 I'm delighted to welcome you today on behalf of the McLean Center for Clinical and Medical Ethics and the Center for Health and Social Sciences, Chess, and the Bucksbaum Institute. Dr. David Meltzer and I welcome you to our lecture in the 2019-2020 series on the present and future of the doctor-patient relationship. It is a special treat to introduce our distinguished speaker today, Dr. Wendy Levinson. Dr. Levinson had been the chief of general medicine here at the University of Chicago. Can I get this to you? Yes, I know what to spell. I lost the top. And then was chair of the Department of Medicine at the University of Toronto, which I believe, but I may be one who believes it, may be the largest Department of Medicine in North America covering a series of hospitals. Dr. Levinson currently is the chair of Choosing Wisely Canada, a campaign that helps physicians and patients engage in conversations about unnecessary tests and unnecessary treatments and procedures. Additionally, Dr. Levinson is the chair and coordinator of Choosing Wisely International, which is a collaborative of the Choosing Wisely campaign that covers 20 countries worldwide. A national and international expert in the field of physician-patient communication. Dr. Levinson studies topics such as the disclosure of medical errors to patients and informed decision-making. Dr. Levinson has led efforts to educate and engage residents and faculty members in patients' safety, quality improvement, and stewardship of finite resources. Other major leadership roles that Dr. Levinson has held over the years include serving as the chair of the American Board of Internal Medicine, as president of the Association of Professors of Medicine, and as president of the Society of General Internal Medicine. A renowned innovator in medicine, Dr. Levinson is the lead author of a book, Understanding Medical Professionalism, a book that teaches healthcare students and clinicians how to deliver the highest quality patient care through professionalism in their medical practice. Additionally, Dr. Levinson is the co-author of both the 24th and 25th editions of the Goldman Cecil textbook of medicine. I grew up with Cecil textbook of medicine, which is one of the most prominent and widely used medical texts in the United States. As a result of her remarkable work, outstanding work throughout her career, Dr. Levinson was appointed an officer of the Order of Canada. I don't know if you know about this award, but this is one of Canada's greatest domestic honors and recognizes a lifetime of outstanding achievement, dedication to the community, and service to the nation. Today, Dr. Levinson's talk is entitled, Patient-Centered Care, Past, Present, and Future. Join me please in giving a warm welcome to anyone. Well, it's a pleasure to be here. I've been in this auditorium many years ago and see some old friends in the audience and appreciate the invitation, of course, of Mark, who we've many years talked about whether things are really ethical problems or communication problems, and we've bantered over these kinds of issues over the years. So I'm very interested to share this talk with you. I've never given this talk before. You're experimental here for me. And really what I want to do is share a bit based on the literature, but a lot based on just my reflections over time because it's a history I've seen unfold. And I will really be interested in your reactions to this and your perceptions about where we are in being truly patient-centered in the care we deliver at this time and where we're headed in the future. So to begin with, what I'm going to do is talk a little bit about the history of patient-centered care and how it emerged. I want to talk about the progress and the barriers to implementing it and reflect on what patient-centered care might mean in the future. So these are back in the old days in the 50s and 60s. That was just for some of you who might remember. That's the time that Chubby Checkers did the twist and Seagler remembered that. It's a time when medicine held a very reductionist view of disease. Disease could be explained by understanding the biology of the problem and the appropriate treatment. Disease could be accounted for as deviations from the norm in measurable biologic variables. Issues that were psychological or behavioral were really delegated to the domain of psychiatry and kind of outside medicine. There was really little consideration of the patient's illness experience or the personal and social issues that might contribute to an illness or be a consequence of the illness. And even for patients with cancer where the emotional issues are critical, the biomedical model led physicians to focus mainly on the biology of the illness even to the extent that patients were sometimes back then not told that they had a cancer diagnosis because it might be upsetting to them. As one physician put it, medicine should quote, concentrate on real diseases and not get lost in the psychosocial underbrush. Secondly, there was a dominant view that doctor knew best and that the diagnosis and treatment patients were asked to comply. That was the word with treatment. Patients who didn't do what the doctor suggested were called non-compliant. Or perhaps they didn't ever agree with the plan that was put forward but the doctor wouldn't have known because they didn't really ask the patient's opinion. After all, the doctor was the expert. So that was back in the 50s and 60s. Then I think a really paradigm-shifting paper was this paper published in Science by George Engel which introduced the concept of the biopsychosocial model in 1966. So that was back when the Eagles did Hotel California. So to provide this really paradigm-shift was to provide a basis for understanding the determinants of disease and arrive at a rational treatment. A medical model must take into account