Abstract

Summary: Models of medical care that are patient-centered have demonstrated capability to improve quality of care and reduce costs, while at the same time improve patient satisfaction, adherence, and clinical outcomes. Patient-centered models also improve clinicians’ satisfaction with their work. The human connection between patient and clinician — the clinical relationship — is at the heart of patient-centered care. Without a clinical relationship that supports patient-centered care, the benefits will not be realized. This paper explores the definition of the clinical relationship in the context of patient-centered care. We propose that providers aspire to create relationships with patients that are characterized by three dimensions: (1) emotional connection, (2) partnership, and (3) guided discovery, with a joint commitment to the scientific method. We describe and give examples of these dimensions that demonstrate their importance in clinical practice, and summarize the evidence that, when these dimensions are present, patient outcomes are better and clinicians are more satisfied. Our goal is to clarify the benefits of the patient-centered clinical relationship so that they can be more widely incorporated into practice, training, and accreditation.
Keywords: Patient-centered care, physician-patient relationship, clinical relationship.
Citation: Dill D, Gumpert P. What is the heart of health care? advocating for and defining the clinical relationship in patient-centered care. J Participat Med. 2012 Apr 25; 4:e10.
Published: April 25, 2012.
Competing Interests: The authors have declared that no competing interests exist.

The Patient-Clinician Relationship Is at the Heart of Health Care

Current health care reform initiatives are being driven by multiple pressures, including the escalating cost of health care, the need for quality improvements to ensure patient safety[1], and our national challenge to recruit and retain clinicians to deliver primary care.[2][3][4][5] Organizations that have reorganized care delivery to be patient-centered (ie, where the work of providing care is organized around what patients want and need, rather than around the convenience of the organization and its clinicians and staff)[a] are achieving success in improving both safety and efficiency, and reducing costs. Also, they are finding that their workforce loyalty is on the rise, and that their overall organizational performance improves, with benefits for profitability.[b]

We believe the central dimension of patient-centered care (or relationship-centered care[6][7][8][9]) is a healthy clinical relationship between patient and clinician. Social interactions that communicate caring — once perceived as central to patient care — have over the last several decades receded as the delivery of technology has advanced, and the social and emotional tasks of delivering care (eg, patient education and counseling, responding to the patient’s emotions, partnership-building) have taken a back seat to the biomedical and administrative tasks of delivering care (eg, gathering and analyzing diagnostic data).[c][7] Further, reimbursement changes have created pressure on clinicians to spend less time with patients, with the implication that the relationship with patients is non-essential.[d] The authors continue to observe that the potential of the clinical relationship to improve the cost-effectiveness and safety of care delivery is frequently overlooked in discussions about how to reform health care systems. But, we believe the wide benefits of patient-centered care require that the importance of the clinical relationship be promoted along with other changes being proposed for health care reform.

What Are the Essential Dimensions of Clinical Relationships for Patient-Centered Care?

In this paper we propose a three-dimensional model of the ideal clinical relationship for patient-centered care — a relationship characterized by emotional connection, partnership, and guided discovery.

We begin with Bordin’s[10] concept of the working alliance. A strong working alliance is one in which the patient experiences an emotional connection to the clinician, and in which the clinician and patient have developed a partnership. We have good evidence, summarized below, that these relational dimensions predict clinical outcomes, in addition to mutual satisfaction and efficacy in the clinical work.

In addition to emotional connection and partnership, we propose that the ideal clinical relationship for patient-centered care should include a guided discovery dimension, characterized by commitment to empiricism and joint use of the scientific method.

We demonstrate each dimension of the ideal clinical relationship and summarize the substantial research evidence that when these dimensions are present, outcomes are better for both patients and clinicians. We also consider why each dimension has a powerful positive impact.

1. Emotional Connection

When patients experience an emotional connection with their clinician (or empathic attunement[11] or rapport), they feel liked, cared for, and understood. When clinicians experience an emotional connection with their patients, they feel they are doing work that has meaning.[2]

Consider this straightforward exchange:

Clinician: What brings you in today?
Patient: My throat has been sore for over a week, I’m running a fever of 99.5, and I’m so tired I just want to stay in bed.
Clinician: That sounds pretty uncomfortable! What concerns you the most about this?
Patient: I’m never usually sick this long. I need to go back to work! What’s the matter with me?
Clinician: It sounds like you’re concerned about how long this has gone on. What are you worried it may be?
Patient: I’m afraid I’m run down. This is the second time this winter I’ve been out of work for a week I can’t afford this.
Clinician: So it sounds like you’re worried about being out of work, and you’re also worried that you’re vulnerable to infections, and maybe you’d like to feel stronger. Do you have any idea about what may be making you feel run down?

The discussion may continue about how the patient may treat the symptoms, cope with the interruption in his or her schedule, and possibly strengthen his or her immunity. The patient feels heard and understood, and the clinician feels there is something to offer the patient.

In contrast, in this exchange the emotional connection is weak:

Clinician: What brings you in today?
Patient: My throat has been sore for over a week, I’m running a fever of 99.5, and I’m so tired I just want to stay in bed.
Clinician: A temperature at 99.5 is most likely a virus, and you’ll just have to wait it out.
Patient: I can’t afford to be out of work this much! Isn’t there anything you can do for me?
Clinician: Unfortunately, for a virus, all you can do is rest and wait it out.

The discussion is unlikely to continue much further. The patient feels dismissed, and the clinician feels discouraged that there is nothing to offer.

