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The Quality of Caring

  • James T.C. Li
    Correspondence
    Address correspondence to James T. C. Li, MD, PhD, Division of Allergic Diseases, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905
    Affiliations
    Allergic Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn
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      No less an authority than the Institute of Medicine (IOM) has declared that quality medical care must include a patient-centered approach.
      • Committee on Quality of Health Care in America, Institute of Medicine
      The IOM publication Crossing the Quality Chasm: A New Health System for the 21st Century recommends that health care should be based on “continuous healing relationships, … customization based on patient needs and values, … and shared decision-making”.
      • Committee on Quality of Health Care in America, Institute of Medicine
      However, the great majority of quality improvement efforts are directed toward “harder” or more measurable outcomes, such as medication use, diagnostic testing, hospitalizations, and costs. Medicine is finding it difficult to free itself from tyranny of the objective.
      Thus, it is refreshing to see an important qualitative study of the physician-patient relationship such as that by Bendapudi et al
      • Bendapudi NM
      • Berry LL
      • Frey KA
      • Parish JT
      • Rayburn WL
      Patients' perspectives on ideal physician behaviors.
      in the current issue of Mayo Clinic Proceedings. These investigators conducted telephone interviews with 192 Mayo Clinic patients, asking questions such as “Tell me about the best experience that you had with a doctor in the Mayo system” and “Tell me about the worst experience that you had with a doctor in the Mayo system.” The researchers compiled patient responses and developed a list of behavioral themes that they believe are 7 ideal physician behaviors: confident, empathetic, humane, personal, forthright, respectful, and thorough.
      Although this study is one of the first of its kind, it has limitations. As qualitative research, it might have been more informative if the authors had reported more verbatim patient responses to allow readers to judge whether the authors' identified “ideal physician behaviors” were in fact the best possible classification. For example, other potential categories of physician behavior might include altruism,
      • Pellegrino ED
      Professionalism, profession and the virtues of the good physician.
      trustworthiness,
      • Keating NL
      • Gandhi TK
      • Orav J
      • Bates DW
      • Ayanian JZ
      Patient characteristics and experiences associated with trust in specialist physicians.
      and humility.
      • Li JTC
      Humility and the practice of medicine.
      In addition, it would be informative to know more detail about the interviewed patients. Blanchard and Lurie
      • Blanchard J
      • Lurie N
      R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care.
      found that minorities were significantly more likely to report being treated with disrespect or looked down on compared to whites. A meta-analysis by Smith et al found that fear of embarrassment was an important barrier to early cancer diagnosis and that men and women reported different concerns.
      From an educational viewpoint, a more important question is whether the
      • Smith LK
      • Pope C
      • Botha JL
      Patients' help-seeking experiences and delay in cancer presentation: a qualitative synthesis.
      ideal physician behaviors in the study by Bendapudi reflect deep-seated character traits of the physician or more superficial “behaviors” or “skills.” That is, is it sufficient to “act empathetic” or is it important to “be empathetic”? Is “acting forthright” as good as “being forthright”? Larson and Yao
      • Larson EB
      • Yao X
      Clinical empathy as emotional labor in the patient-physician relationship.
      suggest that “surface acting” may be acceptable “without achieving affective and cognitive understanding of the patient.” On the other hand, Pellegrino
      • Pellegrino ED
      Professionalism, profession and the virtues of the good physician.
      suggests that predictable physician behaviors flow from character traits or “virtues.” His virtues of the good physician are summarized in Table 1, listed alongside the ideal physician behaviors from the study by Bendapudi et al.
      TABLE 1Physician Behaviors
      Seven ideal physician behaviors by Bendapudi et al
      • Bendapudi NM
      • Berry LL
      • Frey KA
      • Parish JT
      • Rayburn WL
      Patients' perspectives on ideal physician behaviors.
      Virtues of the good physician by Pellegrino
      • Pellegrino ED
      Professionalism, profession and the virtues of the good physician.
