? (A) Judging someone's situation only after talking directly to them (B) Helping to solve someone's immediate problem, whether it be physical or emotional (C) Understanding another person's feelings in the moment (D) Sitting down when speaking with a patient
Understanding another person's feelings in the moment The correct answer is C. The other components are: -Seeing the world as another person sees it -Withholding judgment about the situation and the person's feelings -Communicating the understanding We often think of empathy as an emotion. It is something that we feel when we are deeply connected to the joys and pain another person is experiencing. Empathy can be an emotion, but it's also a skill. It is something that can be learned and practiced. That's good news because studies have shown that it can improve the relationship between patients and providers, and even affect clinical outcomes.