“Patient-centered care implies that the patient is always right and that their opinion should win out over the physician’s opinion.” I read that quote from Dr. Katie Neuendorf in a recent article in The Hospitalist, and it resonated with me right away. In the article, Dr. Neuendorf explains that patient-centered care should really be “relationship-centered care,” which means that the relationship should be prioritized, even when there is disagreement in the plan of care. In this scenario, she pointed out that she can support the patient and still not prescribe a treatment that she feels is inappropriate.
This is brilliant and beautiful. We know, as numerous articles have shown us, that giving patients what they want is not necessarily good for them. Patients with the highest satisfaction scores also have the highest mortality ratings. This is thought to be because patients may be asking for interventions, tests or prescription drugs that are not really needed, and physicians and providers may be acquiescing in an attempt to appease the patient.
Though paternalism is woefully unfashionable, as providers, it is our job to provide interventions that we feel are medically indicated, not those that patients want. There is a crucial distinction. In previous posts, I have outlined situations we have all been in, where patient’s family members request TPN for the dying, or excessive doses of benzodiazepines or an MRI that’s not warranted. How do we navigate these treacherous waters and still maintain our patient satisfaction scores? I think Dr. Neuendorf has the answer: relationship.
I had a patient who was profoundly disabled due to a debilitating neurological disease. The patient was admitted with a urinary tract infection due to an indwelling catheter. The patient’s daughter wanted the antibiotics changed from the quinolone the patient had initially been placed on due to the risk of tendon rupture. As the patient was bedbound, contracted and non-verbal, I felt that was not a good reason to change the antibiotic. The patient’s daughter felt dismissed – that I was not listening or respecting her concerns about the particular antibiotic. She requested another provider.
I confess she was right. I was dismissive. But rather than just exit from this scene, I sat down and talked with the daughter. I really listened both to her concern about the antibiotic as well as her dissatisfaction with me as a provider and about how my communication made her feel. Although this started out to be a not-so-great situation, it turned out in a very positive way. I was able to accept responsibility for making this daughter feel like I thought her concerns were irrelevant. I was also able to communicate why I had chosen the antibiotic I had. Ultimately, the daughter expressed gratitude for my approach and apology, and we continued to have a partnership in the care of her beloved mother. We also continued the initial antibiotic, which was based on previous susceptibility testing.
There is a saying: “Do you want to be right, or do you want to have a relationship?” In my experience, Dr. Neuendorf is spot on: relationship-driven care creates “right.”
Tracy Cardin, ACNP-BC, SFHM is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago. Prior to this employment she worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has over twenty years of inpatient experience which seems incredible as she cannot possibly be that old! She is the current chairperson for the Society of Hospital Medicine’s NP/PA Committee and has been a member of the Society for eight years. Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations.
In her free time she likes to run and lift, read and write and hang out on the front porch of her semi restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.