Patient-Centred Care: If You Could Only Change One Symptom…

26 07 2011

Prelude: As seems to have become a habit of late, I am again cramming all of my month’s blog posts into a matter of days.  Although in theory I suppose I should rejoice in what appears to be my dedication to spending more time living life than writing about it, the truth is this blog is important to me and my personal reflective process, so in practice, I think I simply need to concentrate on posting more consistent, but shorter posts.

Let us see how long this can last…

A little while ago I was at the hospital with the privilege of shadowing the Esophageal Clinic, consisting of four doctors who jointly saw patients one after the other, providing a superb level of patient-centred care that I had yet to witness firsthand in Montreal.

The team consisted of a gastroenterologist, a general surgeon specializing in the thoracoabdominal region, a thoracic surgeon, and a surgical resident specializing in minimally-invasive surgery.

Four extremely talented and competent doctors in one room meeting one patient at a time, spending, in one case, an hour explaining all the options to deal with a particular patient’s achalasia (i.e., difficulty getting food to pass from the esophagus into the stomach).

It was incredible.

I believe the patients are referred to this clinic only if their case is particularly difficult, and I think the idea is that the team of doctors comes to an understanding of each patient together, and offers the best options based on the situation.  For some, maybe all that can be done at the moment is a nitric oxide prescription to try to increase gastric motility.  For another individual, perhaps there are a range of options (from Heller myotomy to balloon dilatation of the lower esophageal sphincter).

I appreciated that the team discussed each individual before seeing them, so that they can provide a professional, united front for the patient.  Each doctor took turns taking the lead at different moments, and they supported each other while joking with each other as well.

In particular, I appreciated that they always asked this: “If you could only choose one symptom that you want to improve after today, what would that be?

I thought it was a beautiful question for so many reasons.

For one, it made care tangible.  Because many of these patients were referred because their diseases were particularly challenging to treat, many of them had multiple illnesses and symptoms that were bothersome.  To focus on the chief reason why the patient came to the clinic today meant that they could focus on trying to improve that one symptom, and perhaps continue forward in a stepwise fashion when the patient comes back in three months.  I think this piecemeal plan is rightly cautious and likely prevents the risks of overmedicating while allowing for better understanding of the nature of the individual disease based on how each treatment helps or fails to.

Perhaps more importantly, though, I think that understanding the principle symptom helped the team much better understand that patient’s perspective.  There can often be a great difference between what is physiologically wrong with someone’s body and how that problem manifests in and bothers the individual patient.  So for example, physiologically, there may be a sizeable diverticulum in one’s esophagus, but if the top concerns of the patient have nothing to do with the diverticulum, is it worth the risk of surgery to remove it?

It was eye-opening to hear firsthand how the same mechanical problems in the esophagus can create such a range of symptoms depending on the patient’s life circumstance.

In short, in our first year of med school, we were assigned to describe what the difference is between the “disease” of a patient and the “illness” in the individual.

For one of the first times since starting medical school, I genuinely believe that I see that difference influencing the action of practicing physicians.

And it gives me tremendous hope.

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5 responses

26 07 2011
woodeast

Thanks for continuing to share your reflections, June!

How much do you think a physician’s limited availability plays a role in asking a patient to address one specific symptom during each visit? This reminds me of the “oh, by the way” syndrome: http://www.cbc.ca/whitecoat/episode/2008/05/26/interminable-waits-in-the-doctors-waiting-room/

26 07 2011
Eric Ma

Team-based diagnosis and treatment. Patient-centered medicine.

WOW.

That’s just like House, but with a MASSIVELY positive twist on it. (And of course, a longer timeframe.) This is a really big improvement.

And I can wager $50 to say that this method, though more time-consuming per patient, provides more holistic care in terms of treatment AND post-treatment education (hence prevention), which in the long run, should reduce healthcare costs immensely.

26 07 2011
Stas

Great post June :) – Strongly recommend to take a look at the book “Opening My Heart” – great take on patient-centered care/our entire medical system through the eyes of an ICU nurse who has a valve replacement surgery.

27 07 2011
June

Thanks for the comments, everyone!

Stas, I will check out that book! It sounds interesting!

Eastwood, I think that’s a good question, but in this case, I thought the doctors spent as much time as was necessary to understand the range of symptoms that each patient had, and they only asked for one symptom to change because it was the safest, best course of action to take (e.g., one patient could not add or change more than one medication because she was on so many already). I think intention and how you go about it are what’s really important, even if it’s the same question asked.

Eric, that is the hope and I couldn’t agree more with your words!

11 08 2011
Eric Ma

I noticed another thing about that “next symptom”. It’s like what we do in coaching, where we ask, what’s your “next step”?

In the case of the doctor-patient relationship, it isn’t a clear-cut coach-student relationship, but the act of articulating the “next step” is a powerful tool in helping one manage the complexity involved.

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