Cases & Commentaries

The "Customer" Is Always Right

Spotlight Case
Commentary By Niraj L. Sehgal, MD, MPH

Case Objectives

  • Understand the importance of identifying
    a patient's agenda.
  • Appreciate the factors that contribute
    to unmet patient expectations.
  • Define the concept of patient-centered
    care.

The Case

An 18-month-old female was brought to the
family medicine clinic with a chief complaint of "rash and
diarrhea." Five days earlier, the patient's mother noted a rash on
her daughter for which she was advised to administer
diphenhydramine (Benadryl) as needed. While the rash improved, the
patient developed diarrhea and low-grade fever, prompting a visit
to the clinic. During the visit, the mother also revealed that her
daughter had fallen from a 1.5-foot-high bed a few hours earlier
and appeared unsteady. The mother expressed concern that the child
might have a fracture and requested an x-ray.

Physical exam revealed a fussy child with
normal vital signs and no evidence of ecchymosis, edema, or
localized tenderness in the extremities. The child was somewhat
unsteady when placed on the floor to stand and remained
uncooperative with an attempt to demonstrate her gait. The resident
physician's diagnosis was a "viral syndrome" causing the diarrhea
and low-grade fever. He attributed the child's unsteadiness to the
Benadryl, perhaps exacerbated by the viral infection. He advised
the mother that a fracture was unlikely based on the exam findings.
The resident discussed his findings with the attending physician,
although he did not specifically mention the mother's request for
an x-ray.

Later that evening, the mother returned to the
emergency department to request an x-ray because of her daughter's
inability to bear weight. An x-ray was performed, which showed a
nondisplaced fracture of the tibia, requiring placement of a cast.
Frustrated with the sequence of events, the mother felt that her
concerns at the first visit were not heard.

The Commentary

For patients and caregivers, this case is bound
to generate a range of emotions. The patient or family member might
think, "The incompetent doctor should have listened to me because I
know my kid better than anyone." Or perhaps, "I should have pushed
harder for the x-rays knowing something was wrong." And physicians
might say, "I try to listen to patients and families, but if I do
everything they ask, there will be no end to it." Regardless of the
prism through which this case is viewed, the tension between a
patient and family's perspective and that of a provider frequently
results in frustration for all, as well as a potentially unsafe
outcome. Is there a system fix that would have prevented this
scenario? The answer is probably not, unless one defines methods to
improve patient-provider communication as a "system."

To analyze this case, we need to consider the
patient's agenda, unmet expectations, and the impact of
"patient-centered" care.

Identifying the Patient's
Agenda

Cases like this, in which patients or family members report diverse
and seemingly unrelated complaints, are common in acute care
settings. Providers often react to a nonlinear history by moving
quickly to focus on the "main problem" rather than identifying the
broader or complete agenda. Although medical students are taught to
begin their history-taking with open-ended questions such as "what
brings you into the clinic today?", many providers frequently
bypass such questions by noting the top line of the triage form and
rapidly directing questions with that chief complaint in
mind—as likely occurred in this case. Empirical research
bears this out: Only one-third of clinic encounters begin with an
open-ended question.(1,2)

Physicians may believe that open-ended questions
are ineffective in getting to key clinical issues, although the
evidence suggests otherwise. One study found a mere 59% concordance
rate between physicians and patients in their understanding of the
visit agenda. The rate increased to 85% when patients were given
the opportunity to fully express their agenda or
concerns.(2)

Why do providers fail to fully solicit a
patient's agenda? Many providers worry that they simply lack the
time to "open the box" and fear the effects of soliciting their
patients' concerns in an open-ended fashion. It turns out that
these time concerns are highly overestimated. It is well known that
providers tend to interrupt patients' opening statements after only
18–23 seconds. Interestingly, when clinicians hold their
tongue and allow patients to finish, patients complete expressing
their agenda in a mere 6 additional seconds.(1,3) Effective techniques to elicit patients' complaints
include using opening statements such as "what concerns do you have
today?" or "how can I help you?" and then adding "anything else?"
on repeated occasions. These skills can improve patient and
physician satisfaction and prescribing practices and reduce the
risk for malpractice claims.(4–7) Recognizing the patient's agenda should be
taught, practiced, and evaluated as a specific communication skill
and one that is equally as important as recognizing a typical
"disease presentation."

Addressing Unmet
Expectations

What happens when the patient's agenda is not properly identified?
Often, patients express dissatisfaction borne of unmet
expectations. Studies suggest that nearly 10%–15% of
office-based visits are associated with at least one unmet
expectation, most frequently the result of physician omissions in
history-taking, physical examination, or diagnostic
testing.(8–10) While none of these studies addressed
specific patient outcomes (e.g., delays in diagnosis), it seems
likely that unmet expectations lead to unsatisfied encounters and,
in turn, may increase the risk for poor clinical outcomes.