Emotional Connections Are Good for Both Patients and Clinicians

How patients benefit. The emotional connection between clinician and patient has the power to relieve the patient’s suffering, both directly and indirectly, in terms of reduced distress,[12][13] greater hope and motivation to manage the paitient’s illness,[14][15] better treatment planning,[16] better adherence to treatment plans,[17] and better symptom resolution.[7][18][19][20]

Failure to connect emotionally may harm patients. The clinician’s failure to make a positive emotional connection is not only a lost therapeutic opportunity, but may actively harm the patient. For example, when patients feel their physician has been hostile or dominating towards them, they are less satisfied with their care, and less likely to adhere to the recommended treatment.[7]

How clinicians benefit. When clinicians experience an emotional connection with their patient, they feel they are doing work that has meaning, and are thus more satisfied with their work.[2][21][22][23][24] In fact, the experience of “being present with” their patients correlates more strongly with finding meaning in work than do diagnostic triumphs.[24] Clinicians who connect emotionally with their patients are more committed to their jobs and less likely to burn out.[2][21][22][23][25] On the other hand, physicians who behave in ways patients find dominating put themselves at increased risk of malpractice litigation.[7]

Reciprocal emotion in a healing relationship

These findings reflect how profoundly patients and clinicians are affected by a healthy emotional connection. Patients experience satisfaction with the connection, and are motivated to work for recovery and self care, and their outcomes are better. Clinicians experience a renewed sense of meaning and fulfillment.

Emotionally supportive relationships in general have a benefit for health. For example, social support has been shown to moderate immediate physical responses to stressful circumstances, to improve longevity after myocardial infarction, to improve immune functioning, and possibly to improve longevity in individuals with cancer.[26][27][28] It is likely that the perception of social support is mediated neurochemically to offset the negative impact of perceived stress.[26]

Physiologic measures confirm that patients and clinicians react strongly to each other in the clinical encounter.[29][30][31] And shouldn’t that be expected? An encounter in which a vulnerable person, the patient, expects to have his or her body cared for is reminiscent of the relationship between a child and his or her caretaker. Attachment theorists[11][32][33][34] have repeatedly demonstrated how profoundly our social relationships affect our well-being throughout life.

The experience of “secure attachment” is critical to healthy development. Indeed, it is important to remember that attachment appears to be part of the biological wiring of the central nervous system in all social mammals.[35] Social mammals regulate each other’s physiology, modify the internal structure of each other’s nervous systems, and help regulate affective states throughout life. Attachment is sought throughout life, particularly when external or internal disruptions are experienced. We suggest that patients, especially when they feel unwell and therefore more vulnerable, similarly wish to feel safe by depending on a competent and predictable person who accepts them and can take care of them.

In contrast, a patient in emotional distress who appeals to the clinician for a connection and does not get one, feels the anxiety and potential health impact that typically results from a disrupted attachment.[35] When patients express distress, and receive an empathic response, their anxiety is reduced; in contrast, an incongruent response (e.g. ignoring, contradicting), harms the patient, distracting from the task at hand, disrupting trust, and increasing anxiety.[11][30][31]

Partnership

Emotional connection is a necessary, but not sufficient, component of the clinical relationship in patient-centered care. We propose partnership as the second critical dimension.

In a partnership, patient and clinician coordinate their separate areas of expertise. The clinician has expertise which the patient hopes to benefit from, and at the same time the patient’s expertise about himself or herself is engaged. Together, they establish agreement on treatment goals, the means to achieve them, and the roles each will take.[7][10][36]

This exchange demonstrates partnership-building:

Clinician: What brings you in today?
Patient: It’s the same as last time. I’m so tired I can’t do the things I need to do.
Clinician: Can you tell me some examples from this week, when you’re too tired to do what you need to do?
Patient: Every day it’s the same, I hit the snooze alarm multiple times, when I finally get up the kids are running around and I have to rush them through getting dressed and out the door, they won’t listen, and I can’t stay on top of them….
Clinician: It sounds pretty overwhelming! What do you think is making you so tired, like you don’t have the energy you need?
Patient: To tell you the truth, sometimes I think I just don’t want to deal with the kids. But I have to. So maybe there’s something you could give me to help me.
Clinician: So you wonder if it’s the job of taking care of the kids that is wearing you out, and you want a break? And you wonder how I might be able to help you? Let’s see what we can figure out together.

The patient and clinician can consider several explanations for the patient’s fatigue, both biomedical (eg, depression, too little sleep, or poor regulation of blood sugar) and socio-emotional (eg, depression, role overload, burnout, or deficit in parenting skills), and consider how to test each one with available and new data. The patient and clinician can determine what the patient can do to build energy, and what the clinician can do to help the patient improve stamina and build resources. For instance, the clinician might suggest a followup “patient counseling” appointment in which support and problem-solving can be offered in more detail. Both patient and clinician will feel more engaged and satisfied as a result of a discussion like this.

In contrast, in this exchange, partnership-building is weak:

Clinician: What brings you in today?
Patient: It’s the same as last time, I’m so tired I can’t do the things I need to do.
Clinician: Have you followed up on changing your sleep habits, the way we discussed?
Patient: Some nights, yes.
Clinician: It’s important to get enough sleep so you’re not too tired for your children.

The patient’s knowledge about her problem has not been engaged, and an important opportunity has been lost to identify the causes of fatigue and its treatment. Also, the patient is less likely to comply with recommendations that she has not actively participated in creating. The patient and clinician are likely to feel less satisfied with their communication.