the patient, the social context in which he or she lives and the complementary system devised by society to deal with the disruptive effects of the illness. This was the biopsychosocial model. And while the concept of patient-centered care wasn't coined yet, the model really required physicians to understand the patient in the broader way and to explore how the illness might affect their life and their social community. The model was really a major departure from the existing paradigm and I would say that it was not broadly accepted at all in the mainstream of medical practice. Although there was a movement that George Engel started back at that time at the University of Rochester that led to a cadre of faculty who tried to embed some of this in medical education. Some of you may remember that the Society of General Internal Medicine really spawned at that time a group of faculty who tried to teach these concepts in medical education. So this really took another step forward, another 10 years later approximately, in 1988. I won't go on with this forever, but Whitney Houston was doing I Will Always Love You. And in 1988, the Picker Commonwealth Program for patient-centered care first coined the term patient-centered care and called attention to the need for clinicians, staff and healthcare systems to shift their focus away from the diseases and towards a broader approach that gave a more central role to the family and to the patient. By the way, the Pickers were a couple, Jean and Harry Picker. When Jean was diagnosed with a terminal illness in Boston they thought that the American healthcare system was technologically and scientifically excellent but, quote, not adequately sensitive to the concerns and personal needs of patients and that this adversely affected the quality of care they received. So remember that was back in 1988 and the term first came about and they started actually the Pickers bringing people together to talk about this concept of patient-centered care and what they learned in their research which was focus groups of patients is that from a patient's perspective back in 1988 quality meant these things respecting patient's values and needs, integrated care, education for the patient and family, physical comfort, emotional support, involvement of the family and friends and continuity through transitions of care might sound actually modern, right, David Meltzer? Some of the things that you are still talking about but this was the patient's perspective and, you know, what's in here is a lot like the biopsychosocial model and what was meant by patient-centered care and as one patient put it back in 1998, nothing about me without me. Something that I think is just a really interesting simple way of expressing patient's desire to be central in the care that they receive. So then I think what happened is in 2001 the Institute of Medicine really helped to put this into focus because until then the term, although it was coined was not part of the mainstream of practice, education or research but I think the IOM put it on the map with crossing the quality chasm. In the book, the IOM included patient-centered care as one of the six dimensions of quality, effective, safe, timely, access, equity and patient-centered. And the IOM defined patient-centered as care that was respectful of and responsive to the individual patient's preferences, needs and values and ensured that patient's values guided clinical decisions. So obviously this highlighted the need for clinicians and patients to work together to define the goals of care and the possible treatment approaches that were appropriate for that patient's values. It used the term patient experience highlighting the primacy of the patient role and how the healthcare system needed to meet their individual needs better than it did for Mrs. Picker. So obviously this followed closely from the work that the Picker Institute started but it may not be obvious that it was really a major turning point in the recognition of the importance of this approach and a shift away from a purely biomedical model that clearly this could not have been written 10 years earlier. This was a major step forward. It was what I would call a game changer in medicine. So now the stage was set for the challenge of really putting this into practice and you might think about whether we've made a lot of progress since this which was written in 2001 because the barriers were pretty significant still that some doctors and clinicians really still held the view that Dr. New best and weren't sure how to incorporate the patient's perspectives. They might have been not convinced that while they might think that these issues were important how important were the psychosocial issues compared to the biomedical issues and I think they asked the obvious question well does it really matter to patient outcomes? Is this really a model that improves the care of diabetes or hypertension or all the diseases that we see so frequently? I think some people asked can you do this new model of care without it taking so much time in short visits? And there were very few tools to facilitate this kind of patient-centered communication. So I think there were pretty significant barriers. But over the next decade research on patient-centered care communication between clinicians and patients and the relationship to outcomes started to build the case of the importance of this model of care. Given the definition of patient-centered care implementing it depends on effective communication because understanding preferences and needs requires skills in exploring these issues. And articles not previously in the medical literature started to appear focusing on particular kinds of communication like breaking bad news or disclosing medical errors. They were kind of a way of talking about patient-centered care but in a more specific