Patient satisfaction is typically assessed via
surveys that focus on variables such as the time spent with
providers, the quality of the interaction, and the perceived
quality of care received. The direct relationship between meeting a
patient's expectations and their level of satisfaction is obvious,
although whether this relationship improves the quality and safety
of care is a more complex question that has not yet been fully
answered.

Patient-Centered Care:
Does It Improve Patient Safety and Quality of Care?

The Institute of Medicine, in their report Crossing the Quality Chasm, defines patient-centered
care as "health care that establishes a partnership among
practitioners, patients, and their families to ensure that
decisions respect patients' wants, needs, and preferences and that
patients have the education and support they need to make decisions
and participate in their own care."(11)
The Picker Institute also produced a report on patient-centered
care with a definition that included seven specific dimensions
(Table).(12)
Patient-centered care is simply a call for improved communication
and collaboration with patients.

Imagine a patient who comes to the physician's
office and states, "I twisted my ankle and I think I need an
x-ray." After examining the ankle, the provider determines that the
findings are consistent with a sprain and, based on the Ottawa
Ankle Rules (13),
makes a recommendation for supportive care and decides not to
perform an x-ray. After discussion and counseling, the patient
responds with, "I'm reassured that you think my ankle is just a
sprain and that I don't need an x-ray." While the encounter fits
the definition of patient-centered care, a greater challenge might
have occurred if the patient still expected an x-ray. Would we
characterize the encounter as having been patient-centered and
reflective of quality care, even though the patient left
unsatisfied? We can envision a number of similar scenarios where
patients may expect a certain treatment or diagnostic test even
when clinical guidelines would suggest otherwise. Patient
satisfaction is one part of being patient-centered, but it
shouldn't be the only component. Patients may ask for medications
or procedures that could cause them more harm than benefit, and
these situations frequently require further discussion about the
risks and benefits.

However, as difficult as the above cases can be
(particularly for providers facing such challenges each day), they
may be easier than ones in which patients ask for tests that are
deemed unwarranted by a clinician because they are expensive and
low yield. There is an active debate over the role of
patient-centered care in an environment of scarce resources,
particularly since such care may well be more expensive.(14)
Some argue that the patient is "the doctor's master" (15)
and that the physician should follow the patient's wishes unless
the requested service is harmful. Others argue that clinicians hold
an obligation to restrict the use of very expensive, low-yield
procedures, even when patients request them. These bipolar views
demonstrate the extraordinary tension embedded in the concept of
patient-centered care. Although no one would disagree that
clinicians should listen carefully to patients and their families
while trying to follow their wishes, few would argue that
clinicians should do so when the effect would be patient harm or
inappropriate use of limited resources. This tension means that
measuring patient satisfaction in the absence of other quality and
efficiency measures could lead to an undue skewing of the system in
the direction of patient-centeredness at the potential cost of
other important values, such as quality, safety, efficiency, and
equity.

These policy considerations notwithstanding, the
present case demonstrates how a patient-centered approach can, at
times, markedly improve the quality of care. In this case, a more
patient-centered approach would likely have prevented the delay in
diagnosing the child's fracture. Even if an x-ray was not warranted
at that initial assessment, a discussion about "why" and a specific
plan for follow-up may have reassured the parent (e.g., "If your
daughter still seems to be having difficulty with her gait in the
next 24 hours, please bring her back to see us as we may need to
re-evaluate her leg"). Or the expressed concern by the mother may
have caused the clinician to rethink his initial assessment of
viral syndrome and medication side effect, potentially "unfreezing"
his assessment and avoiding the possibility of anchoring
bias.

Thoughtful promotion of patient-centered care
deserves our commitment, whether we are organizing health care
systems, training future generations of providers, or caring for
individual patients. Many of our current systems appear to be
designed to meet the needs of providers rather than patients, an
observation supported by the lack of widespread adoption of
patient-centered practices seen on a recent survey.(16) Organizations such as the Institute for Healthcare
Improvement and the Robert Wood Johnson Foundation have partnered
to develop initiatives to drive patient-centered care. Their
Transforming Care at the Bedside effort is a framework for
change on medical/surgical units built around improvements in (i)
safety and reliability, (ii) care team vitality, (iii)
patient-centeredness, and (iv) increased value.(17) In addition, professional societies have developed
policy statements on patient-centered care, evidenced by a recent
joint publication from the American Academy of Pediatrics and the
American College of Emergency Physicians.(18,19) Even as we consider the practical impact of
patient-centered care on safety, quality, and efficiency, we also
need to reflect on the ethical and professional imperative to keep
patients at the center of clinical decision-making.

Take-Home Points

  • Using open-ended questions and eliciting
    a patient's full agenda require little additional time when done
    well. This communication skill should be taught, practiced, and
    evaluated in training future health care providers.
  • Focusing on patient satisfaction
    independent of considerations of quality, safety, and efficiency
    creates an inherent tension that is important to understand.
  • Patient-centered care is a necessary
    commitment, which may contribute to improved patient satisfaction
    and higher quality and safety in care.

