Susan Dorr Goold

The doctor-patient relationship: challenges, opportunities, and strategies.

T he doctor–patient relationship has been and remains a keystone of care: the medium in which data are gathered, diagnoses and plans are made, compliance is accomplished, and healing, patient activation, and support are provided. 1 To managed care organizations, its importance rests also on market savvy: satisfaction with the doctor–patient relationship is a critical factor in people’s decisions to join and stay with a specific organization. 2–5

Patient-Centered Care and Preference-Sensitive Decision Making

OVER THE PAST 20 YEARS OR SO, THERE HAS BEEN A rise of 2 parallel movements, one toward the explicit use of clinical trial data to guide clinical practice (evidence-based medicine) and the other toward patient empowerment through explicit informed consent, shared decision making, and patient-centered care. Both components have been integrated into models of quality clinical care, but sometimes there are conflicts between evidenceand guideline-driven care and patient-centered care. In most situations, patients value prevention of disease and disability and increased length of life, so patientcentered care and application of evidence-based medicine present no conflict. Despite general preferences for health over disease, however, individuals make trade-offs every day by working in dangerous or stressful jobs, driving too fast, eating too much, smoking, and taking dozens of other risks, large and small. These everyday compromises are also seen in clinical practice. Patients may choose a less expensive medication even if that medication is not quite as effective. They may choose a more limited operation for cancer, explicitly trading off survival for quality of life. They may decline chemotherapy because they feel the adverse effects are not worth the small chance of success. When the choices are about technologies at the end of life, it has now been accepted in the United States and much of the world that patients who value quality of life over length of life are making a reasonable and justifiable decision. Shared decision making is also a common feature of more straightforward medical decisions, but because the immediate stakes are lower, the quality of these negotiations has been subject to less scrutiny. Even the everyday decisions about which blood pressure medicine to choose, how to manage diabetes, when to start dialysis, and what is needed to prevent or treat heart disease present these compromises between increased survival and reduced complication and other goals patients may have including cost, time, and control over their lives.

Do Unmet Expectations for Specific Tests, Referrals, and New Medications Reduce patients' Satisfaction?

AbstractBACKGROUND: Patient-centered care requires clinicians to recognize and act on patients’ expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. OBJECTIVE: To describe the nature and prevalence of patients’ specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. DESIGN: Prospective cohort study. SETTING: VA general medicine clinic. PATIENTS/PARTICIPANTS: Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. MEASUREMENTS AND MAIN RESULTS: Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing “excellent”). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction. CONCLUSIONS: Patients’ expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Managed care members talk about trust

Informed choice of health insurance could morally justify later, potentially harmful rationing decisions the way informed consent justifies potentially harmful medical interventions. In complex and technical areas, however, individuals may base decisions more on trust than informed choice. We interviewed enrollees in managed care plans in Southeast Michigan, United States, to explore in detail their expectations and experiences in choosing and using their health plan. Diverse subjects participated in semi-structured interviews about health insurance choices, experiences, and expectations. Results are presented for the theme of trust (and distrust), which emerged spontaneously in discussions about health care and health insurance. Forty subjects diverse in age, ethnicity, and income took part in 31 interviews. Interviewees mentioned many of the elements of interpersonal trust in specific physicians, often in the context of discussions about care experiences, doctor payment, and conflict of interest. Elements included physical and emotional vulnerability, expectations of goodwill, advocacy and competence. and belief in professional ethics. Trust in the medical profession had more hesitancy, and often included mention of honesty or ethics. Elements of trust in hospitals included vulnerability to financial loss, and expectations of competence (quality). Elements of trust in health insurance plans often emerged in discussions about catastrophic illness coverage denials, and profit, and were more often negative. Vulnerability, worry, fear and security were prominent. Fiscal rather than clinical competence was emphasized, while expectations of goodwill remained. Enrollees in managed care plans spontaneously discussed trust and distrust in individuals and institutions during conversations about their insurance expectations and experiences. Similarities and differences in the elements and the context of these discussions illuminate distinctions between these healthcare relationships of trust.