A Clinical Partnership Is Good for Both Patients and Clinicians

How patients benefit. Partnered clinical relationships are more effective than those in which an authoritative clinician — even when there is a strong emotional connection — dominates the interaction. Patients in a partnered clinical relationship are less distressed,[37][38][39][40][41] more satisfied with their care,[7][42][43][44][45][46][47] more motivated to care for themselves,[48][49][50] more likely to follow through on treatment plans,[7][51][52][53][54][55] and enjoy greater functional improvement, symptom reduction, and reduced hospitalizations.[56][57][58][59][60][61][62][63][64][65][66][67][68]

Failure to partner may harm patients. Not only is a clinician-dominated clinical relationship less effective than a partnered relationship, but it may in fact actually harm the patient. When clinicians are more dominant (eg, talking more, engaging the patient in dialogue less), patients are less satisfied,[7] which in turn predicts non-adherence with treatment recommendations. Patients whose clinicians use directive and didactic techniques are less motivated for self-care and are less likely to adopt the health behaviors being discussed than are patients whose clinicians use facilitative and collaborative techniques.[48][49][50][69] In general, when patients defer to authority in a medical setting they feel less competent.[70]

How clinicians benefit. Clinicians in a partnered relationship are more satisfied with their work and feel more effective than clinicians in clinician-dominated relationships,[68][69][71][72][73] and clinicians who collaborate to set goals consistent with patients’ values feel more effective in helping patients change health behavior than do clinicians who judge, confront, and provide unsolicited advice.[68]

Patient Empowerment in a Healing Relationship

The human motivation to exercise control over oneself and one’s environment is as fundamental a motivation as attachment. Across domains of life, human beings want to expect that what happens is a result of their intentions.[74][75]

Respected thinkers in this field contend that (1) conceiving a desired outcome (goal-setting), (2) believing one can achieve it (self-efficacy), and (3) being willing to take action to achieve it (activation) result in greater physiological resiliency in a patient.[76][77] We have evidence that patients with high self-efficacy have better health outcomes.[78][79] For example, patients who believe they have control over the outcome recover better from coronary artery bypass surgery.[80] In contrast, lower self-efficacy leads to poorer health outcomes. Even the act of deferring to authority in a medical setting leads a patient to feel less self-efficacious.[70] Thus clinicians can improve their patients’ sense of self-efficacy through encouraging partnership, and can thereby improve their health outcomes.

Patients vary in the degree of self-efficacy which they present to their clinicians. At one extreme are patients with a helpless attitude, who seem to want their clinician to tell them what to do. However, delegation of control increases patients’ stress, which in turn increases their risk for stress-related exacerbation of their illness.[70] While clinicians may be tempted to respond to their patients’ distress by taking charge and solving the problem for them, these patients will benefit more if their clinicians can help them set goals, plan how to pursue them, and suggest ways that they can help themselves. Clinicians who do not succeed in partnering with their patients to take control of their health lose a therapeutic opportunity.

At the other extreme are patients who have strong beliefs in their self-efficacy. Patients who are self-efficacious, who have learned to take charge of their health and expect to collaborate with their clinicians, are ideally matched with clinicians who also want to collaborate. If these patients encounter clinicians who behave in an authoritative, non-collaborative way, they will feel thwarted and diminished.[81]

Unintended costs result from a clinical encounter in which the patient wants collaboration and the clinician does not facilitate it. If, for example, the patient is distressed and weakened, and particularly if he feels threatened, harm to the patient may result. We can look to studies which have been reliably replicated across multiple animal species—when the animal is shocked (ie, in pain), and the animal has learned that another animal (not itself) has control over when the pain stops and starts, “learned helplessness” can result, ie, a primal “giving up” response which is physiological, behavioral, and emotional, and has negative physical consequences for health.[82][83]

3. Guided Discovery: Commitment to Empiricism and Collaborative Use of the Scientific Method

When patient and clinician work towards partnership during a medical encounter, they develop a shared hypothesis about the origins of the patient’s complaint and the means to address it. It is a small further step for the clinician to make these hypotheses explicit, and to guide the patient in hypothesis testing through data collection and subsequent analysis of results.

This enterprise can be as straightforward as the following example:

Clinician: So to sum up, you and I are thinking that your loss of appetite may be due to the anxiety you’ve been experiencing since the layoffs started at work.
Patient: That’s right.
Clinician: If this is what’s behind your loss of appetite, then, the medication we’ve been discussing may help you feel less physically anxious, and you may find your appetite coming back.
Patient: We hope so!
Clinician: This is our best guess at this time, and it’s important to test whether we’re right about this, rather than assuming we’ve got the answer. How can we test it? If you start taking this medication today…
Patient: I can see whether my appetite comes back.
Clinician: Yes, and let’s treat this seriously, and collect some good data, so we can feel we’re really testing it well. What would you observe about yourself that would let you feel sure your appetite was coming back?
Patient: If I ate the way I used to eat.
Clinician: So what if we use your actual eating pattern as our measure of whether this medication is helping? Can you keep track of when you take your medication and what you eat?
Patient: I can use my notebook app, and write down when I take my medication, and what I eat each day.
Clinician: Good, and I wonder if it would also help to rate how good you feel your appetite is overall?
Patient: Like “A, B, C…”
Clinician: Good, and how about at the end of each day, write down your “appetite grade”
Patient: I can do that.
Clinician: Let’s practice….

Clinician: Now, how long would it take for you to feel your appetite had really changed?
Patient: Probably a week.
Clinician: Then should we review our data in a week or so and see what it shows us? If your appetite looks like it’s getting better over time, then we have evidence we’re on the right track. If your appetite doesn’t look any better, then we’ll consider other possible explanations, ok?
Patient: Ok.

The essential elements of guided discovery, as demonstrated above, are:

• Clinician’s use of Socratic questioning, engaging the patient’s curiosity and willingness to experiment;[84][85]
• Shared hypothesis formation;
• Reliance on empirical observation to test hypotheses;
• Identification of data collection parameters that are meaningful to the patient;
• Planning and rehearsal of the steps in data collection;
• Commitment and scheduling of data analysis; and
• Acknowledgment that the solution may require some experimentation.