way. And people started to measure patient's experience in some cases providing feedback to clinicians. So I think the model started to look like this. An informed and activated patient or family working in a health system that was well organized led to patient-centered clinician communication which improved communication and improved health outcomes. And so the model started to look like this and since patients with cancer particularly needed to make choices about trade-offs weighing the pros and cons of particular treatments I think the field of oncology started first to incorporate this new model. And training programs in oncology started to teach patient-centered care. So articles started to emerge and forgive me if I talk a little bit about my own research but this is one of the parts of history that I knew well because I was interested in physician-patient communication really from very early on in my career. I had actually trained a bit with people who had trained with George Engel and so this was sort of part of my view of the world. And along with some of my colleagues we wanted to do research to engage physicians who didn't really believe this was important in the field. You know it was nice to try and improve patient satisfaction or patient experience but a lot of physicians weren't so actually frankly interested in those outcomes and so we thought we would try to take an outcome that doctors did care about which is whether they were suit or not and link it to communication. I always said I tried to teach patient-centered communication in a physician-centered fashion and so we did this study and it was really an interesting study in which we audio taped orthopedic surgeons with their patients and primary care doctors with their patients out in the community. We did ten audio tapes per doctor and we analyzed the communication between doctors and patients and these are not the patients that sued them. Half of the doctors had been sued at least twice or more and half had never been sued and we tried to analyze which had been sued and which hadn't based on the communication we heard. And what was interesting is that we were able to predict far above chance who had been sued partly by the content of the communication but also by the tone of voice of the doctors. I worked with some at Harvard who whited out the words and just had tone of voice that you could hear and they would rate that and we were able to listen and predict in models who had been sued and who hadn't and this work actually is still my most cited work largely because it was written about in Malcolm Gladwell's book, Blink. So this is the kind of work that started to emerge to make the link between communication and outcomes people cared about. In this work which Clarence Braddock did using some of the tapes we looked at the process of informed decision making and many authors including people in medical ethics have proposed what elements of communication are most important to good decision making. So using these tapes we found that many of these elements were lacking even in patients that were seeing surgeons for consideration of complex surgeries. What we found at the surgeons were very good at providing a lot of information about the technique that would be used in surgery actually too much information for patients with lots of jargon but they rarely explored patient preferences and asked what they valued. In fact what we found is that the patients were much more likely to tell research assistants what they were really thinking about whether they wanted to have the surgery or not like I'm worried about this surgery because I take care of my elderly husband and if I'm in the hospital who will take care of him they would tell research assistants but we knew from listening to the tapes that they had never told the doctors. So Peter Ubel in more recent work 20 years later actually on shared decision making found kind of the exact same thing. He studied surgeons and audiotape them who were talking about prostate cancer diagnosis and treatment options clearly one where there are a lot of views about what's right for an individual and he found like ours that surgeons often provided a lot of technical information but rarely explored patient values. And in both his work and ours we found that physicians rarely commented on patients emotional reactions or concerns. In short there was a long way to go between informed really what we meant by informed decision making in theory and what was happening in practice. And so what happened is then I think people started to develop tools to make informed decision making a little more easier to do. So I don't know how many of you use shared decision making tools in practice but this is an example of a very good one created by the Canadian Preventive Task Force to talk about women who are considering being screened for a mammography in their 40s. And what you can see is that if a thousand women are screened those are all the boxes the women in gray will have a normal mammogram and be reassured. But everybody in blue and purple will have a false positive and many of them will have an unnecessary biopsy. And you can see that less than one breast cancer death will be prevented. That's half of the green person in the corner. So now if you want to have a conversation with a woman about whether she wants a mammogram if you show a person this diagram and discuss it with them it's a completely different kind of conversation in which a woman could talk about what she values and does she care if she's one of these blue or purple women? Will she be anxious if she has a false positive? This is the kind of tool that makes the real choice very different than us saying well we don't really recommend it or we do recommend it it puts it into a shared framework that can allow a true sharing based on patient's values. So