Collaborative Care for Patients, Interns and Physicians

As practitioners, we have inherited a wonderful medical tradition from the East that, as Americans, we naturally seek to make our own. In our culture, we are rarely ready to accept without question the complete package of any practice. It is my goal in this article to ask a question about how we relate to our patients and, in turn, how we teach our interns to interact with their patients. This same question is under discussion and in the process of change in medical schools across the country. I am hoping to begin a dialog encouraging our profession to consider how we connect to patients and how we are guiding our interns.

In the majority of cases, the best outcome requires the cooperation of the patient. Unfortunately, research tells us that for medical doctors, a substantial percentage of patients do not follow the recommendations of their health care providers. It is estimated that a third or more of patients do not comply with the advice of their health care providers, and the figures are less encouraging when the treatment plan requires long-term adherence.^3,7,8 Through this evidence, it becomes clear that patient compliance cannot be dramatically different in our field. It would appear imperative that practitioners learn to more effectively influence the behavior of our patients. Research in this area tells us that a better way to affect the well-being of our patients would be through a relationship of trust, connection and collaboration. In general, few practitioners are equipped or encouraged to develop the collaborative relationship many patients want.

The most valuable clinical training happens in the treatment rooms of our college clinics, where students learn firsthand how to care for patients and gain valuable understanding from these encounters. Clinical training involves the practical application of the didactic study. Clinical supervisors help interns navigate subject matter and evaluate etiology, mechanisms of disease and identification of syndromes, along with options for treatment and clinical care. Most important, the clinic is where interns learn to apply critical thinking to complex medical issues and communicate with patients. Interns are expected to learn how to obtain information from the often nervous, angry or withdrawn patient, and how to advise patients on their options of treatment and healthy practices of daily living.

The relationship that exists between patient and practitioner is much like the relationship between teacher and student. Both relationships are dependent on the other for the most desirable outcome. Curiously, these relationships can all be dramatically different and greatly contrast, as do their results. It appears the collaborative relationship is more desirable and more effective than the authoritarian model, which has been prevalent in medicine and medical education for an extended period of time.

In a collaborative model, patients are considered partners with the practitioner, each with a contribution to make. The collaborative model of patient care is not new.^{1,2,4,6,9,11,12} The practitioner offers skill, technical knowledge and access to resources including a history of patient care experience. In contrast, the patient brings unique knowledge of their symptoms, their support network, resources, living and working conditions, value system and willingness to make changes in their lifestyle - all valuable components of health. In an authoritarian relationship, the practitioner sees the patient as primarily a receiver of treatment. Curiously, it is not uncommon in orthopedic, chiropractic and other health care practices for patients to be referred to as "the back" or "the shoulder," etc., which unconsciously discounts the remainder of the person.

Collaborative practitioners employ an adaptable approach, encouraging patients to participate in their treatment decisions. This is contrasted by a more rigid, authoritarian-style practitioner who may become bothered when a patient seeks control over their treatment. Patients of authoritarian practitioners commonly view the treatment plan and outcome as belonging to the physician. The patient of a collaborative practitioner will participate and openly discuss all aspects of their treatment plan and jointly agree upon treatment goals. This process allows the patient to take ownership and be part of the plan and outcome. The ideal in collaborative patient care is to encourage participation in the development of a treatment plan that will uniquely fit the patient's life circumstances.

A treatment plan that is realistic to the patient's needs has a better chance of achieving patient compliance. Our students can graduate already understanding how to create a collaborative approach to patient health care.

Collaboration in patient care has resulted in positive outcomes. Numerous studies document the usefulness of collaboration in patient care.⁵ Analyzed taped interactions between physicians and patients find a correlation between practitioners who acted in controlling and directive manners and the outcome of patients. They had poor results on measured physiological tests and by their own self-reported experience of health.

In contrast, a positive association between patients being more involved or self-directed during doctor-patient interaction showed beneficial health outcomes. Stewart studied 140 doctor-patient interactions in the offices of 24 physicians.¹⁰ Patients with both acute and chronic illnesses were included. Interviews in which physicians demonstrated patient-centered behavior resulted in significantly better levels of adherence and satisfaction. Positive outcomes increased when physicians explicitly requested patients' opinions.

Laying the Foundation

When clinic supervisors foster a collaborative relationship with interns, the foundation is laid for interns to work collaboratively with their patients. Collaborative clinical education prepares interns to develop such a relationship with patients. Clinical supervisors can help interns become collaborative clinicians through their behavior and attitudes toward their interns and their patients and by encouraging interns to communicate openly with their supervisors and their patients.

Here are some activities to try in your own clinic with your patients and to encourage your interns to work and learn in collaboration:

• Create an atmosphere of trust in which the interns and patients can be open and honest with the supervisor.
• At the beginning of the term, help the interns to understand the goals they are expected to accomplished in the program.
• Help the interns assess their own learning needs in relation to the program's goals. In addition, help the patients to take part in setting their goals for their health and health care.
• Encourage the interns to develop short- and long-term goals for themselves and for their patients.
• Involve the interns in developing their learning plan and identify strategies and activities to assist them in achieving their goals. In addition, work with patients in the same way to jointly identify strategies and activities to assist them in reaching their health care goals.
• Guide the interns in reviewing and critiquing their work.
• Give timely, constructive feedback on their work and progress.
• In general, give the interns and patients awareness that the supervisor wants both to be active partners in the process.
• Foster collaboration rather than competition between the interns and their peers.

References

1. Balint M. The Doctor and His Patient and the Illness. New York: International Press, 1957.
2. Carmichael LP. A different way of doctoring. Fam Med 1985;17(5).
3. Davis MS. Variations in patients' compliance with doctors' orders: analysis of congruence between survey responses and results of empirical investigation. J Med Educ 1966;41:1037-48.
4. Illich I. Medical Nemesis: The Expropriation of Health. New York: Pantheon Books, 1976.
5. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interaction on outcomes of chronic disease. Med Care 1989;27:S110-27.
6. Rogers CR. Client-Centered Therapy. Boston: Houghton-Mifflin, 1951.
7. Sackett DL, Haynes RB. Compliance with Therapeutic Regimes. Baltimore: Johns Hopkins University Press, 1976.
8. Sackett DL, Haynes RB, Tugwell P. Clinical Epidemiology: A Basic Science for Clinic Medicine. Boston: Little, Brown, 1985
9. Sehnert KW. How to be Your Own Doctor (Sometimes). New York: Grosset and Dunlap, 1975.
10. Stewart MH. What is a successful doctor-patient interview? A study of interactions and outcomes. Soc Sci Med 1984;19:167-75.
11. Szasz TS, Hollender MH. A contribution to the philosophy of medicine: the basic models of the doctor-patient relationship. Arch Intern Med 1956;97:585-92.
12. Vickery DM, Fries JF. Take Care of Yourself: A Consumer's guide to Medical Care. Reading, Mass.: Addison-Wesley, 1976.