Guided Discovery Is Good for Both Patients and Clinicians

Engaging patients in experimental inquiry through Socratic questioning is a relational strategy that has been used with success in cognitive behavioral psychotherapy.[11][86] It depends on and augments a foundation of emotional connection and partnership. We are not aware of research which has explicitly isolated and tested guided discovery as an active ingredient in medical outcomes. However, we propose that this approach presents multiple advantages for patients and clinicians in the clinical encounter.

How patients may benefit. We predict that guided discovery will benefit the patient in several ways. We expect patients to enjoy reduced distress because formulating hypotheses, collecting data, and observing results engages a different mental state; patients “de-center”[87] from their distress and become more “mindful.”[77] The act of observing oneself in a neutral manner is effective in reducing emotional responses, and, as a result, makes resolution seem more possible, thus inspiring hope.

Also, we expect patients to become more activated as they plan how to test whether the proposed treatment will help them, and to enjoy greater self-efficacy as they improve their ability to apply cause-and-effect reasoning to their own health. We expect that patients who fully understand the reasoning behind a proposed intervention, who have designed personally meaningful ways of testing its success, and who are monitoring whether they are adhering to their plans, will be more likely to adhere to their care plans.[e][88] In addition, we expect that patients who anticipate the possibility that an intervention may not succeed, and are prepared to rethink and re-plan in partnership with their clinicians, will be more likely to persist in finding a solution.

Further, we expect that health outcomes will be better for patients when they adopt an empirical approach in partnership with their clinician. First, there are the cumulative positive effects on health outcomes of reduced distress, greater adherence to care plans, greater self-efficacy, and greater customization of the plan to the particular patient’s presentation. Second, when there is commitment to a concrete checkpoint to review the intervention and formally assess the results, there is the opportunity to regroup if needed, which will be driven by both patient and clinician, thereby increasing the likelihood of better outcomes.

Also, it is possible that the “attention shift” to empirical observation would provide patients some of the same health outcome benefits which patients obtain in “mindfulness-based stress reduction” (MBSR). In MBSR patients learn to shift their attention away from struggling with a problem to observing it dispassionately. In addition to enjoying reduced distress, their health outcomes are better than for control patients who do not use MBSR.[89]
[90][91][92] Guided discovery similarly shifts a patient’s attention away from struggling with a problem to dispassionate observation.

In addition, we expect that guided discovery will add important controls to the clinical process. Fully informed and empowered patients are better able to monitor their progress, and alert their clinician to negative experiences, thus reducing unanticipated errors.

How clinicians may benefit from guided discovery. We predict that clinicians will find the encounter to be more focused and therefore a more efficient use of time, and that the additional responsibility assumed by the patient will free up more of the clinician’s time. We predict that clinicians will enjoy best access to relevant data and potential conceptions of the problem and intervention, if the expertise of both parties is fully engaged and the scientific method is applied, and will thus experience a greater sense of efficacy.

We predict that clinicians will enjoy reduced emotional burden as they work as co-investigators with their patients in a guided discovery process. When clinician and patient are allied in an empirical approach, the clinician will not be expected to “have all the answers”. If the co-investigators anticipate experimenting with their first intervention, rather than cleaving to it as “the answer,” there is more flexibility and less perfectionism. Also, when clinicians observe rather than react — and the focus on empiricism requires an observing mind, not a reacting mind — their unproductive emotionality is reduced.[2]

In addition, we predict that clinicians will enjoy an expanded sense of meaning as they guide their patients in a discovery process. Surveyed physicians
report most frequently finding meaning in work through their relationships with their patients and through the intellectual stimulation their work provides.[21][22][23] In guided discovery, the clinician’s role is larger than that of a technician applying received knowledge; instead, clinicians act as teachers and scientists, who are trained and empowered to generate and test clinical hypotheses. We predict this role will enhance clinicians’ intellectual satisfaction as they explore with their patients how to heal them.

Conclusion

To meet its current challenges, health care is now focused on discussions and experiments at the largest, most systemic, levels. In our zeal to address these critical issues, we have neglected the potential power of the smallest unit of analysis — the healing relationship between clinician and patient. In doing so, we have contributed to the undervaluing of the relational aspects of care, and risk losing our most immediate and practical lever for change.

The authors propose that health care delivery systems focus their improvement efforts, first, on ensuring best practices in their clinical relationships, and subsequently reform their organizations so as to support these relationships, echoing the Institute of Medicine’s 2001 recommendation.[f] It is especially important to do so now, because the value we place now on the clinical relationship, and the way we define its best practices, will determine clinical training and care delivery for years to come.

What are our best practices? Substantial evidence indicates the importance of emotionally connected and partnered clinical relationships as the care delivery vehicle for patient-centered care. In addition, we expect that guided discovery will prove to be a potent additional care delivery vehicle when it is evaluated for impact on patient and clinician outcomes.

Given these benefits, what are the barriers to implementation of these best practices that organizations face? First, there is the issue of reforming organizational life to support them. Second, there is the issue of clinical staff acquiring the necessary skills. However, we note that these skills are as learnable as other technical skills.[g]Third, there is the concern that relating to patients in this complex way will be too time-consuming. But we contend that these relational strategies can be conducted efficiently,[h] and that they will result in greater efficiencies further down the path of care. We recommend further evaluation to determine whether clinicians’ time investment using this relational model significantly exceeds time investment under current practices before assuming it does so.