Niraj L. Sehgal, MD, MPH
Assistant Professor of Medicine
Medical Director, UCSF at Mount Zion
University of California, San Francisco

Faculty Disclosure: Dr. Sehgal has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, the commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.

References

1. Marvel MK, Epstein RM, Flowers K, Beckman HB.
Soliciting the patient's agenda: have we improved? JAMA.
1999;281:283-287.
[go to PubMed]

2. Dyche L, Swiderski D. The effect of physician
solicitation approaches on ability to identify patient concerns. J
Gen Intern Med. 2005;20:267-270.
[go to PubMed]

3. Beckman HR, Frankel RM. The effect of
physician behavior on the collection of data. Ann Intern Med.
1984;101:692-696.
[go to PubMed]

4. Dugdale DC, Epstein R, Pantilat SZ. Time and
the patient-physician relationship. J Gen Intern Med. 1999;14(suppl
1):S34-S40.
[go to PubMed]

5. Collins KS, Schoen C, Sandman DR. The
Commonwealth Fund Survey of Physician Experiences with Managed
Care. New York, NY: The Commonwealth Fund; 1997.

6. Robbins JA, Bertakis KD, Helms LJ, Azari R,
Callahan EJ, Creten DA. The influence of physician practice
behaviors on patient satisfaction. Fam Med. 1993;25:17-20.

[go to PubMed]

7. Levinson W, Roter DL, Mullooly JP, Dull VT,
Frankel RM. Physician-patient communication: the relationship with
malpractice claims among primary care physicians and surgeons.
JAMA. 1997;277:553-559.
[go to PubMed]

8. Kravitz RL, Callahan EJ, Paterniti D, Antonius
D, Dunham M, Lewis CE. Prevalence and sources of patients' unmet
expectations for care. Ann Intern Med. 1996;125:730-737.
[go to PubMed]

9. Bell RA, Kravitz RL, Thom D, Krupat E, Azari
R. Unmet expectations for care and the patient-physician
relationship. J Gen Intern Med. 2002;17:817-824.
[go to PubMed]

10. Peltenburg M, Fischer JE, Bahrs O, van Dulmen
S, van den Brink-Muinen A. The unexpected in primary care: a
multicenter study on the emergence of unvoiced patient agenda. Ann
Fam Med. 2004;2:534-540.
[go to PubMed]

11. Committee on Quality of Health Care in
America, Institute of Medicine. Crossing the Quality Chasm: A New
Health System for the 21st Century. Washington, DC: National
Academy Press; 2001.

12. The Institute for Alternative Futures on
behalf of The Picker Institute. Patient-Centered Care 2015:
Scenarios, Vision, Goals & Next Steps. Camden, ME: The Picker
Institute; July 2004.

13. Stiell IG, McKnight RD, Greenberg GH, et al.
Implementation of the Ottawa ankle rules. JAMA. 1994;271:827-832.

[go to PubMed]

14. Bechel DL, Myers WA, Smith DG. Does
patient-centered care pay off? Jt Comm J Qual Improv.
2000;26:400-409.
[go to PubMed]

15. Levinsky NG. The doctor's master. N Engl J
Med. 1984;311:1573-1575.
[go to PubMed]

16. Audet AM, Davis K, Schoenbaum SC. Adoption of
patient-centered care practices by physicians: results from a
national survey. Arch Intern Med. 2006;166:754-759.
[go to PubMed]

17. Rutherford P, Lee B, Grelner A. Transforming
Care at the Bedside [white paper]. Boston, MA: Institute for
Healthcare Improvement; 2004.

18. American Academy of Pediatrics Committee on
Pediatric Emergency Medicine, American College of Emergency
Physicians Pediatric Emergency Medicine Committee, O'Malley P,
Brown K, Mace SE. Patient- and family-centered care and the role of
the emergency physician providing care to a child in the emergency
department. Pediatrics. 2006;118:2242-2244.
[go to PubMed]

19. Patient- and Family-Centered Care and the
Role of the Emergency Physician Providing Care to a Child in the
Emergency Department [policy statement]. American College of
Emergency Physicians Web site. Available at: http://www.acep.org/webportal/PracticeResources/
PolicyStatements/peds/ptfamctredcare.htm
. Accessed January 26,
2007.

Table

Picker Institute's Seven Prime Aspects of
Patient-Centered Care (12)
Reprinted with permission from Patient-Centered Care 2015:
Scenarios, Vision, Goals & Next Steps
, Copyright The Picker
Institute.

Respect for the patient's values, preferences, and expressed
needs
Coordination and integration of care
Information, communication, and education
Physical comfort
Emotional support
Involvement of family and friends
Transition and continuity