part0032

Finding common ground, the third interactive component of the patient-centered method, is the process through which the patient and doctor reach a mutual understanding and mutual agreement in three key areas: defining the problem, establishing the goals and priorities of treatment and/or management, and identifying the roles to be assumed by both the patient and the doctor. To reach common ground often requires that two potentially divergent viewpoints be brought together in a reasonable plan (Kon 2010; Edwards and Elwyn 2009). Once agreement is reached on the nature of the problems, the patient and doctor must determine the goals and priorities of treatment and/or management. What will be the patients’ involvement in the treatment plan? Do the plans make sense in terms of the patients’ perceptions of their health, their understanding of their disease and their unique illness experience? How well do the treatment plans match the values and preferences of the patient? Can the patient afford the medication, and can he or she cope with the demands of treatment? Finally, how do the parties involved – patients and doctors – define their roles in this interaction?

Seeking an understanding or explanation for worrisome physical or emotional symptoms is a fundamental human need. Most patients want a “name„ or label for their disease to help them gain some sense of control over what is happening to them (Kleinman 1988; McWhinney 1989; Cas-sell 1991; Wood 1991; Helman 2007; Lang, Floyd and Beine 2000). When patients can assign a label to their problems it helps them understand the cause, what to expect in terms of the course or timeline of the problem and what the outcome will be (Cooper 1998). It also assists them in regaining some degree of mastery over what may have been a frightening symptom.

Patients have usually developed some ideas – their “explanatory model„ (Kleinman 1988; Helman 2007) about their problem before presenting to the doctor. Failure to elicit the patient’s perspective may jeopardize agreement on the nature of the problem(s). Without some common understanding about what is wrong, it is difficult for a patient and doctor to agree on a treatment protocol or plan of management that is acceptable to both. It is not essential that the physician share the same perspective on the problem as the patient, but the doctor’s explanation and recommended treatment must at least be consistent with the patient’s point of view and make sense in the patient’s world.

In defining and describing the problem, it is essential that doctors give the information in language patients can understand, thus complex medical terms and clinical language should be avoided. If patients are intimidated by medical jargon, it may limit their ability to express their ideas and concerns or even to raise important questions. Failure to elicit these patients’ expressions may result in a failure to find common ground. Patients need to be encouraged to ask questions and not fear being ridiculed or embarrassed for not knowing or not understanding technical terms and procedures. Just as active listening is key to exploring patients’ illness experiences, it is also central to finding common ground. Thus it is important to understand and acknowledge patients’ perspectives on their problems.

Once the patient and doctor have reached a mutual understanding and agreement about the problem, the next step is to explore the goals and priorities of treatment and/or the management plan. If doctors ignore their patient’s expectations and ideas about treatment and/or management, they risk not understanding their patients, who may in turn become angry or hurt by this perceived lack of interest or concern. Some patients will become more demanding in a determined effort to be heard; others will become withdrawn and feel abandoned. Patients may be reluctant to listen to their doctors’ treatment recommendations unless they feel that their ideas and opinions had first been heard and respected.

Timing is important. If the physician inquires about the patient’s ideas about what is causing their problems too early in the interview, the patient may think that the doctor doesn’t know what is going on. On the other hand, if the doctor waits until the end of the consultation, time may be wasted on issues irrelevant to the patient. The process of finding common ground begins right from the start of the interview by eliciting the patient’s full list of concerns and showing respect for their ideas and questions. Doctors need to actively engage their patients and explicitly inquire about their expectations. For example, a physician might say, “Can you help me to understand what we might do together to get your diabetes under control?„ Often it is helpful to pick up on patients’ cues that hint at their feelings, ideas or expectations. For example, a patient may express frustration about the failure of treatment recommendations to help: “I have had this back pain for three weeks now and none of the pain medication you gave me has helped. I just can’t bear the pain!„ The doctor should avoid becoming defensive in trying to justify previous recommendations. Instead, it is more helpful to address the patient’s frustration and the implied message that something must be done: “You sound fed up with the length of time this pain has dragged on and would like a different approach to treatment.„

