Monday, October 10, 2016

The Doctor-Patient Relationship: It's Time to Talk

I may be dating myself a bit but when I was growing up, One of the staples on our TV growing up was Little House on the Prairie.  It is a classic that depicted much of the pioneering spirit that as someone who grew up in a rural prairie community could relate too.  As I have contemplated the many complexities of health care I recalled what health care may have looked like a 150 years ago around the time when Little House on the Prairie was situated.  Those who recall the show will remember the doctor who served Walnut Grove, Dr Baker.  Dr Baker would have practiced medicine in a much more simplistic manner than our health care system today. He would have been an integral part of the community, someone everyone knew and respected.  His medical practice would have been based on the fundamental building block, of health care, the doctor-patient relationship.  A relationship that has been marginalized by modern medicine by encapsulating the relationship into 15 minute billable increments.  In today's world we have built a massive industrialized health care complex that has separated the patient and doctor resulting in a system which has lost sight of the needs of the individual patient.  Why?

Dr Hiram Baker as played by actor Kevin Hagen on Little House on the Prairie
I was involved in Patient and Family Centred care long before I even knew what those words meant. Because the complexity of the health care challenges, our family, faced we had frequent interactions with our health care team.  Over time, we communicated freely and easily with our doctors and nurses and developed a relationship with them.  That relationship spawned many benefits.  Mutual trust, understanding, and openness were amazing by products of actually getting to "know" our care team.  They also got to know us as human beings (not just a condition) which made immense improvements to how we were cared for.  I had never seen this level of cooperation before and it made me stop and think..."why doesn't all of health care work this way."  There is a very simple answer to that.  No one bothers to stop and talk to the patient.

Since the days of Doc Baker and 19th century technology the health care system has changed and evolved.  Hospitals, equipment, and the technology of health care are truly marvels of the modern world.  However, all of this change has come about with only occasional input from the people who require the health care system.  The patient.  We have created a leviathan in the health care complex that has forgotten it's roots.  The basic interaction between doctor and patient.

Patient Centred Design: Not so much

A good example of this was a workshop that i participated in a few years ago.  I was the sole patient representative of a team that was tasked with creating a process map of this particular hospital's Emergency Room.  We spent a day diligently identifying all of the key processes and decision points.  The day was nearly done when much to my surprise not once in the discussion did we ever discuss how each process and decision point was communicated with the family.  Yes, we discussed the impact to the patient but never identified how to convey the information with the patient.  We mapped the entire process WITHOUT any patient interaction built into the process.  WOW!

If you thought these kinds of "errors of omission" are uncommon you would be wrong.  I had a chance to share my experience about our ER process, devoid of any patient interaction, with a senior executive from Alberta Health Services.  When I shared the story I was interrupted by laughter.  Ironically, this executive had just been through a similar exercise when going through a planning meeting related to the renovation of an ER.  As part of the planning process the project team identified all of the key groups that would be impacted by this ER re-design.  Just as in my experience the whole process was completed without identifying the "patient" as a stakeholder in the project.

We have many systems within health care that were never designed for the easy access of patients.  Patients have far too often been a footnote in health care system design, an inconvenient necessity.  I am fortunate in the sense that I know enough about health care that i usually know the processes and if not, I usually know who to ask.  For those who are not familiar with how to navigate health care; the learning curve is steep.  I gained a significant amount of my knowledge having been exposed to the hospital day after day for 6 months.  Every in and day out.  I learned out of necessity.  The challenge is how do we integrate patients into the health care system in a much more efficient and timely manner?  Not everyone should have to go through months and months of hospitalization to get the level of access that we do.  How do we orient that patient as soon as they walk into a clinic or the emergency room?  How do we open the lines of communication?

Today we have many resources that Doc Baker in Little House in the Prairie never had.  We have phenomenally competent people working in health care.  When I talk about the doctor-patient relationship I am talking more generically about health care practitioners in general  Not just Doctors.  Nurses and clinicians are very capable of assisting and communicating with the patient.  We also have many technological changes that can facilitate communication.  Why are we not picking up the phone and talking to patients; or better yet why are we not emailing and texting?

Getting Back to Basics

The most important thing we need to remember when we design new systems, or try to correct existing ones, is the basics of what health care is all about.  The basic doctor-patient relationship that was practiced many years before MRI, nuclear medicine, and open heart surgeries.  Patient engagement is not implemented by being part of a committee or an advisory council.  Engagement begins when the patient walks through the door of a health care facility.  By showing up, the patient has already shown that they are engaged at some level.  The patient did not show up to be "triaged" or to be on a "wait" list; they came for some form of treatment.  They came in to have someone explain and walk them through the process.  We need to remember the human element of health care and establish these relationships.  It is only by establishing these relationships that we will learn why the patient is there and what they are looking for.  When we understand what the patient is asking for then we can begin to treat them.  It's time to talk.


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