From a paternalistic “doctor knows best” attitude to what’s known as patient-centered care, doctor-patient relations have been evolving for decades. But many patients today feel that despite this evolution, they don’t get enough time with doctors and are left to manage their own care with little guidance. Kojo explores medical training programs and patient advocacy groups aimed at improving the doctor-patient relationship.

Guests

  • Rhonda Wyskiel Registered Nurse, ICU, Johns Hopkins Hospital; Senior Research Coordinator,Armstrong Institute for Patient Safety and Quality
  • Santi Bhagat Patient advocate
  • Mark Siegler Lindy Bergman Distinguished Service Professor of Medicine and Surgery; Executive Director, Bucksbaum Institute for Clinical Excellence; Director, MacLean Center for Clinical Medical Ethics

Transcript

  • 12:06:45

    MR. KOJO NNAMDIFrom WAMU 88.5, at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. We've spent decades moving away from the paternalistic doctor-patient relationship and the do-as-the-doctor-says approach with little or no consultation with the patient. We are now encouraged to ask questions, get second opinions and advocate for ourselves.

  • 12:07:22

    MR. KOJO NNAMDIWe know that this patient-centered care leads to better outcomes and shorter hospital stays. But for many patients being in charge of their own care also means navigating a complicated network of insurance companies, pharmacies and specialists. And a lot of people want more support and guidance from their doctors, not less, while doctors seem to have less and less time to spend with patients. And many doctors lack the basic skills once known as bedside manner.

  • 12:07:53

    MR. KOJO NNAMDISome hospitals recognize these issues and are taking innovative approaches to address them. Joining us to discuss this is Dr. Mark Siegler, a professor of medicine and surgery at the University of Chicago Medical Center. He's also the executive director of the Bucksbaum Institute for Clinical Excellence and the director of the MacLean Center for Clinical Medical Ethics. Mark Siegler, thank you for joining us.

  • 12:08:20

    DR. MARK SIEGLERThank you very much for inviting me. I'm delighted to be here.

  • 12:08:24

    NNAMDIAlso joining us in our Washington studio is Santi Bhagat, founder and president of Physician-Parent Caregivers. Santi Bhagat, thank you for joining us.

  • 12:08:35

    DR. SANTI BHAGATThank you, Kojo, for inviting me. It's a pleasure to be here.

  • 12:08:38

    NNAMDIJoining us by phone from Baltimore is Rhonda Wyskiel, a registered nurse in the intensive care unit at Johns Hopkins University and a senior research coordinator at the Armstrong Institute for Patient Safety and Quality. Rhonda Wyskiel, thank you for joining us.

  • 12:08:56

    MS. RHONDA WYSKIELThank you, Kojo. I'm excited to share our journey.

  • 12:08:59

    NNAMDIWe'll take our calls at 800-433-8850. You can send email to kojo@wamu.org. Join the conversation and at our website, kojoshow.org, or send us a tweet, @kojoshow. How important is your doctor's bedside manner for you? 800-433-8850. Rhonda Wyskiel, I'll start with you. What is patient-centered care?

  • 12:09:26

    WYSKIELKojo, patient-centered care, as we believe it at Johns Hopkins, and, really, across the nation from talking with other clinicians, is really the focus of thinking about the patient as someone who belongs to you, so thinking about the patient in the bed as your mother, your father or your sister and taking care of them in that way.

  • 12:09:50

    NNAMDIMark Siegler, involving a patient and the family in medical decisions was not always the norm. How did it evolve?

  • 12:09:59

    SIEGLERWell, it was quite the opposite of the norm as your introduction said. Medicine for thousands of years was a paternalistic, parentalistic system in which the doctor was the authority and knew best. But in the last 50 or so years, patients have asked for a voice in deciding their own care. It's consistent with the way students asked for a voice in their own education in the 1960s, the Civil Rights movement of the 1950s, the women's rights movement.

  • 12:10:37

    SIEGLERThere's been a kind of patient rights movement also. And what has emerged is the model that Ms. Wyskiel just referred to, patient-centered care or shared decision-making in which the doctor and the patient work collaboratively to come up with the best decision for the patient under these particular circumstances.

  • 12:11:02

    NNAMDISanti Bhagat, you became an advocate for your daughter's care, even though you are, in fact, Dr. Santi Bhagat. You are an M.D. You found yourself on the other side of the doctor-patient relationship. Tell us about that.

  • 12:11:18

    BHAGATWell, my daughter got sick and -- on the first day of my medical fellowship, and what I found I had to navigate was a health care system that I thought I understood from the inside. But when I had to manage the care for my daughter, it was completely opaque. I couldn't understand how to get good care for her, and it really scared me. I think I lived in perpetual fear for many years.

  • 12:11:41

    NNAMDIIf you find the health care system difficult to navigate, you can call us, 800-433-8850. Tell us exactly what the problem is for you. Or go to our website, kojoshow.org. Join the conversation there. Santi Bhagat, you said you felt that you were on the inside, and you still found it so difficult. Why?