Endnotes

a. In 2001, the Institute of Medicine proposed patient-centered care as one of six general aims for health care quality improvement nationwide. The IOM report acknowledged that delivering patient-centered care according to this definition would require capacity-building in the health care workforce, especially in building stable, trusting relationships between patients and clinicians.[1]

To date, the call for reform in the IOM report has led to some significant changes in medical training and accreditation. For examples, see:

1. Makoul G. Essential dimensions of communication in medical encounters: The Kalamazoo consensus statement. Acad Med. 2001; 76:390-393.
2. Makoul G, Curry R. The value of assessing and addressing communication skills. JAMA. 2007; 298:1057-1059.
3. Lucian Leape Institute at the National Patient Safety Foundation. Unmet needs: Teaching physicians to provide safe patient care. Available at: http://www.npsf.org/about-us/lucian-leape-institute-at-npsf/lli-reports-and-statements/unmet-needs-teaching-physicians-to-provide-safe-patient-care. Accessed February 6, 2012.

In particular, the American Board of Medical Specialties, the gold standard in physician certification, identifies interpersonal and communication skills, ie, skills that result in effective information exchange and teaming with patients, their families, and professional associates, as one of six key core competencies for board certified physicians.[93]

Those wishing for an examination of patient-centered care as a whole will find a variety of sources in the literature. For example:

1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press; 2001.
2. Perla RJ, Bradbury E, Gunther-Murphy C. Large-scale improvement initiatives: A scan of the literature. Journal for Healthcare Quality. Sept 2011 [Epub ahead of print.] [DOI: 10.1111/j.1945-1474.2011.00164.x]
3. Commission on a High Performance Health System. Framework for a High Performance Health System for the United States. New York: The Commonwealth Fund; 2006.
4. Conway J, Johnson B, Edgman-Levitan S, Schlucter J, Ford D, Sodomka P, Simmons L. Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: A Roadmap for the Future. A Work in Progress. Institute for Family-Centered Care and Institute for Healthcare Improvement; unpublished manuscript June 2006.
5. Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. Available at: http://www.ihi.org. Accessed April 23, 2012.

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b. In the past decade, we have seen increasing numbers of health care delivery organizations refocus their work on what patients and their families want. Driven in part by grave concerns over patient safety, in part by urgency to contain and reduce costs of health care delivery, many organizations have taken on improvement initiatives under the banner of patient-centered care (PCC) or patient-and-family-centered care (PFCC). (Examples: Kaiser-Permanente, University of Washington Medical Center, Children’s Hospital St. Paul, University of Michigan Medical Center, Beth Israel Deaconess Hospital , Cincinnati Children’s Hospital, Cleveland Clinic, Geisinger Health System, Intermountain Healthcare, Kaiser Permanente, Virginia Mason Medical Center.)

Their improvement efforts can be reviewed in:

1. Bohmer R. Fixing health care on the front lines. Harvard Business Review. April, 2010.
2. Nelson K. Improving safety and reliability in the physician office. Available at: http://www.ihi.org/offerings/VirtualPrograms/Webinars/Web_Action/OfficeSafety_Reliability/Pages/default.aspx. Accessed April 23, 2012.
3. Institute for Healthcare Improvement. Patient-Centered Care. Available at: http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral. Accessed February 24, 2011.

In fact, these safety- and efficiency-focused innovations have had positive ripple effects throughout health care systems and beyond safety and cost. When health care delivery systems are redesigned around patient-centered care, patients are more actively engaged, patient safety is improved, and clinical outcomes and patient satisfaction with services received are generally better. For reviews of the ripple effects for patients, see:

1. Lee T. Turning doctors into leaders. Harvard Business Review. April, 2010.
2. Bohmer R. Fixing health care on the front lines. Harvard Business Review. April, 2010.
3. Nelson K. Improving Safety and Reliability in the Physician Office. Available at: http://www.ihi.org/offerings/VirtualPrograms/Webinars/Web_Action/OfficeSafety_Reliability/Pages/default.aspx. Accessed April 23, 2012.

The patient-centered care approach benefits clinicians as well as patients. Efforts to improve the patient-centeredness of care have required strong teamwork among clinicians and staff. For further discussion, see:

1. Hoffer Gittell, J. High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience. New York: McGraw Hill; 2009.
2. Wheelan S, Burchill C, Tilin F. The link between teamwork and patients’ outcomes in intensive care units. Am J Crit Care. 2003; 12:527-534.
3. Manion, J. From management to leadership: strategies for transforming health care, 3rd ed. San Francisco: Jossey-Bass; 2011.

Consequently, clinicians and staff who use the patient-centered care approach and enjoy strong teamwork are more satisfied with their work, are absent less often, and stay longer with their organizations. For reviews of the ripple effects for clinicians and staff see:

1. Press Ganey Associates. ROI in Satisfaction Measurement and Iimprovement. Available at: http://www.pressganey.com. Accessed April 23, 2012.
2. Nelson K. Improving safety and reliability in the physician office. Available at: http://www.ihi.org/offerings/VirtualPrograms/Webinars/Web_Action/OfficeSafety_Reliability/Pages/default.aspx. Accessed April 23, 2012.

