Summary<\/em><\/strong>: 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\u2019 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. \tCurrent 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<\/a>[1<\/a>], and our national challenge to recruit and retain clinicians to deliver primary care.<\/a>[2<\/a>]<\/a>[3<\/a>]<\/a>[4<\/a>]<\/a>[5<\/a>] Organizations that have reorganized care delivery to be patient-centered<\/em> (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>[a<\/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.<\/a>[b<\/a>]<\/p>\n \tWe believe the central dimension of patient-centered care (or relationship-centered care<\/a>[6<\/a>]<\/a>[7<\/a>]<\/a>[8<\/a>]<\/a>[9<\/a>]) 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\u2019s emotions, partnership-building) have taken a back seat to the biomedical and administrative tasks of delivering care (eg, gathering and analyzing diagnostic data).<\/a>[c<\/a>]<\/a>[7<\/a>] 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.<\/a>[d<\/a>] 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. <\/p>\n \tIn 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. <\/p>\n \tWe begin with Bordin\u2019s<\/a>[10<\/a>] 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. <\/p>\n \tIn 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.<\/p>\n \tWe 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.<\/p>\n \tWhen patients experience an emotional connection with their clinician (or empathic attunement<\/a>[11<\/a>] 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.<\/a>[2<\/a>]<\/p>\n \tConsider this straightforward exchange:<\/p>\n Clinician: What brings you in today? \tThe 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.<\/p>\n \tIn contrast, in this exchange the emotional connection is weak:<\/p>\n Clinician: What brings you in today? \tThe discussion is unlikely to continue much further. The patient feels dismissed, and the clinician feels discouraged that there is nothing to offer.<\/p>\n \tHow patients benefit.<\/strong> The emotional connection between clinician and patient has the power to relieve the patient\u2019s suffering, both directly and indirectly, in terms of reduced distress,<\/a>[12<\/a>]<\/a>[13<\/a>] greater hope and motivation to manage the paitient’s illness,<\/a>[14<\/a>]<\/a>[15<\/a>] better treatment planning,<\/a>[16<\/a>] better adherence to treatment plans,<\/a>[17<\/a>] and better symptom resolution.<\/a>[7<\/a>]<\/a>[18<\/a>]<\/a>[19<\/a>]<\/a>[20<\/a>]<\/p>\n \tFailure to connect emotionally may harm patients.<\/strong> The clinician\u2019s 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.<\/a>[7<\/a>]<\/p>\n \tHow clinicians benefit.<\/strong> 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.<\/a>[2<\/a>]<\/a>[21<\/a>]<\/a>[22<\/a>]<\/a>[23<\/a>]<\/a>[24<\/a>] In fact, the experience of \u201cbeing present with\u201d their patients correlates more strongly with finding meaning in work than do diagnostic triumphs.<\/a>[24<\/a>] Clinicians who connect emotionally with their patients are more committed to their jobs and less likely to burn out.<\/a>[2<\/a>]<\/a>[21<\/a>]<\/a>[22<\/a>]<\/a>[23<\/a>]<\/a>[25<\/a>] On the other hand, physicians who behave in ways patients find dominating put themselves at increased risk of malpractice litigation.<\/a>[7<\/a>]<\/p>\n \tThese 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. <\/p>\n \tEmotionally 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.<\/a>[26<\/a>]<\/a>[27<\/a>]<\/a>[28<\/a>] It is likely that the perception of social support is mediated neurochemically to offset the negative impact of perceived stress.<\/a>[26<\/a>] <\/p>\n \tPhysiologic measures confirm that patients and clinicians react strongly to each other in the clinical encounter.<\/a>[29<\/a>]<\/a>[30<\/a>]<\/a>[31<\/a>] And shouldn\u2019t 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<\/a>[11<\/a>]<\/a>[32<\/a>]<\/a>[33<\/a>]<\/a>[34<\/a>] have repeatedly demonstrated how profoundly our social relationships affect our well-being throughout life. <\/p>\n \t The experience of \u201csecure attachment\u201d 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.<\/a>[35<\/a>] Social mammals regulate each other\u2019s physiology, modify the internal structure of each other\u2019s 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. <\/p>\n \tIn 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.<\/a>[35<\/a>] 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.<\/a>[11<\/a>]<\/a>[30<\/a>]<\/a>[31<\/a>]<\/p>\n \tEmotional connection is a necessary, but not sufficient, component of the clinical relationship in patient-centered care. We propose partnership as the second critical dimension. <\/p>\n \tIn 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\u2019s 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.