  • 12:12:02

    BHAGATI think in medicine, we really don't understand what it's like to be in the patient's shoes. And as Ms. Wyskiel said, their only way to really do that is to imagine that the patient is a relative of yours. And I didn't get into those shoes until my daughter actually fell sick.

  • 12:12:19

    NNAMDIMark, you were approached to lead a program to train doctors in bedside manner. What does good bedside manner look like?

  • 12:12:29

    SIEGLERWell, we didn't quite call that the name of the program. It was called clinical excellence, and it had to do with communication with patients, reaching good decisions between the health provider and the patient, establishing good relationships between the health provider, the doctor and the patient, or the nurse and the patient, and teaching our young people, the students in medicine and nursing and the residents in medicine, to incorporate these human qualities in their care of patients.

  • 12:13:05

    SIEGLERI mean, we have the most sophisticated scientific training in the history of the world. In the last generation, we've learned so much about medicine. But the pendulum has swung just a little too far and perhaps sometimes neglects the individual human level of care that is a tradition in medicine and nursing, and that is so important.

  • 12:13:31

    NNAMDISanti Bhagat, there's an old adage. If you listen long enough, patients will tell you exactly what's wrong with them. Do you believe that to be true?

  • 12:13:39

    BHAGATCompletely. I think, just like parents, if we listen long enough and listen at the right time to our children, we will hear what they are feeling, and the same goes for health care.

  • 12:13:50

    NNAMDII wish somebody had told me that when I was first a parent.

  • 12:13:54

    NNAMDIBut -- go, please, ahead, Mark Siegler.

  • 12:13:57

    SIEGLERI'm sorry to interrupt. But we had a case last week of a patient transferred to the University of Chicago from a very excellent outside hospital with a diagnosis of malaria. The problem was that the patient's last exposure to a particular kind of malaria was more than seven months earlier. And several of our doctors and others questioned this diagnosis and couldn't quite figure out why the patient was not responding to treatment and whether malaria was the right diagnosis.

  • 12:14:33

    SIEGLERFinally, someone heard the patient report that she had spent her summer on Nantucket. And, indeed, it turned out that the problem was not malaria but a fairly rare tick disease known as Babesiosis, which has a totally different treatment from malaria. And when the treatment was administered, the patient got better. But it was the patient who told us where to look for the diagnosis.

  • 12:15:01

    NNAMDIMark, what aspects of what we call bedside manner were taught and discussed when you were trained as a doctor, Mark Siegler?

  • 12:15:08

    SIEGLERWell, I had fabulous mentors. I trained primarily at the University of Chicago, and I had people who taught me everything that I now put into practice in my own work. I've been practicing for more than 40 years, so I'm talking about training that goes back 50 years ago. But when we announced this new institute for clinical excellence, sitting in the front row was one of my original teachers who really was an inspiration for me.

  • 12:15:40

    SIEGLERHis name is Dr. Joseph Kerschner. And the day before our announcement, he had celebrated his 102nd birthday. So, obviously, these traditions go back quite a way. And Joe Kerschner, as sharp as he was when he was telling me all the things I was doing wrong as a student and still emphasizes that you have to focus first, middle and last on the patient.

  • 12:16:10

    NNAMDITo what extent were you taught what in the profession is referred to as clinical excellence, Santi Bhagat?

  • 12:16:18

    BHAGATWell, I did my residency in pathology and laboratory medicine. So we're a step behind the physicians in providing care for the patients. We have a little bit of interaction with patients, but, really, we're a consultant to the physicians. And I think when my daughter got sick, I think one of the things that really astonished me the most was the fact that she got sick on the first day, on July 1, which is the day all new residents and interns start.

  • 12:16:46

    BHAGATAnd in pathology, we actually aren't allowed to sign out on cases until we're in our final year. But in internal medicine and pediatrics, they really are given a free hand from day one. And I think that, in my training, there's a lot more respect and a lot more concern about possibly providing a wrong diagnosis or, you know, providing, you know, direction towards a wrong treatment.

  • 12:17:13

    NNAMDIAnd so you were schooled on that before you started any kind of practice.

  • 12:17:17

    BHAGATWell, that's correct. Actually, I was schooled in that sense. And when I went into -- onto the patient side, I actually found a lot of mistakes made on pathological errors and...

  • 12:17:28

    NNAMDIRhonda Wyskiel, how about you as a nurse? Were you trained in bedside manner?

  • 12:17:34

    WYSKIELOur training in nursing is really starting from the beginning. We learn as nurses in nursing school about caring and the Florence Nightingale model. So we're very attuned to the caring aspects of the patient very -- throughout our entire nursing training.