Often patients find it awkward or difficult to provide suggestions about their health goals or the treatment or management of their diseases. Some patients may feel that their opinion lacks validity and value, while others may defer to the authority of the “expert„ clinician in the decision-making process. Physicians need to encourage patients’ participation with statements such as: “I’m really interested in your point of view, especially since you are the one who has to live with our decision about these treatments.„ It is important for doctors to clearly explain the treatment and/or management options and to engage patients in a mutual discussion of the pros and cons of different approaches. It is also important to acknowledge and address the patients’ questions and concerns so that patients feel heard and understood. In clarifying patients’ agreement with a specific plan, questions such as the following can be very useful: “Can you think of any difficulties in following through on this?„ “Is there anything we can do to make this treatment plan easier for you?„ “Do you need more time to think this over?„ “Is there anybody you would like to talk to about this treatment?„ These questions and others help forge partnerships with patients; they are, as Tuckett et al . (1985) described, “meetings between experts„ – the physician is the expert in the biomedical basis of the problems, but the patient is the expert in how the problems are affecting him and how options for treatment mesh with his values, preferences and personal situation.

Establishing the goals of treatment and/or management must also take into account the expectations and feelings of physicians. Sometimes doctors are concerned that patients may ask for something they disagree with, because they are not comfortable with confrontation and with saying no. As a result they may prefer to avoid the issue, but then finding common groun d

will not be achieved. Doctors can become frustrated and disheartened when patients are not concordant with treatment protocols and management plans. But what physicians call “non-compliance„ may be the patient’s expressions of disagreement about treatment goals. As Quill and Brody (1996) observe: “Final choices belong to patients, but these choices gain meaning, richness, and accuracy if they are the result of a process of mutual influence and understanding between physician and patient„ (p. 765).

Inherent in articulating the roles to be assumed by the patient and doctor is a definition of mutual responsibility for the actions that will follow. These may be quite simple, such as: “How about I see you again in one month to check that this new medication is lowering your blood pressure.„ Implicit in this statement is the patient’s agreement to use the medication as prescribed, and the doctor’s desire for future follow-up. Certain situations, however, may be more complex and therefore require an explicit statement of the roles to be assumed by the patient and the doctor.

Sometimes there is strong disagreement about the nature of the problem or the goals and priorities for treatment. When such an impasse occurs, it is important to look at the relationship between the patient and the doctor, and at their perception of each other’s roles. Doctors, for example, when caring for a cancer patient, may see themselves as wanting to bring about remission, and may expect the patient to assume the role of a passive recipient of treatment. Patients, however, may be seeking a physician who expresses concern and interest in their well-being, and who is prepared to treat them in the least invasive manner, viewing them as autonomous individuals with a right to have a voice in deciding among various forms of treatment. This is not such a dilemma for doctors when the various forms of treatment are equally effective, but physicians are understandably concerned when the patient chooses a treatment that they consider either less efficacious or even harmful.

Finding common ground about a patient’s role in the decision-making process does not necessarily imply that the patient will assume an active role. Patients’ levels of participation in decision-making may fluctuate depending on their emotional and physical capabilities. Thus doctors need to be flexible and responsive to potential changes in their patients’ involvement. Some patients may be too sick or too overwhelmed by the burden of their illness to actively participate in their care. Others may find decisions about treatment options too complex and confusing, hence delegating the decision-making to the clinician .

In the process of finding common ground, it is the doctor’s responsibility to define and describe the problem. This may be as clear-cut, such as “you have a strep throat,„ or ultimately more complex and uncertain, such as “there are several possibilities to explain your symptoms, so what I suggest we do is …„ Next it is important to provide the patient with an opportunity to ask questions. This is not simply an “okay?„ , but an intentional engagement of the patient: “What do you think?„ Some patients may retort with, “I don’t know? You are the doctor!„ Doctors need to respond with a comment such as: “Yes, and I will provide you with information and my opinion, but your ideas and wishes are important in making our plan together.„ This is when information sharing begins.

