A New Model of Care: How Should the Medical System Focus on Patients?

In the last decade, many players in the medical community—including health care providers, insurers, and policy makers—have moved towards a model of “patient-centered care”. A 2012 article in Health Affairs provides a good description of the ideas surrounding patient-centered care in various clinical specialties:

http://healthaffairs.org/blog/2012/01/24/patient-centered-care-what-it-means-and-how-to-get-there/

While the model was designed to save money while improving patient care (as most healthcare initiatives are designed to do), the patient-centered care model employs a focus on improving the doctor-patient relationship through better communication and increased empathy; physicians who practice patient-centered care employ tools that continually question “patients to assess their needs and the effectiveness of the care they are receiving.” Not only does this model produce better health outcomes, but patients often report reduced symptoms and a higher degree of overall satisfaction.

This kind of relationship is detailed by Danielle Ofri in her 2013 book “What Doctor’s Feel”, described below:

http://www.nytimes.com/video/science/100000002281755/the-doctor-patient-relationship.html

In chapters 14 and 15 of “The Illness Narratives”, Kleinman presents “a practical methodology in the care of the chronically ill… captured by the words empathetic listening, translation, and interpretation… meant to counterbalance, not replace, the standard biomedical approach to the treatment of disease processes.” While Kleinman’s ethnographies were written decades before the concept of patient-centered care became mainstream, his ideas are clearly in line with this model of care. While these ideas are promising and appealing (and working well in many healthcare facilities), the reality of many healthcare systems is that it is incredibly challenging to balance this kind of care within the time constraints that most physicians face. Where should the line between completeness and efficiency be drawn in the doctor-patient interaction? How much of this burden should be placed on the physician, and what parts of this model might best be relegated to other clinicians (like nurses or physician’s assistants)?

Livingston’s Chapter on “The Moral Intimacies of Care” in Improvising Medicine describes many of the same issues, but in a medical system where nurses often provide the primary care-giving. While the emotional component of care-giving is potentially more important in an oncology setting than it is in acute care settings, the discussion of empathy, morals, hope, and faith is certainly pertinent to many other specialties, especially primary care. If we could create an ideal patient-centered care model, what would the role each member of the care giving team be?

Many medical schools, including Brown’s Warren Alpert Medical School, are encouraging this kind of empathy training during their medical training. Last year, an art exhibit called “Beyond the Diagnosis” was featured at the school and encouraged the humanization of patients.

http://www.browndailyherald.com/2015/02/20/med-school-exhibit-takes-people-first-approach/

Compared to Good’s description of the dehumanization of the medicalized body in “How Medicine Constructs Its Objects”, how could this kind of training improve the type of care that new physicians provide to their patients? Can medical schools teach the appropriate balance of empathy and clinical detachment ‘necessary’ for effective care and treatment?

10 thoughts on “A New Model of Care: How Should the Medical System Focus on Patients?”

  1. Hey Lacey, thank you for sharing your thoughts on “patient-centered care.” I find it interesting to learn how America’s healthcare system evolved over the last decade. It is also good to know that improving the quality of medical care does not always have to be at the expense of efficiency. Based on what I’ve read, one of the criticisms about Arthur Kleinman’s work is that he sometimes does not take into consideration the larger politic-economic conditions wherein care practices take place. Following this line, I wonder how could this type “patient-centered” care be put into practice in areas where medical resources are constrained. How does one deploy a “patient-center” care practice when seeing a higher volume of patients means not only financial rewards, but is also simply part of the clinical reality created by an inadequate public health infrastructure?
    Also, it seems to me that a patient-centered approach to healthcare also demands certain amount of “emotional labor” from physicians, which has been argued by many sociologists (like Arlie Hochschildm) as a form of capitalist exploitation because, although we’d like to believe otherwise, the ultimate purpose of investing emotions and attentions into a service—a physician’ efforts to “connect” with his/her patients, for example—is in exchange for monetary compensation.