  • 12:17:52

    WYSKIELA lot of what occurs, though, is in the hospital regarding training programs that hospitals provide to teach us to really how to better care for our patients and how to better communicate with our patients and families to provide better outcomes for them. So much of our training is really hands-on after nursing school and not necessarily always formalized training.

  • 12:18:18

    NNAMDIHere is David in Reston, Va. David, you're on the air. Go ahead, please.

  • 12:18:22

    DAVIDHi. Yeah, I'm taking a class right now in George Mason University, a health communication class with Melinda Villagran. And I actually just kind of realized the importance of a patient-centered interaction between a doctor and a patient. And I was just curious what any training you guys did for cultural barriers that I've studied 'cause I've noticed that, you know, breaking down this cultural barriers to get better care for minorities and stuff like that. And I wonder if you had any training in that field.

  • 12:18:54

    NNAMDIRhonda Wyskiel, I'll start with you.

  • 12:18:58

    WYSKIELWe actually do a lot of cultural adaptations where we're training our nurses in patient-centered care, but it's not necessarily, as I mentioned, formalized training. We're doing kind of impromptu where we ask questions during nurses' orientation to nurses and physicians, questions like, have you ever been a patient in a hospital before? And if so, tell me a little bit about that experience.

  • 12:19:27

    WYSKIELOr have you had a loved one who's been a patient in the hospital before? Because we really believe fundamentally as nurses that you're a different kind of nurse or a different kind of clinician if you've had those kinds of personal experiences. And we'll interact sort of on an informal basis with each other, and that's really hands-on training for us.

  • 12:19:51

    NNAMDISanti Bhagat? Cultural competency?

  • 12:19:53

    BHAGATI think cultural competency is actually an evolving phenomenon right now, and, from the patient's standpoint, it's very important. I'm of Indian origin, and when my daughter got sick, I don't think that the treating physician or the specialist understood how our whole family would be involved, including the extended family in my daughter's, you know, care in her life.

  • 12:20:16

    NNAMDIAnd in your case, Mark Siegler?

  • 12:20:20

    SIEGLERI agree with exactly what Dr. Bhagat and Rhonda Wyskiel have said. Cultural competency is extremely important. We emphasize it in our discussions with the students about decision making and doctor-patient relationships. We emphasize it in our medical ethics classes for the students. It has to be taken account in working with different kinds of patients and families.

  • 12:20:48

    SIEGLERThe value systems that the patient and the family bring to the encounter are very important and often determinative in reaching the right decision for that patient.

  • 12:21:01

    NNAMDIBut are there other potential issues with doctors showing empathy? If in the case of the misdiagnosed malaria, the physician said, I'm sorry, we made the wrong diagnosis initially, is that a malpractice suit waiting to happen?

  • 12:21:18

    SIEGLERWell, it was a -- things were complicated, and malpractice is something you don't think about all the time -- at least I emphasize that what you think about is good patient care and doing the absolute best to solve the patient's problem and help the patient in the terms in which they want your assistance. And so this was one in which everybody had an open mind. And as we continue to think and listen to the patient, we fortunately came upon this fairly rare but important change in diagnosis.

  • 12:22:06

    NNAMDIGot to take a short break. When we come back, we will continue our conversation on patient-centered care and its evolution. Inviting your calls at 800-433-8850. Do you find yourself wishing for more or less guidance from your doctor? You could also go to our website, kojoshow.org. If you'd like to ask a question or make a comment, send us a tweet, @kojoshow, or email us at kojo@wamu.org. I'm Kojo Nnamdi.

  • 12:24:33

    NNAMDIWe're discussing patient-centered care with Rhonda Wyskiel, a registered nurse at the Intensive Care Unit at Johns Hopkins University and the senior research coordinator at the Armstrong Institute for Patient Safety and Quality, Santi Bhagat, is the founder and president of Physician-Parent Caregivers. She's also an M.D. who formerly practiced as a pathologist.

  • 12:24:54

    NNAMDIAnd Mark Siegler is a professor of medicine and surgery at the University of Chicago Medical Center and executive director of the Bucksbaum Institute for Clinical Excellence. He's also director of the MacLean Center for Clinical Medical Ethics. We're taking your calls at 800-433-8850.

  • 12:25:12

    NNAMDIRhonda Wyskiel, here's this email we got from Anne. "I have a complicated medical situation that involves neurologists, surgeons, obstetricians, specialized ophthalmologists and others. I was at Johns Hopkins and very lucky to be because I had some of the best doctors in the country. What really struck me, though, was that each specialist was really very narrowly focused and really ne'er the twain did meet.

  • 12:25:34

    NNAMDI"I felt like it was up to me to put the pieces together into some kind of sensible picture in order to mover forward to greater health. I will note that, for the most part, they had great bedside manner." But, Rhonda Wyskiel, she seemed to feel like she had to be the coordinator herself.