<\/a>[7<\/a>]<\/a>[10<\/a>]<\/a>[36<\/a>]<\/p>\n \tThis exchange demonstrates partnership-building:<\/p>\n Clinician: What brings you in today? \tThe patient and clinician can consider several explanations for the patient\u2019s 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.<\/p>\n \tIn contrast, in this exchange, partnership-building is weak:<\/p>\n Clinician: What brings you in today? \tThe patient\u2019s 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.<\/p>\n \tHow patients benefit.<\/strong> 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,<\/a>[37<\/a>]<\/a>[38<\/a>]<\/a>[39<\/a>]<\/a>[40<\/a>]<\/a>[41<\/a>] more satisfied with their care,<\/a>[7<\/a>]<\/a>[42<\/a>]<\/a>[43<\/a>]<\/a>[44<\/a>]<\/a>[45<\/a>]<\/a>[46<\/a>]<\/a>[47<\/a>] more motivated to care for themselves,<\/a>[48<\/a>]<\/a>[49<\/a>]<\/a>[50<\/a>] more likely to follow through on treatment plans,<\/a>[7<\/a>]<\/a>[51<\/a>]<\/a>[52<\/a>]<\/a>[53<\/a>]<\/a>[54<\/a>]<\/a>[55<\/a>] and enjoy greater functional improvement, symptom reduction, and reduced hospitalizations.<\/a>[56<\/a>]<\/a>[57<\/a>]<\/a>[58<\/a>]<\/a>[59<\/a>]<\/a>[60<\/a>]<\/a>[61<\/a>]<\/a>[62<\/a>]<\/a>[63<\/a>]<\/a>[64<\/a>]<\/a>[65<\/a>]<\/a>[66<\/a>]<\/a>[67<\/a>]<\/a>[68<\/a>]<\/p>\n \tFailure to partner may harm patients.<\/strong> 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,<\/a>[7<\/a>] 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.<\/a>[48<\/a>]<\/a>[49<\/a>]<\/a>[50<\/a>]<\/a>[69<\/a>] In general, when patients defer to authority in a medical setting they feel less competent.<\/a>[70<\/a>]<\/p>\n \tHow clinicians benefit.<\/strong> Clinicians in a partnered relationship are more satisfied with their work and feel more effective than clinicians in clinician-dominated relationships,<\/a>[68<\/a>]<\/a>[69<\/a>]<\/a>[71<\/a>]<\/a>[72<\/a>]<\/a>[73<\/a>] and clinicians who collaborate to set goals consistent with patients\u2019 values feel more effective in helping patients change health behavior than do clinicians who judge, confront, and provide unsolicited advice.<\/a>[68<\/a>]<\/p>\n \tThe human motivation to exercise control over oneself and one\u2019s 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.<\/a>[74<\/a>]<\/a>[75<\/a>]<\/p>\n \tRespected 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.<\/a>[76<\/a>]<\/a>[77<\/a>] We have evidence that patients with high self-efficacy have better health outcomes.<\/a>[78<\/a>]<\/a>[79<\/a>] For example, patients who believe they have control over the outcome recover better from coronary artery bypass surgery.<\/a>[80<\/a>] 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.<\/a>[70<\/a>] Thus clinicians can improve their patients\u2019 sense of self-efficacy through encouraging partnership, and can thereby improve their health outcomes. <\/p>\n \tPatients 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\u2019 stress, which in turn increases their risk for stress-related exacerbation of their illness.<\/a>[70<\/a>] While clinicians may be tempted to respond to their patients\u2019 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. <\/p>\n \tAt 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.<\/a>[81<\/a>] <\/p>\n \tUnintended 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\u2014when 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, \u201clearned helplessness\u201d can result, ie, a primal \u201cgiving up\u201d response which is physiological, behavioral, and emotional, and has negative physical consequences for health.<\/a>[82<\/a>]<\/a>[83<\/a>] <\/p>\n \tWhen patient and clinician work towards partnership during a medical encounter, they develop a shared hypothesis about the origins of the patient\u2019s 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. <\/p>\n \tThis enterprise can be as straightforward as the following example: <\/p>\n Clinician: So to sum up, you and I are thinking that your loss of appetite may be due to the anxiety you\u2019ve been experiencing since the layoffs started at work. Clinician: Now, how long would it take for you to feel your appetite had really changed? \tThe essential elements of guided discovery, as demonstrated above, are:<\/p>\n \tEngaging patients in experimental inquiry through Socratic questioning is a relational strategy that has been used with success in cognitive behavioral psychotherapy.<\/a>[11<\/a>]<\/a>[86<\/a>] 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.<\/p>\n \tHow patients may benefit.<\/strong> 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 \u201cde-center\u201d<\/a>[87<\/a>] from their distress and become more \u201cmindful.\u201d<\/a>[77<\/a>] 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. <\/p>\n \tAlso, 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.<\/a>[e<\/a>]<\/a>[88<\/a>] 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.