Ethics and Professionalism: What Does a Resident Need to Learn?

Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.

Choosing healthplans all together: A deliberative exercise for allocating limited health care resources

CHAT (Choosing Healthplans All Together) is an exercise in participatory decision making designed to engage the public in health care priority setting. Participants work individually and then in groups to distribute a limited number of pegs on a board as they select from a wide range of insurance options. Randomly distributed health events illustrate the consequences of insurance choices. In 1999-2000, the authors conducted fifty sessions of CHAT involving 592 residents of North Carolina. The exercise was rated highly regarding ease of use, informativeness, and enjoyment. Participants found the information believable and complete, thought the group decision-making process was fair, and were willing to abide by group decisions. CHAT holds promise as a tool to foster group deliberation, generate collective choices, and incorporate the preferences and values of consumers into allocation decisions. It can serve to inform and stimulate public dialogue about limited health care resources.

Measuring patient expectations: Does the instrument affect satisfaction or expectations?

Background.Fulfillment of patients’ expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. Objective.The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. Design.Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. Subjects.The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. Measures.A “short” instrument asked about 3 general expectations for tests, referrals, and new medications, while a “long” instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. Results.Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. Conclusions.These different instruments elicit different numbers of expectations but do not affect patient satisfaction.

Trust and the Ethics of Health Care Institutions

Though trust is essential to relationships between people, including that between patient and clinician, its role in organizational ethics is largely unexplored. Nonetheless, trust is also ideally a part of the relationship between patient and health care institution, both because it is desirable in and of itself, and because it makes for better medical care.

Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review.

Objective: To develop a reliable measure of physician attitudes postulated to influence resource utilization.Design: Statements related to attitudes that may influence resource use were culled from the literature and informal discussions with physicians.Setting: Academic medical center.Participants: All faculty and housestaff in internal medicine, pediatrics, family medicine, and surgery at an academic medical center were surveyed. The response rate was 59% (n=428).Results: Exploratory factor analysis of all internal medicine surveys revealed four prominent domains. These closely corresponded with our a-priori hypothesized domains and were interpreted as cost-consciousness, discomfort with uncertainty, fear of malpractice, and annoyance with utilization review. A replication of the analysis using 25 survey items and conducted on the remainder of the data (surgeons, pediatricians, and family practitioners) revealed a similar four-factor solution. Scales were constructed for each of the four domains. Cronbach’s alpha ranged from 0.66 to 0.88. Discomfort from uncertainty and fear of malpractice were moderately correlated (r=0.42); other scale-scale correlations were modest. Of the four attitude measures, only cost-consciousness was associated with lower self-estimates of resource use. Both annoyance with utilization review and fear of malpractice increased as the proportion of time spent in patient care increased.Conclusions: Although various physician attitudes and beliefs have been hypothesized to influence health services resource use, reliable and valid measures for most of these have not been developed. The authors developed a 19-item survey instrument designed to measure these attitudes reliably. The four scales developed in this study may help identify physician attitudes that are important determinants of physician decision making and help foster a better understanding of physicians’ reactions and acculturation to different practice environments.

“Listen to the People”: Public Deliberation About Social Distancing Measures in a Pandemic

Public engagement in ethically laden pandemic planning decisions may be important for transparency, creating public trust, improving compliance with public health orders, and ultimately, contributing to just outcomes. We conducted focus groups with members of the public to characterize public perceptions about social distancing measures likely to be implemented during a pandemic. Participants expressed concerns about job security and economic strain on families if businesses or school closures are prolonged. They shared opposition to closure of religious organizations, citing the need for shared support and worship during times of crises. Group discussions elicited evidence of community-mindedness (e.g., recognition of an extant duty not to infect others), while some also acknowledged strong self-interest. Participants conveyed desire for opportunities for public input and education, and articulated distrust of government. Social distancing measures may be challenging to implement and sustain due to strains on family resources and lack of trust in government.