  • 12:25:51

    WYSKIELYes. And that is not an uncommon, really, statement from many family members. As you move through the complex health care system and you find yourself in a place where you have multiple problems -- and maybe even just one problem. And as our specialists come in to see you and tell you their little piece of the puzzle to better move you through the system, it's often confusing because you really aren't understanding who's truly responsible for your care. So I empathize with you in that situation.

  • 12:26:27

    WYSKIELAnd we're making efforts at the hospital level and at the national level to better coordinate care so that patients can really have a central contact for when they have questions. In the intensive care unit, many ICUs now have central -- they have intensivists, so that the intensivist manages that patient's care. So that sort of makes it easier.

  • 12:26:51

    WYSKIELBut if you're in a community hospital and you don't have that kind of luxury, then it does make it more difficult when you have multiple people coming in and providing information regarding your care. So just know, please, that we're making efforts in many areas to better improve that kind of coordination of care that you're struggling with, and many others are as well.

  • 12:27:13

    NNAMDISanti Bhagat, you've dealt with coordination and dealing with the health care system for years in caring for your daughter. What, for you, are the most important attributes a doctor or a nurse can have? And do you make a distinction between primary care practitioners and specialists?

  • 12:27:29

    BHAGATDefinitely, I make a distinction between primary care and specialist. There's a new model of care that's being promoted right now called the medical home. And in the medical home, usually the primary care practitioner serves as the main person who coordinates all of the care with the family and with all of the other specialists. And sometimes, it will be the specialist who actually takes that role, but, usually, it's the primary care provider.

  • 12:27:54

    BHAGATAnd in my experience, we had a -- our primary care pediatricians were in the community. And they did everything they could to provide a medical home long before medical homes were really discussed. But they really struggled in trying to communicate with the specialists in the hospital, although all of our specialists were in the same hospital.

  • 12:28:14

    NNAMDIHow do you deal with that issue, Mark Siegler, the coordination between primary care physicians and specialists? And who all else has to be involved in the care of a specific patient?

  • 12:28:25

    SIEGLERI've been a general internist all my life, and I take it that my responsibility is to be one of those coordinators of care. My new specialization has been one of the great advances in modern medicine. It brings untold benefits to patients by bringing this remarkable expertise to the care of an individual patient. But the lack of coordination that your questioner raised and that each of us believes exists in American medicine is an ongoing problem.

  • 12:29:00

    SIEGLERWe are, Kojo, the only health system in the world, developed countries, developing countries, that doesn't base its model of health care on a primary care physician. It's remarkable. I've practiced in England and in -- worked a little bit in Norway and Italy. In every country that we've gone to, the primary care is the foundation, the fundamental system, except for this country.

  • 12:29:33

    SIEGLERAnd the medical homes that have been referred to are a new effort to try to regain some of what we have traditionally not had here, which is this organized primary care system.

  • 12:29:47

    NNAMDIAnd, of course, it's my understanding that in much of Europe, Mark Siegler, they still do house calls, which, for us, would be, like, archaic.

  • 12:29:57

    SIEGLERYes. I mean, some of us still do an occasional house call, where the patient is often too old or too ill to make transport to the doctor's office easy and convenient. Sometimes it takes four or five people to bring a patient in to see me in the office. And if I can go over to the house occasionally and maybe get a lab technician to help me draw some bloods, it turns out to be so much more efficient and easier on the patient.

  • 12:30:29

    SIEGLERI'm not saying that this is a regular occurrence, but, perhaps once a week, I find myself still doing a house call.

  • 12:30:38

    NNAMDIOn to Jordan in Washington, D.C. Jordan, you're on the air. Go ahead, please.

  • 12:30:42

    JORDANOh, thank you, Kojo. Thank you for taking my call. And hello, Mark. Nice to talk to you again.

  • 12:30:46

    SIEGLERNice to talk -- oh, Jordan. Hi.

  • 12:30:49

    JORDANYes. Hi. Kojo, I just wanted to, first of all, congratulate Mark Siegler for the Bucksbaum Institute. I think he's going to be a terrific addition to the educational...

  • 12:31:00

    NNAMDIHow do you know Mark Siegler, Jordan?

  • 12:31:02

    JORDANWell, I've known Mark for almost 40 years, as a matter of fact. I was on the faculty of University of Chicago. And I was the chairman of medicine at Michael Reese Hospital. And I've kept in contact with Mark over the years, and I've been very admiring of all the work that he's done. It happens that I also was the president of the Association of American Medical Colleges for 12 years here in Washington, which oversees the curriculum and other aspects of medical education in this country.

  • 12:31:28

    JORDANAnd this issue that Mark is talking about is one that's been extraordinarily important for medical educators. And it's been a very difficult issue to emphasize in the way that it needs to be, given all of the seductive power of the technology and all of the science that has tended to overbalance the attention of our students and residents. And I think the challenge is to rebalance the efforts so that physicians understand the ultimate importance -- all the critical importance of the caring aspect of the care of the patient.

