“So what does this ideal medical care look like? The great Tip O’Neill, himself a Boston man, used to say, ‘All politics is local.’ We believe in its corollary, that all medicine is personal. The world of better medicine starts with the individual patient interacting with the individual doctor.”
-The October ALiEM Bookclub Selection:
When Doctors Don’t Listen1,
by Leana Wen and Joshua Kosowsky
The Rise of Patient-Centered Care
The nature of the patient-physician relationship has seen significant evolution over the past century, for better and for worse. As technology has increased our ability to treat disease, some of the human aspects of delivering medical care–such as keeping the patient at the center of the medical process–have been lost along the way. Today, we find ourselves surrounded by scores of clinical decision making rules, diagnostic algorithms, and smartphones filled with apps. While these tools have a role in helping care for patients, alone they do nothing to improve the delivery of healthcare at the bedside.
Since the Institute of Medicine (IOM) declared patient-centered care as one of its six aims for improvement in healthcare for the 21st century, this approach to the patient-physician relationship has become widely recognized across all domains of medicine. Patient-centered care is defined by IOM as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”2
Patient-centered care seems clear enough on paper, but is far more nebulous to employ in day-to-day practice. In pursuit of this model for healthcare, various approaches to incorporating patients in the delivery of their care have been studied; some familiar strategies include shared decision-making, building engaged communities of patients and providers, and integrating patient data and technology in the care plan for patients. Still, these approaches do not provide a relatable means of reframing our mindset for every clinical encounter.
In examining shared decision-making and participatory medicine through the lens of an element central to all clinical situations– the diagnosis–authors Dr. Leana Wen and Dr. Joshua Kosowsky aim to change the way patients and doctors think when they enter the exam room.
When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests is, at its core, an argument for the revival of the art of diagnosis through meaningful dialogues with patients. Through a collection of insightful anecdotes, critical analysis of current trends in medicine, and actionable advice for both patients and healthcare providers, Drs. Leana Wen (@DrLeanaWen) and Joshua Kosowsky (@DrKosowsky) make a compelling case for the return of individualized, patient-centered care anchored in the practice of excellent bedside medicine. In addition to the compelling stories of patients helplessly tangled in an algorithmic healthcare system, the authors also provide a stepwise strategy to empower patients each time they interact with the healthcare system and to improve their own health literacy. Drs. Wen and Kosowsky also offer a complementary approach for physicians to improve their communication skills and practice more patient-centered medicine. After a careful dissection of the obstacles to accurate diagnosis and participatory medicine, Drs. Wen and Kosowsky prescribe a ground up approach for reforming healthcare: cut out the “rule-out” mindset and return to a thoughtful, individualized approach to medicine.
The patient-physician relationship and a skillful diagnosis constitute cornerstones of medicine. This book is directly aimed at improving those cornerstones in a new era of healthcare. Despite being primarily aimed at patients, When Doctors Don’t Listen offers skills that physicians can directly implement at the bedside. In the main text, the authors provide a detailed plan for patients to be more active in their healthcare interactions–the so called 8 Pillars to Better Diagnosis. While understanding these goals for participatory care from the patient’s perspective can easily allow doctors to reconsider their own practices, the book’s appendix includes an entire section that explores the 8 pillars from the perspective of a healthcare provider. Throughout, clinicians can find specific advice, example phrases, and even responses to common criticisms that are immediately employable in daily practice. If nothing else, this book can open physicians’ minds to reconsider some aspects of their care and gain an understanding of the expectations of the 21st-century patient.
On October 8, 2014, Dr. Jordana Haber (Maimonides Medical Center) and I hosted a bookclub discussion featuring Dr. Leana Wen.
Podcast Version of Discussion (Edited)
Book Club Questions
- Participatory medicine requires significant investment from both doctors and patients. Given the huge disparities that exist in health literacy, how much responsibility should patients be expected to take for their role in their healthcare? How can we foster continual growth of this role?
- Is shared decision-making and active collaboration between patients and physicians sufficiently well defined to monitor the extent to which it is delivered?
- The authors respond to various common criticisms of their approach in the text. What are some challenges you have encountered when trying to individualize care for patients and champion a participatory approach to your practice of medicine? Have you found any solutions to these challenges?
- Emergency physicians can often recall stories of close calls–when something just seemed off about a patient, and they were able to catch an insidious presentation of a life-threatening problem. Less often, we hear about situations when an overlooked fact or patient concern led to a change of course in a patient’s care. Tell us about a time you have changed your diagnostic reasoning based on a deeper dialogue with a patient. How did this experience inform your future practice of medicine?
HOW TO JOIN IN THE DISCUSSION
There are two main way to join our ALiEM Book club discussion this month:
- You can comment directly below in the comment section.
- Tweet us directly at @ALiEMBook, use hashtag #ALiEMbook.
Disclaimer: We have no affiliations financial or otherwise with the authors, the books, or Amazon.