<\/p>\n \tFurther, 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\u2019s 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. <\/p>\n \tAlso, it is possible that the \u201cattention shift\u201d to empirical observation would provide patients some of the same health outcome benefits which patients obtain in \u201cmindfulness-based stress reduction\u201d (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.<\/a>[89<\/a>] \tIn 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. <\/p>\n \tHow clinicians may benefit from guided discovery.<\/strong> 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\u2019s 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.<\/p>\n \tWe 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 \u201chave all the answers\u201d. If the co-investigators anticipate experimenting with their first intervention, rather than cleaving to it as \u201cthe answer,\u201d 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.<\/a>[2<\/a>]<\/p>\n \tIn addition, we predict that clinicians will enjoy an expanded sense of meaning as they guide their patients in a discovery process. Surveyed physicians \tTo 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. <\/p>\n \tThe 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\u2019s 2001 recommendation.<\/a>[f<\/a>] 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. <\/p>\n \tWhat 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. <\/p>\n \tGiven 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.<\/a>[g<\/a>]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,<\/a>[h<\/a>] and that they will result in greater efficiencies further down the path of care. We recommend further evaluation to determine whether clinicians\u2019 time investment using this relational model significantly exceeds time investment under current practices before assuming it does so. <\/p>\n <\/a>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.<\/a>[1<\/a>]<\/p>\n To date, the call for reform in the IOM report has led to some significant changes in medical training and accreditation. For examples, see:<\/p>\n 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.<\/a>[93<\/a>]<\/p>\n Those wishing for an examination of patient-centered care as a whole will find a variety of sources in the literature. For example:<\/p>\n \u21a9<\/a><\/p>\n <\/a>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\u2019s Hospital St. Paul, University of Michigan Medical Center, Beth Israel Deaconess Hospital , Cincinnati Children\u2019s Hospital, Cleveland Clinic, Geisinger Health System, Intermountain Healthcare, Kaiser Permanente, Virginia Mason Medical Center.)<\/p>\n Their improvement efforts can be reviewed in:<\/p>\n 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: <\/p>\n 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: <\/p>\n 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:<\/p>\n 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:<\/p>\n \u21a9<\/a><\/p>\n <\/a>c. For a historical review of physicians\u2019 perceptions of their roles and patients\u2019 experiences of care, see Shorter E. Bedside Manners: The Troubled History of Doctors and Patients. New York: Simon and Schuster; 1985. \u21a9<\/a><\/p>\n <\/a>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.<\/a>[93<\/a>] \u21a9<\/a><\/p>\n <\/a>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. \u21a9<\/a><\/p>\n <\/a>f. In particular, \u201c\u2026that 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. \u21a9<\/a><\/p>\n <\/a>g. For a summary of skill sets required and training resources, see: http:\/\/www.workingtogetherforhealth.com\/journal.html. \u21a9<\/a><\/p>\n <\/a>h. For a demonstration, see: http:\/\/www.workingtogetherforhealth.com\/journal.html. \u21a9<\/a><\/p>\n
\nKeywords<\/em><\/strong>: Patient-centered care, physician-patient relationship, clinical relationship.
\nCitation<\/em><\/strong>: 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.
\nPublished<\/em><\/strong>: April 25, 2012.
\nCompeting Interests<\/em><\/strong>: The authors have declared that no competing interests exist.<\/p>\nThe Patient-Clinician Relationship Is at the Heart of Health Care<\/h3>\n
What Are the Essential Dimensions of Clinical Relationships for Patient-Centered Care?<\/h3>\n
1. Emotional Connection<\/h3>\n
\nPatient: My throat has been sore for over a week, I\u2019m running a fever of 99.5, and I\u2019m so tired I just want to stay in bed.
\nClinician: That sounds pretty uncomfortable! What concerns you the most about this?
\nPatient: I\u2019m never usually sick this long. I need to go back to work! What\u2019s the matter with me?
\nClinician: It sounds like you\u2019re concerned about how long this has gone on. What are you worried it may be?
\nPatient: I\u2019m afraid I\u2019m run down. This is the second time this winter I\u2019ve been out of work for a week I can\u2019t afford this.