  • 12:32:08

    JORDANI also happen to chair a foundation called the Arnold P. Gold Foundation for Humanism in Medicine, which, for the past 20 years, has been pursuing this issue. And we're just absolutely delighted that the Bucksbaum Institute now has -- now become another focal point for pursuing these issues, which every current and future physician and other health care professional really needs to take (unintelligible).

  • 12:32:36

    NNAMDIJordan, I am so glad you raised that issue because, Mark Siegler, some people would say, does it really matter if a doctor is a little gruff, a little rough around the edges, as long as he or she knows their medicine? But, in fact, studies show otherwise, do they not?

  • 12:32:53

    SIEGLERThey absolutely do. They show that competence is very important as the foundation of medical care. But beyond that, a good relationship with the patient improves patient care and outcomes in the following ways: It improves patient confidence in the doctor. It improves likelihood that the patient and the doctor will agree on what tests are appropriate and what medicines are reasonable, and the patient will actually take them.

  • 12:33:26

    SIEGLERIt improves trust on the patient side. It decreases cost of care by making decisions more reasonable and appropriate. It actually improves outcome in a lot of chronic conditions, such as blood pressure control, diabetes, rheumatoid arthritis, depression, peptic ulcer disease. And, of course, everybody talks about how it decreases lawsuits and malpractice.

  • 12:33:56

    SIEGLERA good relationship is one of the fundamental things that decrease unnecessary malpractice suits. So, in many ways, it's a great addition to the technical and scientific side of medicine.

  • 12:34:12

    NNAMDIAnd, Jordan, thank you very much for your call. Santi Bhagat, as a trained doctor yourself, how difficult was it for you to understand the options and treatments involved for your daughter?

  • 12:34:24

    BHAGATFor several years, my daughter was being diagnosed with a new condition that nobody had heard of while I was training. And when I tried to understand it, I actually went to the medical library and copied three chapters out of the neurology textbook. And I took it to my primary care pediatrician, trying to understand how I should make a decision on the next course of treatment.

  • 12:34:49

    BHAGATAnd my pediatrician looked at me and said, Santi, she said, you shouldn't be doing this. So here's my physician telling me I shouldn't be doing this, but my specialist is telling me that I should be doing this.

  • 12:35:00

    NNAMDISo you're conflicted at this point.

  • 12:35:02

    BHAGATCompletely conflicted, scared to death, and I didn't know how to go forward. So I do think that there is a huge role for patient-centeredness, but it's really important for physicians to lead the way and for patients to be able to trust their physicians.

  • 12:35:18

    NNAMDII'm glad you brought that up -- I keep saying that on this show -- because, Rhonda Wyskiel, you can tell us about an episode about the fact that family members are now included in morning rounds, how that works and how it sometimes works, even if the family doesn't quite understand all of the technical jargon that's being used, right?

  • 12:35:37

    WYSKIELYes. And we've been very fortunate in our particular ICU and in many of the ICUs and inpatient areas at Johns Hopkins where we've really incorporated some patient-centered inventions to improve outcomes in patient care. And one of the things we did back in 2003, and many across the nation have done now, is to invite patients and families into daily rounds.

  • 12:35:59

    WYSKIELSo, in our ICU, we round in the morning, and it's a multidisciplinary team with physicians, nurses, pharmacists and respiratory therapists. And we'll go and introduce ourselves to the family and to the patients, suggest that we're going to be discussing their case and their care and developing a plan of care for the day and, would you like to be a part of that? And if so, step into the circle.

  • 12:36:22

    WYSKIELAnd if it's a patient in the bed, then we'll open up a circle so that the patient can really hear what we're talking about. And there was one incident that was really quite powerful for us to realize the impact that we were having by doing this where an attending physician invited the husband of -- the wife of his -- his patient was the wife into the circle.

  • 12:36:47

    WYSKIELAnd we started talking about the patient's case -- it was a very complex case -- and discussing all the teaching and the plan of care. And at the end of that rounding session of about 45 minutes, our attending looked at the husband and said, do you have any questions? And he looked at her, and he said, you know, I didn't understand a word you said.

  • 12:37:07

    WYSKIELYou could have been speaking a whole another language, but I trust you. Now, I trust you. So thank you for including me, and I trust that you're going to take the best care of my wife. And that was really powerful for us to help us realize that what we were doing had such an impact by just inviting them to be a part of our multidisciplinary team.

  • 12:37:27

    NNAMDIThat inclusion in the process itself can inspire trust and confidence. Mark Siegler, the idea of patient-centered care was a huge cultural shift, I understand. What has it meant in practice?

  • 12:37:41

    SIEGLERWell, I think in practice, it's meant that many, not all, but many decisions made in the medical situation both in the outpatient and, in Rhonda Wyskiel's situation, the inpatient setting are made in collaboration and cooperation with patients and families. And that has been a sea change. It didn't happen overnight. And it evolved perhaps over the last 50 or 60 years.