    See here for emotional labor: http://www.ucpress.edu/book.php?isbn=9780520272941

  2. Hi Lacey, thanks for the post! I agree with Yuezhu that, while patient-centered models are excellent in theory, they are sometimes difficult to implement in resource-lacking environments. You mention that physicians are often faced with time (and other) constraints that impede their ability to provide more involved care-giving. What I have noticed is that, in response to these types of constraints, a new kind of medical professional has evolved: the hospitalist. As described by the American College of Physicians, “the discipline of hospital medicine grew out of the increasing complexity of patients requiring hospital care and the need for dedicated clinicians to oversee their management. The hospitalist model supplanted the traditional method of caring for hospitalized patients, which was often done by clinicians also seeing ambulatory patients or with other clinical obligations that limited their ability to provide the intensity of care often required by these patients. By focusing their practice on this specific group of patients, hospitalists gain specialized knowledge in managing very ill patients and are able to provide high-quality, evidence-based, and efficient patient and family-centered care in hospital settings.” So, in theory, hospitalists have more time to provide deeper/more focused/more intensive care to their patients. However, it seems that the kind of care hospitalists provide is not drastically different after all. For example, on their webpage, the Department of Medicine at University of California San Diego states that hospitalists strive “to improve the quality of care and the care delivery processes.” Yet, none of the hospitalist-led quality improvement programs they list have anything to do with improving the care-giving experience or the patient’s experience (http://hospitalmedicine.ucsd.edu/people/about.shtml).

  3. Hi Lacey,

    “Patients want a personal relationship with their doctors, good communication, and empathy. (Health Affairs 2012)” This quote along with some of the questions you pose about the ideal patient-centered care model had me thinking about other systems elsewhere that I think could help us think about potential ways to reform our medical system.

    Brotherton’s book, Revolutionary Medicine (2012), investigates the structural and ideological changes endured by the health care system in Cuba following el periodo especial. Some context, Cuba exhibits an unparalleled, altruistic medical presence worldwide, deploying thousands of professionals to zones of abandonment where physicians undergo aggressive training in epidemiological diseases, and participate in courses that educate them on local cultural norms and history. In an ambitious move towards securing health care as a universal right, the government decentralized its health profession and instituted far-reaching curricular reform to re-envision the physician profile and doctor-patient model. Suarez et al. (2008) describes the proliferation of Cuban doctors in Venezuela. For years, these doctors established relationships with patients and served rural communities that Venezuelan doctors neglected to work in. Cuban physicians are known as the six-star doctor. (1) They provide comprehensive curative, preventative, and rehabilitation care; (2) make detailed and economical decisions regarding the equitable allocation of medicines given resource constraints; (3) work in partnership within multidisciplinary teams; (4) initiate positive community activities; (5) are perceived as partners in health; and (6) are community-based educators that advocate for lifestyle changes to improve better health. They even reside in the community of the populations they work with so they are perceived as their patients’ neighbor meaning there is a bit of transparency that allows physicians to communicate with their clients outside of the office and in a less formal environment. According to Spiegel et al. (2004), Cuba’s relies on its extensive primary care and preventative activities in the community to carry out its vision of health consciousness has raised its health profile tremendously and created a very medically literate population.

    Wouldn’t patient centered care provide greater emphasis on prevention in order to meet its dual objectives of being economical sustainable and attentive to the patient’s and doctor’s needs.
    If prevention isn’t the way, doesn’t it make more sense to start with the first tier of defense in the medical system (i.e. primary care physicians), and make sure that they have the resources at their disposal to do their job well? Pressured by its aging population, the UK has taken a proactive approach by redirecting public funding to this division of care because they see it as a priority. They have created incentives to produce more medical students that go into primary care (general practice) within the next 5 years to reduce the volume of cases and balance out the pay per patient system. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/304139/Transforming_primary_care.pdf

    In my opinion, it would be difficult for the United States to shift to these models. One, there is an entrenched interest within medical education and practical training that presents a formidable obstacle to accepting a different pedagogy. We are comfortable with the gaze currently employed. As Good (1994) and Foucault (2003) noted, medical students are overwhelmed with layers of information and responsibility. They are currently trained to look for the biological relationships and diagnose, there is not much room or time to invest in the patient. Secondly, there are plenty of lobbying fractions that would become very active if the paradigm shifted away from biomedicine. The first article you provided noted that overworked doctors have a tendency to prescribe expensive medicines and tests but wouldn’t the patient-doctor model which strives to improve health outcomes economically hinder health care professionals and special interest groups that are in business because people are sick.