The patient and doctor can then participate in a mutual discussion of their shared understanding of the problem and how it can best be addressed. At the conclusion of their discussion of treatment options and management goals it is the clinician’s responsibility to explicitly clarify the patient’s understanding and agreement. It is during this summation that the doctor and patient can make specific their respective roles in achieving the mutually agreed upon treatment goals. This may be as simple as agreeing on how follow-up plans will be arranged, or as complex as a discussion of how a cancer patient in the palliative phase needs the doctor to assume a caring role versus a curative stance.

Finding common ground requires that patients and physicians reach a mutual understanding and mutual agreement on the nature of the problems, the goals and priorities of treatment and/or management, and their respective roles. Sometimes patients and doctors have divergent views in each of these areas. The process of finding a satisfactory resolution is not one of bargaining or negotiating but rather of moving towards a meeting of minds or finding common ground.

In this section, the narratives emphasize how the third component, finding common ground, can be the lynchpin of the patient-centered clinical method, but this is not without its challenges.

In the first narrative, Chapter 21 , we witness the challenges in caring for people who are homeless. In this story we learn how the patient has experienced much trauma and violence in her life, yet she is a survivor .

She then faces an extremely serious medical condition that is potentially life-threatening. The patient is paralyzed with fear - the prospect of invasive surgery is untenable. Gently the physician seeks to build a relationship with a patient who avoids authority figures. With a tentative bond established, the crisis is averted, and they find common ground regarding the needed surgery. But this is just the beginning of the story, and finding common ground is ongoing between the patient and doctor as they circumvent the patient’s many crises.

Chapter 22 demonstrates how attentive listening, an active presence, and communication all play a pivotal role in gaining trust – trust that is necessary for an effective patient-doctor relationship. It also highlights the critical distinction between the diagnosis of disease and the illness experience of patients, and how some patients need this explicitly clarified through effective communication to foster healing.

The next story, Chapter 23 , emphasizes the role families play in finding common ground during acute illnesses and resuscitation. It illuminates the value of including families during the resuscitation process in order to foster healing and closure. Furthermore, it emphasizes how physicians can overcome institutional blindness to appreciate the suffering patient as a previously normal, functioning, non-sick individual – a mother, a wife, a gardener – a whole person.

When do we feel justified to act against the wishes of a patient in order to maintain his or her safety and forfeit finding common ground? Chapter 24 reveals the struggles experienced by a physician who strives to build a trusting patient-doctor relationship with a woman who has both physical and social challenges. The goal is to provide her with a safe environment and preserve her dignity, but in the end they fail to find common ground, and the relationship is shattered. While this narrative may sound desolate, it offers many valuable lessons about being patient-centered.

We often think about finding common ground with patients as being focused on management or the treatment of a specific disease, often with a cure in mind. However, finding common ground can also be directly applied to how we help patients face a terminal disease and their decision about how they die. The two-part story in Chapter 25 and Chapter 26 serves as an illustration.

Chapter 27 exemplifies how relinquishing control on the part of both the physician and parent can be empowering in a patient’s life. It also demonstrates how this behavior can facilitate finding common ground and can foster a solid foundation for a healthy, long-term patient-physician-family relationship .

Sometimes finding common ground is a precarious process that can easily unravel when patient’s expectations and concerns remain unheard. Chapter 28 underscores how the strength of the patient-doctor relationship preserves this pivotal component. Indeed, it is the patient’s courage to address her dissatisfaction and the physician’s ability to listen to the criticisms that lead them to successfully finding common ground.

Chapter 29 demonstrates how finding common ground can sometimes be a fine balance. In this story, the elderly patient’s physical and emotional pain are tightly interwoven, reflecting a lifetime of loss and sorrow. This presents the physician with a monumental task in trying to relieve her patient’s profound suffering. At times this feels overwhelming, yet the doctor perseveres in her attempts to alleviate her patient’s multiple concerns. With time and constancy they strike a balance – the pain remains but becomes less of a burden for both the patient and the doctor.

We end this section with a story Chapter 30 that examines the challenges of an adolescent with a long history of living with cancer and pain management. His story portrays the potentially fragile nature of the patient-doctor relationship and as such serves as a transition to the next section of this book, the foundation of patient-centered care – the patient-doctor relationship.