  • 12:38:14

    SIEGLERSome think that the 1980s and '90s were a kind of turning point when more people move towards this collaborative model of decision making than the old-fashioned, unilateral model of the doctor making decisions for the patient. And it's been a fabulous change. It puts patients and families in the center of the discussion and of the process. You can't make decisions unless you know the information and the information accurately.

  • 12:38:50

    SIEGLERSo it's changed the hidden culture of medicine, which had always been a bit secretive, not revealing all the truths to patients. But you have to tell the full truth to patients if they and their families are going to be involved in helping to reach the final decision. They have to know what the circumstances are. So I think it's been a huge change, and I don't see it going away.

  • 12:39:17

    SIEGLERI think this may well be a permanent change in American medicine, and from America, you know, it will influence Canada, Western Europe and much of the world.

  • 12:39:30

    NNAMDIWhich brings us to Louise in Loudoun County, Va. Louis, you're on the air. Go ahead, please.

  • 12:39:36

    LOUISEI was a nurse for many years and quit nursing because things became task-oriented. And for efficiency and to save money, there is one nurse who goes around, gives everybody their pills. She's gone. She doesn't see the reaction. Nobody spends time exclusively with a patient. Observation is much better than relying on just lab tests and diagnosing things. Patients, when the doctor makes rounds, he's there for a short time.

  • 12:40:09

    LOUISEPatient may forget things to tell them. Somebody that spends time with them, like nursing used to be, you were assigned as a nurse to a patient, and you knew all of their care. You talked with them while you were doing treatments to them. They were involved, and that's what I see as patient-centered care, not, you know, having everybody having an input in diagnosing.

  • 12:40:34

    LOUISEYou're looking at it from the doctor's point of view instead of from the patient's point of view, and that was my unhappiness and why I'm not nursing.

  • 12:40:43

    NNAMDIRhonda Wyskiel, that was the problem, wasn't it, task-centered care as opposed to patient-centered care?

  • 12:40:50

    WYSKIELYes. And we really have made some efforts to study that scientifically and look at cognitive stacking and technical stacking of work and adding in duties for nurses to do, such as managing a ventilator and managing a dialysis machine, while we're also required to provide the kinds of caring aspects of nursing that we're taught in nursing school.

  • 12:41:14

    WYSKIELSo we're really making efforts to study that again, to really start to pull away from the stacking of technical work and really start to look at nurse-patient ratios and how that impacts patient's outcomes. So as we become more versed in patient-centered care and as the movement of patient-centered care spreads through institutes like Dr. Siegler's and others -- at the Armstrong Institute, it's a center of focus for us there -- hope to make efforts to move that bar back to that caring center that we all know is important to us.

  • 12:41:54

    WYSKIELBecause, ultimately, it's going to be each of us in the bed, and for us to be able to move health care to allow us to provide the kind of care that we want for ourselves and for our loved ones, that's really where we need to shift. And we hope to be making big movements into that in the near future.

  • 12:42:13

    NNAMDILouise, thank you very much for your call. We're going to have to take a short break. When we come back, we'll continue the conversation. If you have called, stay on the line. We'll try to get to your call. If the lines are busy, send us an email to kojo@wamu.org, or go to our website, kojoshow.org, and ask a question or make a comment there. Or send us a tweet, @kojoshow. I'm Kojo Nnamdi.

  • 12:44:32

    NNAMDIWe're trying to trace the evolution of patient-centered care and why it's important today. We're talking with Mark Siegler. He's a professor of medicine and surgery at the University of Chicago Medical School, executive director of the Bucksbaum Institute for Clinical Excellence and director of the MacLean Center for Clinical Medical Ethics.

  • 12:44:50

    NNAMDIRhonda Wyskiel is a registered nurse in the intensive care unit at Johns Hopkins University and the senior research coordinator at the Armstrong Institute for patient safety and quality. And Santi Bhagat is the founder and president of Physician-Parent Caregivers. Before we took the break, Mark Siegler, Rhonda Wyskiel was talking about why your institute, the Bucksbaum Institute for Clinical Excellence, is necessary.

  • 12:45:18

    NNAMDIAnd we do know, as we mentioned earlier, that students in medical schools do get classes in the importance of listening to patients and showing empathy. So why do you think a new approach, like the institute you are heading, Mark Siegler, is needed now?

  • 12:45:37

    SIEGLERWell, I think, many medical schools have wonderful programs in aspects of the doctor-patient relationship, including the one that Rhonda Wyskiel was telling us about at the intensive care unit where she works, which I should say in passing is one of the most important intensive care units the Armstrong Institute -- for which she is the research coordinator -- has given us so much information about patient safety and quality beginning in the early 2000s, with Peter Pronovost's work on checklists to reduce patient infections and to improve patient outcomes in a variety of ways.

