Healthcare is awash in quality metrics. Registries of PHQ-9 scores. Frequency of visits. Decreased utilization rates. Reduced response times to emergencies. We believe they create better clinical outcomes through greater accountability of interventions and systems. Of course, there’s a great deal of truth here. But the touchy-feely therapist in me tells me there’s something essential missing. How do we account for the quality of human connection in healthcare–the real basis for healing? How do we put TLC—tender loving care—into our growing love affair with measurement?
This is not a new concern. A decade ago, when the primary care model known as the Patient-Centered Medical Home (PCMH) was touted as the savior of American healthcare, I thought it was a misnamed farce. There was little in the early implementation of the PCMH that had anything to do with the real people we call patients. It was all about technical changes then—implementing EHRs, gathering data, improving “office flow,” and creating staff huddles. It wasn’t until much later that the proponents of the PCMH started advocating for the formation of community advisory boards for practices and a greater emphasis on patient, not provider, goals. But those changes seemed like late afterthoughts. Healthcare was enamored with a system. The patient was largely beside the point.
I worry about something similar occurring now with today’s popular measurement-based care. Where is the human connection in the numbers we collect? Yes, it is de rigueur now for all healthcare providers to use Motivational Interviewing and make some attempt at documenting patient goals. But do these steps really improve the quality of the relationship? Or are they what we tell ourselves should be effective because we want to believe that?
In my opinion, there are better ways for us to improve our connections with the people we serve that have to do with training, time, place and, finally, measurement:
In the last 20 years, every American medical school has adopted standardized patient training to teach budding physicians how to conduct better interviews. But that methodology has not spread significantly to other disciplines. We all need to undergo a rigorous program of observation and feedback during our formative stages to increase our self-awareness of how we come across to patients. We also need training in empathy and cultural competence to help us decrease our own stigma toward people with substance abuse disorders, mental health problems or cultural backgrounds very different than our own.
We can’t give lip-service to the importance of provider-patient relationships and then short-change the development of those relationships by creating a system that limits that amount of time any provider has with a patient. Plans for increasing worker productivity are unproductive if the healthcare workers all feel like hamsters on wheels. How do we create a temporal context that fosters the deeper interaction and understanding that leads to better engagement?
Healthcare providers are not technicians. We are humanists.
Yes, there is greater emphasis on home- and community-based care now than ever before. But those are still rare instances. The vast majority of interactions between healthcare providers and patients still occurs in the antiseptic environs of hospitals and offices. Here’s my hunch: We will create better relationships with patients if we meet on their turf, not ours. Will that cost our healthcare system more money? Most definitely. But will we be more effective at understanding them and their needs and create shared care plans that are taken more seriously? Without a doubt.
I was taught a medical aphorism nearly from the first day I started working as a faculty member in a family medicine residency program in 1994: What do patients look for in a doctor? Affability, proximity and ability—in that order.
Human beings haven’t changed much in 25 years. It doesn’t matter how much we refine our systems of care, how many evidence-based protocols we devise, and how many feedback mechanisms like dashboards we create for providers unless we learn to instill and spread affability. That’s what engenders trust. That’s what creates alliance and the perception of TLC.
We shouldn’t focus so much on measuring patient satisfaction with a visit as we should ask a more basic question: Do you like your healthcare provider? I believe that, if you like him or her, then you are more likely to take up the cudgel for your own health.
In short, healthcare providers are not technicians. We are humanists. Any effective healthcare system must reinforce our human qualities and our capacity for love.