Huge changes are sweeping the health care landscape; electronic medical records (EMR), the resurgence of clinics as the point of care delivery, the medical home, care disparities, cost and financing issues, the Affordable Care Act, and the market-driven nature of medical care. But their significance, however, is not matched by one that is passionately mentioned in that list. It’s the primacy of the patient and their satisfaction.
Several months ago I spent several days in Duke Regional Hospital in Durham, NC. It was memorable for the care I received but the experience persuaded me to reexamine the use of the word patient. Upon being admitted, among the first questions asked of me was whether I was, “under the care of a family physician.” As the examination proceeded, I was eventually told that depending on what was uncovered, a decision would be made on admitting me for further tests and observation. It sounded as if I was excluded from any role in that decision.
Before being installed in my room on the fifth floor, a doctor in a white coat came to see me and in a tone that communicated confidence told me that he would be “taking care of me.” After several days in the hospital, I received calls from family and friends who said, they heard I am “suffering from” (and they named the illness). I was exposed to language that was so powerful in assigning me a place relative to others that on one occasion when a nurse came in to just check on my progress, I remarked that I was a “victim” of (and I named the illness).
The origin and use of the term, “the patient” is an intriguing one. A patient is a person who seeks and receives treatment for an injury or an illness from a clinician. Original research has established that the word “patient” made its first appearance in English in the 14th century. Its meaning, among others, was a person bearing difficulties without complaint. From this early definition, it morphed in the 18th century to signify a person with an injury or illness and became exclusively associated with medical treatment. Before that its medical and non-medical meanings coexisted. But as physicians appropriated and narrowed the meaning of patient, the word's reference to someone suffering in any other sense than the medical, disappeared. In the 19th century, it became firmly attached to hospitals as places to go for medical services. Hospitals, however, have been in existence from antiquity.
The dominant connotation of the word, patient, is that of an individual who is appreciative of medical attention and to convey this, such expressions as, “under the care of a physician” or “being cared for in the hospital” became common phrases. From its earliest use, however, there was more than a hint that there was a distinct imbalance of power in the interaction between the clinician and patient. It went beyond gratitude to an implication that patients were subservient to and entrusting of whatever the clinician conveyed as the solution to their health concern. Ignoring a physician’s directives was considered more than very risky; it was worthy of opprobrium.
This power imbalance is at the center of a major shift in how health care is delivered. The patient has emerged as a subscriber and the evolution of what the patient becomes continues as resources are trained on the delivery mechanisms and channels of care.
Before this attention on the patient, clinicians reinforced their power-position in the medical language they used to affirm both the illness and the recommended therapy. For the patient, it often was so incomprehensible it must be the right thing to do. The patient was very motivated to comply with the clinician’s instructions, especially so if coming from a physician, because they were impressed by the language and the demeanor reinforcing the therapeutic directives. It was a reflection of how medical encounters, in spite of the fact that the interactions could involve two or more persons, were virtually clinician centered. Compliance was de rigueur of the interaction.
Over the past seven years, the monumental changes regarding how health care is delivered have shifted the encounter away from the physician-centered model to the patient-centered one and enormous resources now propel it to the center of a new health care delivery emphasis. This sea change in the relationship, now enshrined in the phrase, “patient-centered care,” elevates and emphasizes the person receiving care and is at the center of the competition for patients and how medical care is marketed. Because of this, we are now able to release “the patient” in the medical interaction and welcome the “subscriber” to health care. It will be unsettling for some to embrace this change but it will happen. It is probably a transitional expression.
The emergence of the subscriber as the recipient of health care services is attributable to several powerful forces that have coalesced to place the patient at the center of health care delivery or at the very least to equalize the relationship with the clinician. Today, medicine’s transformation as the most segmented profession is dominated by market-driven forces and this is virtually responsible for the power shift in the clinician – patient relationship. It is not yet comparable to selling computers, tires or even refrigerators, but it is close.