In addition, both patient-centered care improvement efforts and team efficacy improvement efforts contribute to improved metrics for the organizations involved, in terms of more efficient use of resources, lower cost of providing services, a more loyal patient base, lower clinician and staff turnover, higher revenue, and higher profit margins. For examples of ripple effects for organizations, see:

1. Henriks G. Developing innovative solutions to everyday problems: Session 1. Innovations in Health Care. Web and Action. Available at: http://www.ihi.org. Accessed April 23, 2012.
2. Hoffer Gittell, J. High Performance Healthcare: Using the Power of Relationships to Achieve Quality, Efficiency and Resilience. New York: McGraw Hill; 2009.
3. Gallup Healthways, 2009. Cited in: Watson J, Bell K, Kaplan M: Raising Joy in the Health Care Workforce. Available at: http://www.ihi.org/knowledge/Pages/AudioandVideo/WIHIRaisingJoyintheHealthCareWorkforce.aspx. Accessed July 9, 2009.
4. Nelson K. Improving Safety and Reliability in the Physician Office. Available at: http://www.ihi.org/offerings/VirtualPrograms/Webinars/Web_Action/OfficeSafety_Reliability/Pages/default.aspx. Accessed April 23. 2012.
5. Press Ganey Associates. ROI in satisfaction measurement and improvement. Available at: http://www.pressganey.com. Accessed April 23. 2012.
6. Press Ganey Associates. The Loyalty Connection: Patient Loyalty Starts with Employees. Available at: http://www.pressganey.com. Accessed April 23. 2012.

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c. For a historical review of physicians’ perceptions of their roles and patients’ experiences of care, see Shorter E. Bedside Manners: The Troubled History of Doctors and Patients. New York: Simon and Schuster; 1985. ↩

d. We acknowledge that forming and promoting a good clinical relationship does require time — somewhat more, but perhaps not much more time than “business as usual” in a clinical interview. As our examples will show, relationships can be formed efficiently if the right strategies are used. It is worth noting that there are changes being proposed in reimbursement for services (eg, the patient-centered medical home, pay-for-outcome models), which may support clinicians in allocating the time they feel is necessary to treat their patients. In support of this direction, a recent assessment showed that more effective use of primary care would significantly reduce hospitalizations, use of outpatient services, and postacute care.[93] ↩

e. See this meta-analysis of the relative success of behavioral strategies patients can use to change health behaviors. Self-monitoring emerges as the strongest tool: Michie S, Abraham C, Whittington C, et al. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychology. 2009; 28:690-701. ↩

f. In particular, “…that reform for patient-centered care be supported by medical care organizations and by regulatory and payment environments.[1]” Granted, the systems in which health care is delivered have shaped the clinical relationships which we have today, and re-forming clinical relationships without reforming the organizations which support them will require swimming upstream. However, if medicine does not succeed in restoring the primacy of the healing relationship, the impact of system reforms will be diluted. ↩

g. For a summary of skill sets required and training resources, see: http://www.workingtogetherforhealth.com/journal.html. ↩

h. For a demonstration, see: http://www.workingtogetherforhealth.com/journal.html. ↩