      ConfidentBenevolence
      EmpatheticCompassion
      ForthrightCourage
      HumaneFidelity to trust
      PersonalIntellectual honesty
      RespectfulPrudence
      ThoroughTruthfulness
      It is worthwhile to consider the place of the physician-patient relationship in the quality and safety agenda. The IOM has proposed 6 aims for improvement of health care, 1 of which is patient centeredness.
      • Committee on Quality of Health Care in America, Institute of Medicine
      These 6 aims have been embraced by most of the health care community and provide guidance for quality and safety improvement efforts. Most improvement efforts target objective, technical, and measurable processes and end points. The explicit goal of most improvement work is the standardization, even the “ultrastandardization,” of medicine.
      • Amalberti R
      • Auroy Y
      • Berwick D
      • Barach P
      Five system barriers to achieving ultrasafe health care.
      This concept derives from quality improvement work in manufacturing and aviation safety.
      There is an important place for standardization and ultrastandardization in medicine. However, the application of standardization and quality improvement methods to the practice of medicine must account for the human activity central to the clinical encounter. Failure to do this reduces the opportunity for real quality improvement and risks dehumanizing both the patient and the physician. In fact, many improvements in aviation safety have centered on communication and teamwork. Placing the 7 ideal physician behaviors
      • Bendapudi NM
      • Berry LL
      • Frey KA
      • Parish JT
      • Rayburn WL
      Patients' perspectives on ideal physician behaviors.
      alongside the IOM's 6 aims for improvement of health care may be helpful (Table 2). Attention to both relationship and system improvements using appropriate and creative improvement methods may yield better results than focusing on one area alone.
      TABLE 2Physician Behaviors
      Seven ideal physician behaviors by Bendapudi et al
      • Bendapudi NM
      • Berry LL
      • Frey KA
      • Parish JT
      • Rayburn WL
      Patients' perspectives on ideal physician behaviors.
      The Institute of Medicine's 6 aims for improvement of health care
      • Committee on Quality of Health Care in America, Institute of Medicine
      ConfidentEffective
      EmpatheticEfficient
      ForthrightEquitable
      HumanePatient-centered
      PersonalSafe
      RespectfulTimely
      Thorough
      Woolf
      • Woolf SH
      Patient safety is not enough: targeting quality improvements to optimize the health of the population.
      has proposed that caring is a quality issue. Focusing on patient safety, he describes a hierarchy of lapses in quality. First is the problem of medical errors that lead directly to patient harm, second is the problem of all medical errors, and third is the problem of gaps in quality other than errors. “Lapses in caring” represent the fourth and over-arching deficiency in quality of care. Woolf
      • Woolf SH
      Patient safety is not enough: targeting quality improvements to optimize the health of the population.
      defines this as follows: Unsatisfactory care resulting not only from failure to meet normative benchmarks for quality, … but also from experiences that leave patients feeling uncared for, affecting them in domains that are less easily measured (for example, feeling unheard, rushed, inconvenienced or humiliated; or being unable to access desired information, instruction or reassurance)….the extent to which the technical elements of care seem good on the basis of performance indicators but ultimately fail to be caring [italics in original] because of deficiencies not captured by these measures. The rudeness or insensitivity that patients encounter or the frustrations they experience in obtaining information and control over treatment decisions illustrate gaps in quality, of deep concern to the public, that often are not measured under normative standards.
      These points may be best illustrated by considering those qualities of physician-patient encounters that led to the worst experience that patients had with their physicians. Bendapudi et al report that these undesirable physician behaviors are mirror opposites of the 7 ideal physician behaviors; a representation of undesirable physician traits or behaviors is shown in Table 3. Can health care really ever be high quality if the patient-physician interaction is hurried, disrespectful, cold, callous, and uncaring?
      TABLE 3Physician Behaviors
      Seven ideal physician behaviors by Bendapudi et al
      • Bendapudi NM
      • Berry LL
      • Frey KA
      • Parish JT
      • Rayburn WL
      Patients' perspectives on ideal physician behaviors.