    Medical schools may be able to reform themselves and produce stellar physicians that take a patient centered approach, but there are other components outside of medical school that will make it difficult to provide patients with this care as a unified medical practice.

  4. Hi Lacey,

    The questions you pose about the ideal patient-centered care model had me thinking about other systems elsewhere that I think could help us think about potential ways to reform our medical system.

    Brotherton’s book, “Revolutionary Medicine” (2012), investigates the structural and ideological changes endured by the health care system in Cuba following el periodo especial. Some context, Cuba exhibits an unparalleled, altruistic medical presence worldwide, deploying thousands of professionals to zones of abandonment where physicians undergo aggressive training in epidemiological diseases, and participate in courses that educate them on local cultural norms and history. In an ambitious move towards securing health care as a universal right, the government decentralized its health profession and instituted far-reaching curricular reform to re-envision the physician profile and doctor-patient model. Suarez et al. (2008) describes the proliferation of Cuban doctors in Venezuela. For years, these doctors established relationships with patients and served rural communities that Venezuelan doctors neglected to work in. Cuban physicians are known as the six-star doctor. (1) They provide comprehensive curative, preventative, and rehabilitation care; (2) make detailed and economical decisions regarding the equitable allocation of medicines given resource constraints; (3) work in partnership within multidisciplinary teams; (4) initiate positive community activities; (5) are perceived as partners in health; and (6) are community-based educators that advocate for lifestyle changes to improve better health. They even reside in the community of the populations they work with so they are perceived as their patients’ neighbor meaning there is a bit of transparency that allows physicians to communicate with their clients outside of the office and in a less formal environment. According to Spiegel et al. (2004), Cuba’s relies on its extensive primary care and preventative activities in the community to carry out its vision of health consciousness has raised its health profile tremendously and created a very medically literate population.

    Wouldn’t patient centered care provide greater emphasis on prevention in order to meet its dual objectives of being economical sustainable and attentive to the patient’s and doctor’s needs. If prevention isn’t the way, doesn’t it make more sense to start with the first tier of defense in the medical system (i.e. primary care physicians), and make sure that they have the resources at their disposal to do their job well? Pressured by its aging population, the UK has taken a proactive approach by redirecting public funding to this division of care because they see it as a priority. They have created incentives to produce more medical students that go into primary care (general practice) within the next 5 years to reduce the volume of cases and balance out the pay per patient system. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/304139/Transforming_primary_care.pdf

    In my opinion, it would be difficult for the United States to shift to these models. One, there is an entrenched interest within medical education and practical training that presents a formidable obstacle to accepting a different pedagogy. We are comfortable with the gaze currently employed. As Good (1994) and Foucault (2003) noted, medical students are overwhelmed with layers of information and responsibility. They are currently trained to look for the biological relationships and diagnose, there is not much room or time to invest in the patient. Secondly, there are plenty of lobbying fractions that would become very active if the paradigm shifted away from biomedicine. The first article you provided noted that overworked doctors have a tendency to prescribe expensive medicines and tests but wouldn’t the patient-doctor model which strives to improve health outcomes economically hinder health care professionals and special interest groups that are in business because people are sick.

    Medical schools may be able to reform themselves and produce stellar physicians that take a patient centered approach, but there are other components outside of medical school that will make it difficult to provide patients with this care as a unified medical practice.

  5. I loved the themes of the reading this week that were related to the intricacies of a provider’s professional and personal identities, and the relationship of those provider identities with the patient. I thought the ideas about the construction of the professional identity as being integral to the success of the physician, posited both by Good and Robertson, were especially interesting. Good and Robertson spent significant amounts of time describing the nature in which medical students learn to “speak, see, and write” like doctors, and the ways that medical professionals compartmentalize their personal lives in a way that makes their personal identities “irrelevant” to their provision of care.

    These ideas, however, seem to conflict with Kleinman’s portrait of the “ideal” physician, and they certainly conflict with the physician persona idolized in the patient-centered care model. So, the question is, by “creating” physicians that reduce patients to their disease symptoms, or doctors that fail to incorporate any social or cultural dimensions into their diagnosis, is quality care being sacrificed? Does this kind of medical education and practice system facilitate cold, detached physicians instead of emotionally invested ones?

