"Do you want the appointment or not?"
To what extent have we implemented person-centred medical care in our daily practice?
According to the writer of the article, ‘What you might hear in the waiting room’1 each of us is able to change the culture of our institutions to be more patient-centred. First, he tells us two stories.
Professionally being a doctor, but now as a patient waiting in the clinic waiting room, David P. Sklar observes two remarkable incidents with patients around him. He relates the following two stories of events not because they were extraordinary but precisely because they were not.
The author was waiting after having to make sure he did not have a severe reaction after an allergy shot. He observes a conversation of an elderly man arriving for an appointment with his cardiologist with the clerk at the registration desk. The elderly man had white hair and sallow skin, and he sat in a wheelchair with oxygen attached.
“Hello,” he said to the clerk.
“Name and hospital number,” said the clerk.
“I am Harold Thomas and, uh, my number is 232467.”
“Mr Thomas, we called you yesterday. Your appointment has been rescheduled for Thursday”.
“But I can’t come on Thursday. I don’t have any transportation.”
“Well, we called you and left a message.”
“My phone isn’t working.”
“Well, our next appointment with your doctor is in three months. I have an appointment open for him on March 18th.”
“March 18th. I’ll be dead by then.”
“Do you want the appointment or not?”
The clerk looked at her watch. There were two more people lined up behind Mr Thomas.
Mr Thomas sighed, “Someone will have to come and get me.”
“We can call for you. Shall I mark you down for the 18th of March?”
“Yes, OK,” he said, sighing.
The author watched as he was wheeled over to a corner of the waiting room away from the arrival desk to await his ride back to his assisted living facility.
The second encounter of the author in the waiting room was with a lady with short grey hair, wrinkles around her eyes, and a barrel chest. She was breathing deeply with an audible wheeze and reading a brochure handed out to her at the registration desk that described end-of-life decisions and procedures. She started a conversation with the author not knowing about his identity, and asked whether he knew what an advance directive was. During the conversation she revealed much about her life: her husband who had died at the intensive care with tubes in his mouth against his will; her wish to go to a veterinarian and to have him put her to sleep peacefully, just like he did with their dog. When the questions of the woman became too complex he advised her to ask the doctor or nurse to help her with filling out this advance directive. Her answer was: “They never have time to talk. Anyway, they are doctors and they only want to do tests on me, and I get a different doctor every day.” Then the nurse called the author’s name and he got up and looked at the woman. “Oh, that’s you they’re calling. You better go or they will cancel you out just like this poor man in the wheelchair. Thank you for listening to an old woman’s chatter.”
When the author came back to the waiting room the woman was gone and only the old man in the wheelchair waiting for his ride was still there in the corner.
In his article the author gives four suggestions how each of us can contribute to a culture that identifies the patient’s needs as our core value, and how we can teach this cultural value to our students and colleagues. These four suggestions are based on three maxims: the needs of the patient come first; nothing about me without me; and, every patient is the only patient.
1. Do not be afraid to intervene.
Many of us feel inadequate to intervene because of not having all the information and we do not want to assume we know what is best. However, we can certainly ask patients whether they need help in navigating a difficult situation. We could empower all members of our organisations to behave similarly to begin creating a culture change.
2. Teach patient-centred care when supervising students and residents.
We need to teach and role-model a patient-centred culture through our conduct during rounds and when we supervise.
3. Demonstrate patient-centred decision making.
Issues such as end-of-life care that involve an examination of individual values, societal resources, and medical care uncertainty provide the opportunity for the physician and patient to participate in patient-centred shared decision making. As advocated for our patients, we must be able to understand our patient’ values, translate medical concepts, and engage in discussions that are respectful of a broad range of values.
4. Invest in partnerships with patients and patients advocacy groups.
By doing this, we will better understand their perspectives and incorporate them into our clinical services and educational programs.
These four statements provide a good foundation for actions that each of us can take to change the cultures of our institutions to be more patient-centred. Changing institutions can be difficult, but each one of us can be change agents today by becoming good observers of the care around us and advocated for patient-centred care in our institutions.
The author finishes with a motivation that comes very near to us as persons:
“And if we need any additional motivation, we should consider that one day it will be our friends, our families, or ourselves who will be sitting in the waiting room.”
1 Sklar DP. What you might hear in the waiting room. Acad Med.2013;88:1191-1193.
Anita Verhoeven