\nClinician: So it sounds like you\u2019re worried about being out of work, and you\u2019re also worried that you\u2019re vulnerable to infections, and maybe you\u2019d like to feel stronger. Do you have any idea about what may be making you feel run down?<\/p><\/blockquote>\n
\nPatient: My throat has been sore for over a week, I\u2019m running a fever of 99.5, and I\u2019m so tired I just want to stay in bed.
\nClinician: A temperature at 99.5 is most likely a virus, and you\u2019ll just have to wait it out.
\nPatient: I can\u2019t afford to be out of work this much! Isn\u2019t there anything you can do for me?
\nClinician: Unfortunately, for a virus, all you can do is rest and wait it out.<\/p><\/blockquote>\nEmotional Connections Are Good for Both Patients and Clinicians<\/h4>\n
Reciprocal emotion in a healing relationship<\/h4>\n
Partnership<\/h3>\n
\nPatient: It\u2019s the same as last time. I\u2019m so tired I can\u2019t do the things I need to do.
\nClinician: Can you tell me some examples from this week, when you’re too tired to do what you need to do?
\nPatient: Every day it\u2019s 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\u2019t listen, and I can\u2019t stay on top of them\u2026.
\nClinician: It sounds pretty overwhelming! What do you think is making you so tired, like you don\u2019t have the energy you need?
\nPatient: To tell you the truth, sometimes I think I just don\u2019t want to deal with the kids. But I have to. So maybe there\u2019s something you could give me to help me.
\nClinician: So you wonder if it\u2019s 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\u2019s see what we can figure out together.<\/p><\/blockquote>\n
\nPatient: It\u2019s the same as last time, I\u2019m so tired I can\u2019t do the things I need to do.
\nClinician: Have you followed up on changing your sleep habits, the way we discussed?
\nPatient: Some nights, yes.
\nClinician: It\u2019s important to get enough sleep so you\u2019re not too tired for your children.<\/p><\/blockquote>\n A Clinical Partnership Is Good for Both Patients and Clinicians<\/h4>\n
Patient Empowerment in a Healing Relationship<\/h4>\n
3. Guided Discovery: Commitment to Empiricism and Collaborative Use of the Scientific Method<\/h3>\n
\nPatient: That\u2019s right.
\nClinician: If this is what\u2019s behind your loss of appetite, then, the medication we\u2019ve been discussing may help you feel less physically anxious, and you may find your appetite coming back.
\nPatient: We hope so!
\nClinician: This is our best guess at this time, and it\u2019s important to test whether we\u2019re right about this, rather than assuming we\u2019ve got the answer. How can we test it? If you start taking this medication today\u2026
\nPatient: I can see whether my appetite comes back.
\nClinician: Yes, and let\u2019s treat this seriously, and collect some good data, so we can feel we\u2019re really testing it well. What would you observe about yourself that would let you feel sure your appetite was coming back?
\nPatient: If I ate the way I used to eat.
\nClinician: 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?
\nPatient: I can use my notebook app, and write down when I take my medication, and what I eat each day.
\nClinician: Good, and I wonder if it would also help to rate how good you feel your appetite is overall?
\nPatient: Like \u201cA, B, C…\u201d
\nClinician: Good, and how about at the end of each day, write down your \u201cappetite grade\u201d
\nPatient: I can do that.
\nClinician: Let\u2019s practice….<\/p>\n
\nPatient: Probably a week.
\nClinician: Then should we review our data in a week or so and see what it shows us? If your appetite looks like it\u2019s getting better over time, then we have evidence we\u2019re on the right track. If your appetite doesn\u2019t look any better, then we\u2019ll consider other possible explanations, ok?
\nPatient: Ok.<\/p><\/blockquote>\n\n
Guided Discovery Is Good for Both Patients and Clinicians<\/h4>\n
\n<\/a>[90<\/a>]<\/a>[91<\/a>]<\/a>[92<\/a>] Guided discovery similarly shifts a patient\u2019s attention away from struggling with a problem to dispassionate observation.<\/p>\n
\nreport most frequently finding meaning in work through their relationships with their patients and through the intellectual stimulation their work provides.<\/a>[21<\/a>]<\/a>[22<\/a>]<\/a>[23<\/a>] In guided discovery, the clinician\u2019s 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\u2019 intellectual satisfaction as they explore with their patients how to heal them.<\/p>\nConclusion<\/h3>\n
Endnotes<\/h3>\n
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References<\/h3>\n
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\n \u21a9<\/a><\/li>\n