    I’m not sure about this answer. The “correct” response seems to be a resounding no – how can these kinds of physicians provide compassionate, culturally competent care? But on the other hand, many physicians are constantly being asked to work within a large, impossibly bureaucratic system that would make the practice of a more patient-centered medical model more challenging – and likely not as successful for the patient’s health outcomes. As it stands, the current healthcare system values efficiency, on both the patient and the provider side of things. With this in mind, I almost feel like Good’s formative practices theory speaks to the necessity of physicians becoming efficient doctors, rather than emotive providers, in order for them to “fit” in with the larger medical hierarchy and the normative model of care. I am interested to read what others think about the role of the provider in the patient-centered care model, and how the physician’s shaped professional identity may need to be changed in order to adapt to such a model.

  6. Thank you for your blog post Lacey. Your background in the medicine and public health provide a fresh perspective for me. What is most interesting is your question if it’s possible to teach medical students both the clinical detachment and empathy. What strikes me most is that, even after reading Good’s and Foucault’s piece, even being (I think) totally on board with why the medical education will (have to) teach students to see patients not as Mr. Dalloway or Mrs. Johnson, but a body consisting of organs, tissues, veins, and genes, the question you raised at the end of the post wasn’t even a question in my mind until you asked it. It’s due to my own assumption and perspective: How is it possible humans can not feel empathy for others? How is it possible one doesn’t find a tiny little bit of sympathy for an ailing fellow human being? Isn’t that what humanity is? Do we need to be taught to be human? I don’t have a mature answer to these questions. But just as Kleinman’s works shows a wide range of influences and perceptions of medical practices, I guess it suffices to say here that subjectivities are highly complex, and how medical education influences an individual is hard to tell.

    I also think Sun’s comment, especially the concept of “emotional labor” is a productive and provocative point to think about. It certainly can be grounded in everyday life. For example, the “neoliberalization” of medical services in China is a case in point, where doctors and nurses work more like businessmen trying everything they can to make profit out of their work, even at the expenses of the patients’ health (and life!). It is echoed in several of these couple weeks’ of readings. We are cautioned about the tendency to think that the medical field is a value-neutral, objective, and scientific one. In reality, however, the medical domain is as vexed with power relations, inequalities, and uncertainties as any other institution.

    I will proceed with caution with the concept of “emotional labor,” however, for this concept in some ways is reductionistic. It reduces intentionality of individuals into a mere calculation of monetary benefits. While it’s helpful to bring in the profit side of the story, I suggest that a more nuanced reading of intentionality. I remember the first speaker this year in the anthropology department, Cati Coe, talked about the intimacy and care established between African immigrant home-care providers and the elderlies they work for. I’m also reminded of stories of many men who sell sex to men and their entanglements with their clients. Work, life, personhood are intricately entangled, and increasingly so the boundaries are blurry and fluid (Carla Freeman has a wonderful ethnography on Caribbean middle-class women that illustrates this merging of work and life: https://www.dukeupress.edu/Entrepreneurial-Selves). Sometimes if seems far-fetched to me to argue that the reason individuals do something is “just that.”

  7. Thanks for the post, Lacey. I think you raise a lot of interesting points about the burden of care, and how to integrate more patient-centered care into health care settings. I think William Robertson’s article about the heteronormative assumptions of medicine are also interesting to explore in this context. How would an implementation of a patient-centered care model deal more holistically with the patient? Would this model focus on the whole person, including their personal identity and history, or would it still be centered on relevant behavior and symptoms of illness?

    Another question I am interested in when thinking about this topic of patient-centered care is one that Sun brought up about “emotional labor.” A generally agreed upon aspect in considering emotional labor is that it is highly gendered, and women are primarily in these laboring roles. While more men are entering nursing in the U.S., the field is still dominated by women. I find the depiction of the dichotomy between nurses and doctors in Livingston’s book to be particularly compelling, as nurses do the primary acts of physical care in her depictions, such as cleaning out wounds and preparing bodies of the dead for families to see. I wonder how a patient-centered care system would distribute the emotional labor of caring for patients, and if it might reflect gendered norms of society where predominantly female nurses would shoulder the primary burden of emotional labor roles.