  • 12:46:25

    SIEGLERBut many institutions don't coordinate that across their entire medical school or their entire hospital. And we're hoping to begin with the medical students, to include junior faculty and senior faculty and to make this a university medical school-wide activity that will touch our people in the intensive care unit and to the outpatient offices, also, at all levels of the medical school.

  • 12:46:57

    SIEGLERI've been in contact with great schools around the country to figure out how we might work cooperatively with places like Harvard and Stanford and Johns Hopkins to advance the goals that we're all seeking, which is to improve the experience that patients have and the care that patients and their families receive. And we all want the same thing.

  • 12:47:24

    SIEGLERAnd we're just working towards it, each of us in somewhat different ways, but maybe additional cooperation would work. One of the things -- and I'll stop right there, Kojo -- apologize -- is to get doctors and nurses to be more collaborative in their teaching of medical students and nursing students. Nurses have so much to teach the young physician.

  • 12:47:48

    SIEGLERAnd when I was training, there was regular work with nurses on the wards. And much of that, for reasons that one of the people who called in said, are no -- is no longer the case, and I think we have to regain some of that.

  • 12:48:05

    NNAMDIOn to the telephones. Here is Deborah in Potomac, Md. Deborah, your turn.

  • 12:48:10

    DEBORAHI'm sorry, Kojo. I couldn't hear you.

  • 12:48:12

    NNAMDIYes, it's you, Deborah. You're on the air.

  • 12:48:14

    DEBORAHYes. I'm currently a doctoral candidate in social work at Catholic University, and I am doing my dissertation research at Georgetown University Medical School. They were -- allowed me to do research there, which I appreciate, because they are very concerned with how they can improve empathy in their medical students. And my topic actually is focusing on the personal and contextual factors that are related to empathy in medical students.

  • 12:48:43

    DEBORAHAnd just two points, one is that I just want to make the point that the social work profession is very important in -- speaking to Dr. Siegler's point, into the collaborative effort as we consider the biopsychosocial spiritual self. And also, I feel that -- first of all, Dr. Siegler, I'm very keenly aware of your work. I'm very, very impressed with your work.

  • 12:49:05

    DEBORAHAnd I was personally happy that Georgetown is equally interested and that they are allowing a social scientist to do this kind of research.

  • 12:49:17

    NNAMDIOkay. Thank you very much for your call, Deborah. And I guess that underscores the centrality and importance of this. Santi Bhagat, did you get that impression when you yourself were in medical school, the centrality and importance of empathy?

  • 12:49:31

    BHAGATI think I did. But I think, again, this really resonates at the personal and individual level and what you come to the table with. I think we're all human beings, and I think it's very important to understand that physicians and nurses and health care providers are human beings. A, they can make mistakes. And, B, they have their own experiences, which is going to, I guess, lead them to be in a position to show empathy, so...

  • 12:49:57

    NNAMDIWe got an email from Ed in Chevy Chase in D.C., who says, "From my experience, having a physician available by email is very critical and time saving on both sides. Can you discuss the pros and cons of such communications?" And here is Eric in Ellicott City, Md. on the phone. Eric, you're on the air. Go ahead, please.

  • 12:50:16

    ERICHey. How are you doing? Thanks for taking my call. This pretty much goes out to everybody. I was just wondering, in your practice, how you find a patient who comes in, who has self diagnosed himself on the Internet, how you find that might hurt or hinder your practice with them.

  • 12:50:34

    NNAMDIAnd I'll start with you, Mark Siegler.

  • 12:50:38

    SIEGLERInformation is always a good thing. Integrating information is a hard thing so that -- I'm all in favor of email communications between doctors and patients and other easy ways of communicating, but the email has become one of the easiest. And I'm all in favor of patients learning as much as they can about their problems and their conditions and coming to the meeting with their doctor with -- armed with that information.

  • 12:51:10

    SIEGLERNow, often, it requires additional perspective on how that information ought to be used in an individual case, and I think that that's the task of the doctor. The doctor -- the word doctor comes from the Greek and Latin meaning teacher. And I think doctors have always been people who have taught patients about medicine and health and illness.

  • 12:51:39

    SIEGLERAnd I think that this new access to information is just another opportunity to fulfill our traditional role as a doctor, as teacher.

  • 12:51:49

    NNAMDIThank you very much for your call, Eric. And here now is Beth in Columbia, Md. Beth, your turn.

  • 12:51:57

    BETHGood afternoon. I am really excited about this work that's going on. However, I've spent way too much time in the past two years in hospitals with family members, from the community hospitals in North Carolina, West Virginia and Maryland and a teaching hospital in North Carolina. And I just have to say that, as a family member, I feel that my role as advocate is not just important but often essential because communication isn't made.

  • 12:52:37

    BETHFrequently, the nurses are too busy to answer questions, or they haven't read the record properly. And I almost feel like it's dangerous to leave a family member or friend alone in a hospital, so I'm looking forward to this trickling down.