      Opposites of the 7 ideal physician behaviors
      ConfidentTimid
      EmpatheticUncaring
      ForthrightMisleading
      HumaneCold
      PersonalCallous
      RespectfulDisrespectful
      ThoroughHurried
      This is the challenge of the report by Bendapudi et al: can medicine embrace the physician-patient relationship as essential to health care quality? Is the clinical encounter the “central-defining phenomenon” of medicine
      • Pellegrino ED
      The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions.
      or an epiphenomenon unrelated to quality? Are the 7 ideal physician behaviors as important as the 6 aims for improvment of health care?
      One of the most important contributions of the quality movement is the emphasis on measurement, systems, and the environment of care. It is time for leaders in health care quality to develop creative ways to improve the quality of caring, starting with an emphasis on measurement, systems, and the environment of care. Relationships in health care can likely be improved, supported, nurtured, taught, modeled, developed, practiced, and measured. We can do better in all these areas. Furthermore, quality in the clinical encounter goes beyond physician virtues and encompasses individualization and attention to the unique circumstances of the clinical encounter.
      There are some hopeful signs in this area. The American Board of Medical Specialties (ABMS) and the Accreditation Council of Graduate Medical Education have jointly stated that physicians must “demonstrate caring and respectfulbehaviors when interacting with patients and their families, … create and sustain a therapeutic and ethically sound relationship with patients, … and demonstrate respect, compassion and integrity.” The American Board of Internal Medicine has developed Maintenance of Certification modules that incorporate patient and peer assessment of physician relationship and communication skills. The ABMS is codeveloping a set of validated survey instruments (Consumer Assessment of Healthcare Providers and Systems) that assess the physician-patient relationship and peer relationships. These instruments will be available to all specialty and subspecialty boards and may touch the lives of most physicians. Further development of valid and reliable measures of the physician-patient interactions should lead to more improvement initiatives in health care relationships.
      Attention to both the “formal” and “informal” curriculum on relationships and communication is important in improving the quality of the physician-patient encounter. Many health care organizations, including Mayo Clinic, have developed formal curricula on physician-patient communication and relationships. One academic medical center, Indiana University School of Medicine, successfully transformed the social environment of the medical school by addressing the “informal” or “hidden” curriculum on professionalism.
      • Suchman AL
      • Williamson PR
      • Litzelman DK
      • et al.
      Toward an informal curriculum that teaches professionalism: transforming the social environment of a medical school.
      This group formed a Relationship-Centered Care Initiative Discovery Team that used a non-linear, interactive approach to culture change. More such quality initiatives are needed.
      Pellegrino
      • Pellegrino ED
      The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions.
      wrote that, “Illness remains a universal human experience and its impact on individual human personsremains the reason why medicine and physicians exist in the first place.” Of the helping and healing professions, of which medicine is the prototype, Pellegrino
      • Pellegrino ED
      The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions.
      elaborates as follows: Each profession deals with humans in vulnerable states; each confronts the most personal, intimate recesses of the lives of other humans; each is permitted access to the inner life of another human being; each promises to help and invites trust; each is judged by the degree to which the good of the person served is attained by their professional activities.
      The quality of care and the quality of caring are inseparable. We can hope for a day when medicine is practiced by knowledgeable, competent, and compassionate physicians who create high-quality therapeutic and healing relation-ships with patients and their families in the setting of safe, effective, and efficient health care systems.

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      Linked Article

      • Patients' Perspectives on Ideal Physician Behaviors
        Mayo Clinic ProceedingsVol. 81Issue 3
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          We incorporated the views of patients to develop a comprehensive set of ideal physician behaviors. Telephone interviews were conducted in 2001 and 2002 with a random sample of 192 patients who were seen in 14 different medical specialties of Mayo Clinic in Scottsdale, Ariz, and Mayo Clinic in Rochester, Minn. Interviews focused on the physician-patient relationship and lasted between 20 and 50 minutes. Patients were asked to describe their best and worst experiences with a physician in the Mayo Clinic system and to give specifics of the encounter.
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