From the President
January 29, 2014 DOI: 10.1176/appi.pn.2014.2a15
Lisa Dixon, M.D., M.P.H.; Jeffrey Lieberman, M.D.
Psychiatry has long been considered the medical specialty most attuned to listening to the patient. With few diagnostic laboratory or imaging tests available or other physical indicators of illness, psychiatrists have been trained to attend carefully to their patients’ histories and subjective reports of symptoms to make a diagnosis and determine the course of treatment. But the nature of the doctor-patient relationship was traditionally one-sided. Patients talked and their physicians listened, and then the doctor prescribed the treatment and the patient followed.
But now psychiatry is changing as the field of medicine adopts patient-centered care. This model of care places greater emphasis on the patient’s involvement in determining the goals of treatment that are meaningful to them and the nature of their care. Meaningful goals for patients generally go beyond symptoms to include quality of life, functioning, and a sense of hope and self-efficacy. Patient-centered care isn’t just about putting the patient at the center of the care equation. Rather, it shifts the balance of authority and responsibility of the doctor-patient relationship and incorporates shared decision making (SDM) between the clinician and the patient, particularly when it comes to treatment. SDM is defined as “a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.” Practicing SDM requires that psychiatrists assess the patient’s interest in participating in decisions, providing information to them on the risks and benefits of specific treatments or approaches in an understandable format, and dialogue with patients about their choices. SDM does not mean that psychiatrists don’t make strong recommendations; rather, it means that those recommendations need to be reconciled with patients’ views and choices.
The promise of this change is that, with patients taking a more involved role in their treatment decisions, physicians will better understand their patients’ needs and concerns and be better able to offer an informed course of treatment. It also brings the hope that patients will be more inclined to adhere to treatment and share important information about their response (including side effects), thereby enabling their physician to make adjustments as needed. This is not an insignificant change. In psychiatry, as in all of medicine, patient adherence is a prevalent problem and major limitation of treatment. For numerous reasons, many patients are unable or unwilling to follow through on “doctor’s orders,” with worsening symptoms as a consequence. In this context, doctors may discover that their orders may cause problems that the patient has not previously been willing to reveal.
There are other benefits to patient-centered care. Shared decision making between psychiatrist and patient can improve the efficiency and productiveness of patient visits, both indicators of quality care and precursors to improved patient mental health.
This new paradigm is not without its challenges. Empowering patients to be active participants in their care often requires educating them about their disorder and options for therapy to ensure they are prepared to ask relevant questions and understand the answers. Certainly this process is more difficult for patients whose disorders impair their cognitive and decision-making abilities. In fact, these concerns are cited by some psychiatrists as the reasons they are reluctant to embrace this care model. However, it is our job to develop the means to facilitate this mode of communication with patients and their participation in care. Initially, clinicians may find this role difficult because of the increased time and effort it requires and uncertainty on how best to teach and motivate patients in this way.
There are several innovative efforts seeking to address these concerns by providing new direction on how to educate patients and increase their engagement in care. One study utilized group training on shared decision making among people with schizophrenia, comparing it with a control group that did not receive the training. Those patients engaged in the decision-making instruction were more involved in their own care, and more likely to continue to take their medications. CommonGround, a web-based application that facilitates shared decision making among individuals with mental illness, received APA’s 2013 Psychiatric Services Gold Achievement Award. Electronic tools have great potential in facilitating communication and shared decision making.
Family engagement that is contingent on the patient’s agreement and invitation can also be an important part of patient-centered care. Many prior efforts to implement family-based services for adults with mental illness have had a disappointing response, perhaps because there has been too little focus on the patient’s preferences. New models of family engagement are seeking to improve this component of treatment. A pilot program implemented within the Veterans Affairs system in Maryland and in California encouraged family participation contingent upon the interest and invitation of the patient. This program served to elicit significant and sustained engagement by both families and patients.
Psychiatry has always been the field of medicine that prided itself on emphasizing the doctor-patient relationship. We now need to extend this practice, to enhance patient involvement, and begin listening—and talking—to our patients in new ways. To do so will only enhance the physician-patient relationship and the quality of health care.