  • 12:52:53

    NNAMDIWell, Beth, allow me to have Rhonda Wyskiel tell you about the family involvement menu that was created for the intensive care unit at Johns Hopkins. Rhonda Wyskiel.

  • 12:53:06

    WYSKIELBeth, I think your thoughts exactly are mirrored by many in the health care system where they're -- they feel like they really need to be in the room, not because they want to be necessarily always in the room with their loved ones but because they have to be for safety reasons. And we see that often in our ICU and throughout the hospital where we wish the family were there more.

  • 12:53:28

    WYSKIELSo, you know, over the years that I've been a nurse, I used to watch the families come in and sit in the corner, watching TV or reading the newspaper, and about a year ago, I thought, wow, what a resource gone untapped. So I started to have some dialogue with a couple of families. And, ultimately, through an engagement exercise with the nurses and a survey to the patients, figured it out that we could develop an opportunity to involve families and further invite families into the patient care experience.

  • 12:54:05

    WYSKIELSo we developed something called the family involvement menu where it hangs -- it's a true menu of sorts, and it hangs in the patient's room. And there's a dialogue that occurs on admission or at some point during the patient hospitalization early on that says, you know, you are a patient in this intensive care unit, but it's centered on patient and family involvement.

  • 12:54:29

    WYSKIELSo with education and information provided by us, you're invited to take part in some of these cares, and, please, check which ones you're interested in. We'll educate you. And there are cares, such as providing oral care, helping us with the turn, helping to walk the patient, maybe applying lotion to the patient, little things that mean a lot, and we found, over the past year-and-a-half that we've been doing this initiative, that the families are so excited.

  • 12:54:55

    WYSKIELThey're so engaged, and they love feeling like they have something to do. But it also creates that presence that you're talking about and allows them to really see what's happening with the patient and touch them physically to say, wow, their legs are a little more swollen today than yesterday and start to ask the questions that maybe are sometimes overlooked by the healthcare providers.

  • 12:55:17

    NNAMDIBeth, thank you very much for your call. How does that sound to you, by the way, Beth?

  • 12:55:21

    BETHWell, it sounds exactly what's needed. And, in fact, we have a family member who's being transferred to the neurological ICU at Hopkins tomorrow, and so I look forward to seeing the menu.

  • 12:55:33

    NNAMDIOkay. Thank you very much for your call, Beth. Santi Bhagat, even though you can have family involved, there are sometimes patients and family members who would like the doctor to tell them the right course of treatment, especially when the situation is serious. Do you find yourself wanting more guidance rather than less from your daughter's doctors?

  • 12:55:54

    BHAGATMy daughter is now turning 24 in a couple of days, and, especially with children who are transitioning to young adulthood, it's really important to have good guidance from the physicians. For me as a parent, it's a little bit different because I know the history. I know the story.

  • 12:56:09

    BHAGATBut it's really important, when somebody's learning, how to navigate the health care system and to go from pediatric to adult-centered care where there isn't a focus on the development of a young person to have extra guidance, actually, for that young person. So in that particular regard, I do. I think that when there's issues regarding surgery and complicated medical treatments, we do need to have more direction from the medical community.

  • 12:56:38

    NNAMDIAnd, finally, there is Buff (sp?) in Chester, Md. Buff, we're running out of time. So could you make your question or comments as brief as possible?

  • 12:56:45

    BUFFOkay. Thanks, Kojo. I'll try and make it quick. My question is, you know, is training sufficient? Or does there a need to be more of a systematic approach? I was diagnosed with kidney cancer last year, and there was questions about whether there was metastatic disease. And even though the sister institutions of Anne Arundel and Johns Hopkins were working on me with the best doctors, one doctor said that he was 90 percent sure it wasn't cancer. One said he was 99 percent sure it was cancer.

  • 12:57:10

    BUFFAnd, basically, what it got down to was a bunch of questions over email with no resolution. And my wife, who's a clinical educator, is saying, you've now become a pain in their -- meaning their rear end. And I was surprised by that because I was just trying to look for a diagnosis. And so my question is, does there need to be systematic, more than just training to get this to be prevalent...

  • 12:57:34

    NNAMDIAnd I'm sorry, but, Mark Siegler, you've only got about 30 seconds to respond to this.

  • 12:57:39

    SIEGLERA difficult diagnosis will remain difficult, even with modern technology. And I think staying with the case and using the history and the technology that we've got will ultimately resolve the matter as best we can in most cases. I can't speak specifically about the gentleman's kidney problem.

  • 12:58:05

    NNAMDIOf course not, but we'd like to thank you for joining us. Mark Siegler is a professor of medicine and surgery at the University of Chicago and Medical Center. Rhonda Wyskiel is a registered nurse in the intensive care unit at Johns Hopkins University. And Santi Bhagat is the founder and president of Physician-Parent Caregivers. Thank you all for joining us. And thank you all for listening. I'm Kojo Nnamdi.

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