References

1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington D.C.: National Academy Press; 2001 ↩
2. Krasner M, Epstein M, Beckman H, Suchman M, Chapman B, Mooney C, Quill T. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; 302(12):1284-1293. ↩
3. Adams D. Doctor morale shaky as practice stressors surge. Available at: www.ama-assn.org/amednews/2007/01/15/prl20115.htm. Accessed on October 1, 2011. ↩
4. US Dept of Health and Human Services. 2008 National sample survey of registered nurses. Washington D.C.: US Dept of Health and Human Services, Health Resources Services Administration; 2010. ↩
5. Physicians Foundation. Health reform and the decline of physician private practice. Available at: http://www.physiciansfoundation.org/uploadedFiles/Health%20Reform%20and%20the%20Decline%20of%20Physician%20Private%20Practice.pdf. Accessed on October 1, 2011. ↩
6. Beach M, Inui T, and the Relationship-Centered Care Research Network. Relationship-centered care: a constructive reframing. J Gen Intern Med. 2006; 21(S1):S3-S8. ↩
7. Roter D, Hall J. Doctors Talking with Patients/Patients Talking with Doctors. Westport, Connecticut: Praeger; 2006. ↩
8. Manion J. From Management to Leadership: Strategies For Transforming Health Care, 3rd ed. San Francisco: Jossey-Bass; 2011. ↩
9. Safran JD, Muran JC. Negotiating the Therapeutic Alliance. New York: Guilford; 2000. ↩
10. Bordin ES. Theory and research on the therapeutic working alliance: new directions. In Horvath AO, Greenberg LS, eds. The Working Alliance: Theory, Research and Practice. New York: Wiley; 1994. ↩
11. Safran J, Segal Z. Interpersonal Processes in Cognitive Therapy. New York: Basic Books; 1990. ↩
12. Fiscella K, Meldrum S, Franks P, Shields CG, Duberstein P, McDaniel SH, Epstein RM. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. Nov 2004; 42(11):1049-55. ↩
13. Roter D, Hall J, Kern D, Barker L,Cole K, Roca R. Improving physicians’ interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Int Med. 1995; 155:1877-1884. ↩
14. Thorne S, Hislop T, Armstrong E, Oglov V. Cancer care communication: the power to harm and the power to heal? Patient Educ Couns. 2008; 71(1):34-40. ↩
15. Fox S, Chesla C. Living with chronic illness: a phenomenological study of the health effects of the patient-provider relationship. J Am Acad Nurse Pract. 2008; 20(3):109-117. ↩
16. Charon R Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press; 2006. ↩
17. Berry L, Parish J, Janakiraman R, et al. Patients’ commitment to their primary care physicians and why it matters. Ann Fam Med. 2008; 6(1):6-13. ↩
18. DiBlasi Z. Influence of context effects on health outcomes: a systematic review. Lancet. 2001; 357(9259):757-762. ↩
19. Haezen-Klemens I, Lapinska E. Doctor-patient interaction, patients’ health behavior, and effects of treatment. Soc Sci Med. 1984;19(1):9-18. ↩
20. Hojat M, Lous D, Markham F, et al. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011 Mar;86(3):359-64. ↩
21. Shanafelt T. Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009; 302(12):1338-1340. ↩
22. Shanafelt T, West C, Sloan J, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009; 169(10):990-995. ↩
23. McMurray J, Williams E, Schwartz MD, Douglas J, Van Kirk J, Konrad TR, Gerrity M, Bigby JA, Linzer M. Physician job satisfaction: developing a model using qualitative data. SGIM Career Satisfaction Study Group. J Gen Intern Med. 1997; 12(11): 711-714. ↩
24. Dunn P, Arnetz B, Christensen J, Homer L. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med. 2007; 22(11):1554-1562. ↩
25. Raiziene S, Endriulaitiene A. The relations among empathy, occupational commitment, and emotional exhaustion of nurses. Medicina. 2007; 43(5):425-431. ↩
26. McEwen B, Lasley E. The End of Stress as We Know It. Washington, DC: The Joseph Henry Press; 2002. ↩
27. Gerin W. Pieper C, Levy R, Pickering T. Social support in social interaction: a moderator of cardiovascular activity. Psychosom Med. 1992; 54:324. ↩
28. Frasure-Smith N, Lesperance F, Gravel G, et al. Social support, depression, and mortality during the first year after myocardial infarction. Circulation. 2000; 101:1919-1924. ↩
29. Reiss H. Empathy in medicine — a neurobiological perspective. JAMA. 2010; 304(14):1604-1605. ↩
30. Glucksman M. Psychological measures and feedback during psychotherapy. Psychother psychosom. 1981; 36(3-4):185-199. ↩
31. Marci C, Ham J, Moran E, Orr S. Physiologic correlates of perceived therapist empathy and social-emotional process during psychotherapy. J Nerv Ment Dis. 2007; 195(2):103-111. ↩
32. Bowlby, J. A Secure Base: Parent-Child Attachment and Healthy Human Development. New York: Basic Books; 1980. ↩
33. Fonagy, P. Attachment Theory and Psychoanalysis. New York: Other Press; 2001. ↩
34. Karen R. Becoming Attached: First Relationships and How They Shape Our Capacity to Love. New York: Oxford University Press; 1994. ↩
35. Bowlby J. Attachment, Security, and Loss. New York: Basic Books; 1982. ↩
36. Epstein RM, Street RL. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda MA: National Cancer Institute, NIH Publication No. 07-6225; 2007. ↩
37. MacKay C, Cox T, Burrows G, Lazzerini T. An inventory for the measurement of self-reported stress and arousal. British journal of social and clinical psychology. 1979; 17:283-284. ↩
38. Dormaar M, Dijkman C, Devries M. Consensus in patient-therapist interactions: a measure of the therapeutic relationship related to outcome. Psychothe Psychosom. 1989; 51:69-76. ↩
39. Safran J, Wallner L. The relative predictive validity of two therapeutic alliance measures in cognitive therapy. Psychological Assessment. 1991; 3:188-195. ↩
40. Tryon G, Winograd G. Goal consensus and collaboration. In Norcross J, ed. Psychotherapy Relationships That Work. New York: Oxford University Press; 2002. ↩
41. Marmar C, Gaston L, Gallagher D, Thompson L. Alliance and outcome in late-life depression. J Nerv Ment Dis. 1989; 177::464-472. ↩
42. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999; 49:651-661. ↩
43. Gattelari M, Butow P, Tatterall M. Sharing decisions in cancer care. Soc Sci Med. 2001; 52:1865-1878. ↩
44. Krupat E, Bell R, Kravitz R., Thom D, Azari R. When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract. 2001; 50:1057-1062. ↩
45. Krupat E, Rosenkranz S, Yeager C, et al. The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction. Patient Educ Couns. 2000; 39:49-59. ↩
46. Bertakis K, Roter D, Putnam S. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991; 32:175-181. ↩
47. Stewart M. What is a successful doctor-patient interview: a study of interactions and outcomes. Soc Sci Med. 1984; 19:167-175. ↩
48. Deci E, Ryan R. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum Press; 1985. ↩
49. Williams G, Rodin G, Ruan R, et al. Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychol. 1998; 17:269-276. ↩