  8. Thanks for the post, Lacey. I think you bring up incredibly important points and highlight both the strengths and limitations of medical anthropology and an anthropological approach to clinical care. An anthropological approach can attend to the nuances of a clinician – patient relationship. The importance of thinking about the relationship, especially as these readings do can help us possibly understand how something like this could happen (even if perceived as an extreme case, which I don’t think it necessarily is).

    http://www.gaystarnews.com/article/trans-teen-kills-suicide-watch-hospital-nurses-kept-calling-girl/

    However, considering the degree to which adequate healthcare is still inaccessible in this country, it is hard to not feel like there is a much bigger picture we are missing. When the quality of US healthcare is so sub-par (relative to other “developed” nations), I wonder if we are often too focused on the minute when the macro picture has such a strong impact on even the possibility of empathetic or patient-centered care. Considering the forms of structural racism, sexism, homophobia, transphobia, and class oppression, at what point do we decide what to prioritize.

  9. This is a really fruitful discussion. I hope not to re-spin any wheels with this comment. Perhaps, I can offer another perspective that I do not believe anyone has brought up. This relates to the “neoliberalization” of care all around the world. Troy briefly mentioned this, but I will try to elaborate on it.
    It seems that one thing that we can assume with a patient centered care approach is that the patient transforms into a client. In fact, I have especially noticed this in the mental health settings in which I work in Iran. It is now considered not politically correct to use the word patient in psychiatry and psychology clinics. There are two potential ramifications:

    1) When it is established that “the first step in understanding patient-centered care is an understanding that patients must be asked to rate or judge their health care” (health affairs article), then is being a doctor not much unlike turning your practice into a yelp account? My father is a physician, and he often complains that people come to see him, and before he even diagnosis them, they say that they think they know what it is based on various medical websites that help them self-diagnose. Sometimes, they disapprove of the care they received because my father, the trained professional, in this situation does not offer a diagnosis that aligns with their idea of their illness. Or he does not prescribe those medications that they think they should get. While I think a more patient centered approach and a leveling of the hierarchy between patient and practitioner is necessary, we also need to be cognizant of the ramifications of acting based on what the patient thinks is the best form of care.

    2) When the “client” role is born, this places the patient into a sort of corporate relationship. While it may allow for a more participatory role on the level of care, I think we should also think about if it works in the opposite direction on other issues. For instance, does it allow the chronically ill to also become active on hospital boards or governmental offices so that they can influence policy? Basically, I am saying that does a patient center approach in these small moments of care (which is very important!) not eclipse larger social problems that remain unaddressed. Here is a good article that examines the problems of more participatory models of care: https://www.researchgate.net/profile/Jon_Zibbell/publication/257396542_Can_the_lunatics_actually_take_over_the_asylum_Reconfiguring_subjectivity_and_neo-liberal_governance_in_contemporary_British_drug_treatment_policy/links/54ad7ddd0cf2828b29fca5cb.pdf

  10. Thanks everyone – I’ve found this discussion to be really productive!
    I want to pick up on just one of the many important points raised in the comment thread: the question of whether providers need to or should be trained in ’empathy’,.
    Yifeng raised the question of whether it makes sense to train physicians in being empathic (or what Kleinman calls “empathic witnessing”) – shouldn’t this be an automatic response as a human witnessing the suffering of another human? This question really gets at a core theoretical discussion that medical anthropologists have debated for years. Much of this debate turns on the work of Levinas, a French phenomenological philosopher that has been deeply influential on the work of Kleinman and Biehl, among others. Levinas argues that there is in fact a sort of primordial ethical response, based in empathy, that takes place whenever a person is in the presence of an Other and really ‘sees’ what he calls the ‘Face’ of the Other. But that requires really ‘seeing’ the Other as a subject. Good’s piece I think raises the question of whether or not that necessarily happens in the clinical encounter – on the one hand the process of constructing the patient-as-object would suggest not; on the other hand, the recognition of the patient’s suffering as a moral drama would suggest that it actually does. As Lacey suggests, there seems to be a core struggle going on here between the presumed need for emotional detachment – you can’t do surgery on a person if you’re thinking too hard about them as a person rather than a machine – and the presumed need for empathic engagement – you don’t want to lose sight of that human drama and start treating the person like just a body even outside of the anatomy lab or the OR.
    I don’t think there is an easy solution to this but perhaps we might consider that there may well be costs to trying to swing the pendulum too far in the empathy direction too.

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