Sunday, October 9, 2011

Compassionate Care Requires Support from Health Organizations

An article about compassionate care in the September issue of Health Affairs identifies the core focus of this blog - health care organizational ethics - as a key determinant of whether or not patients receive compassionate care.

Beth Lown and Julie Rosen, the lead authors, are, respectively, medical director and executive director of the Schwartz Center for Compassionate Care, whose mission is "to promote compassionate healthcare so that patients and their professional caregivers relate to one another in a way that provides hope to the patient, support to caregivers and sustenance to the healing process."

The article reports on a telephone survey of 800 recently hospitalized patients and 500 physicians. Interviewees were read the following description of compassionate care before being questioned further:
“Now, I would like to turn to an approach to treating patients known as compassionate health care that focuses on improving the relationships between doctors, nurses and other professional caregivers and patients and their families. Its particular focus is to improve the communication and emotional support that patients receive from their doctors, nurses and other professional caregivers.”
Patients and physicians agreed on the importance of compassionate care, but differed in their assessment of how reliably it is provided: 78% of physicians said that most health care professionals provide compassionate care, but only 54% of patients said that they do.

More than half (53%) of the physicians reported spending less time than they wanted with their patients, and 55% of physicians and 67% of patients were worried about how changes in the health system, very much including emphasis on cost containment, would affect clinician-patient communication in the future.

The authors concluded that to achieve compassionate care, providers need (1) time to listen to patients; (2) education in the relevant skills, (3) feedback based on measures of their performance, and (4) leaders and systems that support their healing relationships with patients and families.

Health plans, hospitals, group practices, and other health organizations can't solve the time problem by printing money, but they can devote savings from efficiencies to enhancing the potential for compassionate care. Time with patients is indeed a key factor. Psychiatrists are often asked to do "medication management" in 15 minute blocks. I found that this could work for me with patients who (a) I knew well when (b) what we needed to accomplish was relatively simple and (c) I had flexibility to make more time available when we needed it. But by making my modal appointment 30 minutes rather than the 50 or 60 that was routine, I was able to meet "productivity" expectations and have more appointments available so that I could see patients sooner in followup or on short notice when urgent issues emerged. The system I worked in facilitated my doing this.

My colleagues across specialties in the group I practiced with would periodically share our clinical "pearls" for how to provide compassionate care in circumstances of time pressure. I learned important lessons not just from psychiatrists, but also from a pediatrician colleague who saw the largest number of patients and received the highest evaluation from patients for compassionate care.

Leaders are most effective in supporting compassionate care by improving tools and providing relevant education, not by preaching. The two leadership interventions I found most helpful were (1) providing individual voice mail before this was standard and (2) systematically surveying patients about their experience with their clinicians. The surveys taught me how much my patients valued being able to get a message to me 24/7 and receiving a prompt return call.

Most clinicians want to provide compassionate care. The concept doesn't require selling - it's intuitively obvious that compassionate care is the right thing to do. The challenge is getting beyond lip service. Health organizations play a crucial role in moving from endorsing the importance of compassionate care to providing it in a reliable manner!


Anonymous said...

It's a delicate balance. I've thought a lot about the changes in medicine over the last 200 years. Arthur Herzler, a country doctor in the late 19th/early 20th centuries observed the following about medical practice before 1850:

“Doctors knew how to relieve suffering, set bones, sew up cuts and open boils on small boys. Perhaps the greatest service the old doctor rendered was during childbirth…The doctor was eagerly awaited when disaster came. He did his best.”

My great-grandfather was a contemporary of his. He was often paid in farm produce rather than money, and the sharecroppers he served paid whatever they could afford, but it was nothing compared to what he would make today.

Dr. Herzler witnessed the transition brought about by mass vaccination aseptic surgery with general anesthesia and early antibiotics. Before that, the doctor was essentially powerless to stop the progress of major illness, but his fees were very modest. It was mostly cognitivo services with low technology. Today's high-tech medicine has taken us to the opposite end of the spectrum. Thank you for directing us back toward a place of balance where we can have some of both.

(Dr. Herzler's book, "The Horse and Buggy Doctor" is available on the Internet. It is humorously philosophical and altogether a very enjoyable look at a point in our professional history that few of us spend much time thinking about.)

Jim Sabin said...

Dear Anonymous -

First, retrospective congratulations to your great-grandfather for his way of providing compassionate care. What a wonderful piece of family tradition his experience provides!

Your great-grandfather was part of the community within which he provided care in a way that is more challenging in urban settings. But even without going out in a horse and buggy to make house calls, it's still possible - and vital - to create the kind of bond your great-grandfather had with his patients and his community.

I've requested "The Horse and Buggy Doctor" from my local library. Thank you for telling me, and readers of the blog, about it!