50. Williams G, Grow V, Fredman Z, et al. Motivational predictors of weight loss and weight-loss maintenance. J Personality Soc Psychol. 1996; 70:115-126. ↩
51. Roumie C, Greevy R, Wallston K, Elasy T, Kaltenbach L, Kotter K, Dittus R, Speroff T. Patient centered primary care is associated with patient hypertension medication adherence. J Behav Med. 2011; 34(4): 244-253. ↩
52. DiMatteo M. Enhancing patient adherence to medical recommendations. JAMA. 1994; 271:79-83. ↩
53. DiMatteo M, Reiter R, Gambone J. Enhancing medication adherence through communication and informed collaborative choice. Health Comm. 1994; 6:253-265. ↩
54. DiMatteo M, DiNicola D. Achieving Patient Compliance. New York: Pergamon Press; 1982. ↩
55. Eisenthal S, Emery R, Lazare A, Udin H. “Adherence” and the negotiated approach to patienthood. Arch Gen Psych. 1979;36(4):393-398. ↩
56. Bodenhemier T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469-2475. ↩
57. Lorig K, Sobel D, Stewart A, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37:5-14.
    ↩
58. Stewart M. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423-1433. ↩
59. Roter D The enduring and evolving nature of the patient-physician relationship. Patient Educ Couns. 2000;39:5-15. ↩
60. Sidani S. Effects of patient-centered care on patient outcomes: an evaluation. Res Theory Nurs Pract. 2008;22:24-37. ↩
61. Andersen M, Bowen D, Morea J, et al. Involvement in decision-making and breast cancer survivor quality of life. Health Psychol. 2009;28:29-37. ↩
62. Klein S and the Commonwealth Fund. Case Study: Health Plan-Led Coaching Program Leads to Improved Outcomes and Cost Savings. Available at: http://www.commonwealthfund.org/Newsletters/Quality-Matters/2010/December-January-2010/Case-Study.aspx. Accessed February 6, 2012. ↩
63. Wolever R, Dreusicke M, Fikkan J, et al. Integrative health coaching for patients with type 2 diabetes: a randomized clinical trial. Diabetes Educ. 2010; 36:629. ↩
64. Edelman D, Oddone E, Liebowitz R, et al. A multidimensional integrative medicine intervention to improve cardiovascular risk. J Gen Intern Med. 2006; 21:728-734. ↩
65. Artinian N, Fletcher G, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 2010; 122:406-441. ↩
66. Rubak S, Sandback A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract . 2005;55: 305-312. ↩
67. Butterworth S, Linden A, McClay W, Leo M. Effect of motivational interviewing-based health coaching on employees’ physical and mental health status. Journal of Occ Health Psychol. 2006; 11:358-364. ↩
68. Pollak K, Alexander S, Coffman CJ, Tulsky JA, Lyna P, Dolor RJ, James IE, Brouwer RJ, Manusov JR, Østbye T. Physician communication techniques and weight loss in adults. Am J Prev Med. 2010; 39:321-328. ↩
69. Spence G, Cavanagh M, Grant A. The integration of mindfulness training and health coaching: an exploratory study. Coaching: An International Journal of Theory, Research, and Practice. 2008; 1:145-163. ↩
70. Langer E. Counterclockwise: Mindful Health and the Power of Possibility. New York: Ballantine Books; 2009:28. ↩
71. Roter D, Stewart M, Putnam S, Lipkin M, Stiles W, Inui T. Communication patterns of primary care physicians. JAMA. 1997; 270:350-355. ↩
72. Hayes E, Kalmakis K. From the sidelines: coaching as a nurse practitioner strategy for improving health outcomes. J Am Acad Nurse Pract. 2007; 19: 555-562. ↩
73. Vale M, Jelinek M, Grigg L, Newman R. Coaching patients on achieving cardiovascular health (COACH). Arch Int Med. 2003; 163:2775-2783. ↩
74. Stern D. The Interpersonal World of the Infant. New York: Basic Books; 1985. ↩
75. Bandura A. Self-efficacy: towards a unifying theory of behavior change. Psychological Review. 1977; 84:191-215. ↩
76. Seligman M. Learned Optimism: How to Change Your Mind and Your Life. New York: Vintage Books; 2006. ↩
77. Langer E. Mindfulness. Reading MA: Addison-Wesley Publishing; 1989. ↩
78. Langer E, Rodin J. The effects of enhanced personal responsibility for the aged: a field experiment in an institutional setting. J Pers Soc Psychol. 1976; 34:191-198. ↩
79. Seligman M, Peterson C, Vaillant G. Pessimistic explanatory style as a risk factor for physical illness: a thirty-five year longitudinal study. J Pers Soc Psychol. 1988; 55:23-27. ↩
80. Scheier, M, Carver C. Effects of optimism on psychological and physical well-being: theoretical overview and empirical update. Cognit Ther Res. 1992; 16:201-228. ↩
81. Berwick D. What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood). 2009 Jul-Aug;28(4):w555-65. Epub 2009 May 19. Available at: http://content.healthaffairs.org/cgi/content/full/28/4/w555. Accessed April 8, 2012. ↩
82. Seligman M, Maier S. Learned helplessness: theory and evidence. Journal of Experimental Psychology. 1976; 105:3-46. ↩
83. Walker, J. Control and the Psychology of Health: Theory, Measurement and Applications. New York: Open University Press; 2006. ↩
84. Padesky C. Socratic questioning: changing minds or guiding discovery? Keynote address delivered at the European Congress of Behavioral and Cognitive Therapies, London, September 24, 1993. Available at: http://www.padesky.com/clinicalcorner/pubs.htm#Socratic Questioning. Accessed Feb 7, 2012. ↩
85. Oh R. The socratic method in medicine — the labor of delivering medical truths. Family Med. 2005; 37(8): 537-539. ↩
86. Beck AT, Rush JA, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979. ↩
87. Segal Z, Williams M, Teasdale J. Mindfulness-Based Cognitive Therapy for Depression: a New Approach to Preventing Relapse. New York: Guilford; 2002. ↩
88. Carver C, Scheier M. Control theory: a useful conceptual framework for personality-social, clinical and health psychology. Psychol Bull. 1982; 92: 111-135. ↩
89. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York: Hyperion; 1994. ↩
90. Segal Z, Williams M, Teasdale J. Mindfulness-Based Cognitive Therapy for Depression: a New Approach to Preventing Relapse. New York: Guilford; 2002. ↩
91. Linehan M, Armstrong H, Suarez A, et al. Cognitive behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psych. 1991; 48:1060-1064. ↩
92. Kabat-Zinn J, Massion A, Kristeller J, et al. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am Journ Psychiat. 1992; 149: 936-943. ↩
93. American Board of Medical Specialties. MOC Competencies and Criteria. Available at: http://www.abms.org/maintenance_of_certification/MOC_competencies.aspx. Accessed Feb 6, 2012. ↩
94. Reschovsky JD, Ghosh A, Stewart K, Chollet D. Paying More for Primary Care: Can It Help Bend the Medicare Cost Curve? The Commonwealth Fund, Issue Brief, March 2012. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Mar/1585_Reschovsky_paying_more_for_primary_care_FINALv2.pdf. Accessed April 12, 2012. ↩

Copyright: © 2012 Diana Dill and Peter Gumpert. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.