For example, advertising by American hospitals, clinics, and medical centers rose 20.4% over 2010 to one billion dollars for 2011, according to the Kantar Media unit of WPP Group that tracks these expenditures. Expenditures like these in other sectors of the economy would have to be reconciled against, “satisfied customers and market share growth.” In health care, it’s “satisfied patients and market share growth.”
Simultaneous with the market-driven phenomenon was the rise in the demand for personal responsibility. In health care, self-management and the emergence of a vigorous wellness movement began to chip away at the power differential between clinician and patient. Together they propose that if a healthy lifestyle is followed inclusive of exercising, maintaining a healthy weight, not smoking, and adhering to a healthy diet, then visits with a clinician will be less frequent. Advocates, including clinicians, encouraged patients to access the mountain of wellness and prevention information that’s only a Google click away. This became a display of individual freedom and patients’ autonomy. Visits with a physician were a deliberate and conscious choice but no less a shared responsibility. Clinicians were swept up in its advocacy.
Patient-centered approach to the delivery of care is increasingly being considered a paradigm for high-quality interpersonal care, according to research findings reported by Drs. Klea D. Bertakis and Rahman Azari. Although their findings do not support the linkage of patient-centered care to improved patient outcomes, they do say that there is evidence to suggest that when the patient is actively involved in decision making regarding their own health, significantly lower primary care charges result. “Moreover, there is emerging evidence,” they say, “for an association between patient-centered communication and the utilization of medical resources.” They further add, “It has been found that patients who perceived their visit as having been patient-centered received fewer diagnostic tests and referrals and corresponding lower expenses for diagnostic testing.” These would most certainly be visits where shared decision making (SDM) was practiced.
A solid patient-clinician relationship can potentially help reduce the incidence of tort claims. Studies reported in the Journal of General Internal Medicine have shown that most cases of iatrogenic complications and adverse outcomes never enter the tort system. One reason is that patients will be much less likely to sue when they have feelings of well-being and goodwill and are satisfied and respected.
As hospitals in particular and the medical community generally embarked on service differentiation because of competition for patients, and with increasing choice options available to patients, those receiving care began to be seen as “customers” within the medical services community. The highly segmented medical services sector encouraged the exercise of significant selectivity. This pattern mimicked what takes place in the generalized market place. The delivery of medical services shifted deliberately to one of service niches.
Patients were now being wooed to subscribe to services that were more identifiable with their pattern of purchases. One provider was marketed as specializing in cancer treatment, another with having facilities that made child birth a very pleasurable experience, another with specialization targeting athletes -- that’s sports medicine, and even another with capabilities in integrative medicine where the patient’s cultural perspectives on wellness resonated with their clinical staff. The conclusion was that the provider’s brand had become paramount.
However, the least empowered are those whose wellness diversity is often times discounted by clinicians who often times say with amazing irony that they treat all patients alike. An empowered patient sector persuades providers to listen and communicate with them within the context of their wellness paradigm. Health diversity is linked to care delivery when it is viewed as a public health issue precisely because of the association of disease with certain demographic entities. It’s in this context that inclusion serves to elevate disparity to the forefront of what needs focused attention and correction in our health care system.
The implications for the health care system are that clinicians now accommodate a new paradigm and have had to restructure how care services are delivered to attract and maintain subscriber patronage because of emphasis on shared decision making, regulation, access to health information, and market competition. These changes have had a profound impact on redesigning the power dynamics in the patient-clinical encounter.
The compelling question that’s posed in view of this shift is this: Is the patient-centered approach and the corresponding power-shift a good thing or not, and will it deliver improved health care outcomes? This much is certain from the research, patient-centered care has been associated with decreased utilization of health care services and lower total annual charges.
Reduced annual medical care charges may be an important outcome of medical visits that are patient-centered and power-balanced. There will be no going back to the clinician as medical oracle. The patient has been liberated; if not to the role of customer most assuredly to that of subscriber. But so has the clinician as truth teller.
James Daniels, MS, MPA, is the principal consultant for J Z Daniels Co. Ltd., a cultural health care competency practice.