these kind of tools actually are pretty hard to come by for a variety of reasons they're hard to make they're hard to keep up to date in fact a lot of them that used to be around are now behind paywalls so they're hard to access but Cochrane has done a variety of studies they looked at 115 trials and found overall that when patients did have decision aids to help in decision making they had very positive outcomes greater knowledge, more accurate risk perceptions because you can see on that diagram where you would have a more accurate risk perception greater comfort with decisions and engagement in decisions and what's of course interesting is as you probably know that if people do use these tools they're much less likely to take aggressive pathways like to have prostate surgery or aggressive surgeries because they understand the risks and benefits a lot more fully so there started to be a body of literature that talked about benefits of shared decision making but I think also what happened then is it was clear that the relationship between patient-centered care and outcomes was sort of more complicated than I think earlier research put forward and in this diagram what you see is that if there's communication that happens between providers and patients like information expand and responding to emotions how does it lead to health outcomes? Well it could directly affect it like emotional well-being might be directly affected by responding to patients' emotions but it could go through indirect pathways of greater trust and greater trust than might build greater sort of self-care skills or emotional management so the relationships between how you got from patient-centered care to better outcomes people started to understand was more complex and I think one of the reasons the literature is difficult is that we haven't had a really clear model of how what the flow is between better patient-centered communication and outcomes and so this article which was written in 2009 tried to articulate that in a way that research could then hang its hat on a different kind of framework but overall I would say that the work that has tried to study the relationship between patient-centered care and outcomes has been pretty inconsistent in its findings partly because the complexity of it partly because the way of assessing communication and whether it's patient-centered is not standardized some people use audio tapes or try to use video tapes or self-reports and so as you can see these behaviors are not as directly linked to outcomes as makes it easy to study so I think overall it's still a work in progress understanding the relationships to biologic outcomes there is a fair amount of evidence though that patient-centered care makes patients more knowledgeable activates them to be more engaged in some cases improves management of chronic disease particularly hypertension and diabetes it is being linked to decreasing malpractice risk and so it's still like I said a work in progress so I think another driver that has led to increased attention to patient-centered care is the feedback that we in many hospitals and clinics now receive this CAP survey started to be commonplace this is the national one and you know it asks questions like in the last six months how often did your provider explain things in a way you could easily understand listen carefully to you show respect for what you had to say and spend enough time with you and in general the three biggest complaints of patients are that clinicians didn't listen to their concerns adequately that they didn't provide enough information and that they didn't spend enough time so gradually providers started to get feedback on how they were rated by patients in comparison to their colleagues and there's nothing like some healthy competition to get physicians to want to improve so this clearly signaled that healthcare systems cared about the patient experience so in some over the decade after the IOM report patient-centered care became more of a mainstream in our language it was broadly agreed that it was part of quality of care it became less about convincing clinicians that it was important and more about the skills of doing it and in short visits so this is a long way to get to the present but I'll be shorter in the present and the future and you might think about where we are now in our transitions so the present I'd say is dominated by the major force of the internet and the use of electronic medical record the impact on, by the way this is University of Chicago in Toronto I just thought they looked the same so I left but still the same so the impact of electronic medical record and internet has just been profound in a way that I think all of you know because you live it and breathe it and it's impossible to cover the topic of how it's affected patient-centered communication in a short time I mean there are thousands of articles on it but they basically fall into several categories the internet informed patient the impact of the EMR during the visit communication with physicians through email and texting and chart notes being available to patients so I'll start by telling you a quick story I have a cousin in Boston who's the husband of my first cousin and he's 70 years old he's a retired computer engineer and he's very adept at computer technology I'd say he was an early adopter of anything that was technologic but he's the most passive patient I've ever met driving his doctors and his wife completely crazy and unfortunately for him he has many major healthcare problems he's had a non-Hodgkin's lymphoma treated with toxic drugs temporal arthritis treated with high-dose prednisone and toxic side effects and more recently his idiopathic pulmonary fibrosis so if anyone needs to be an activated patient involved in their healthcare decision-making he does and in the last 10 years his approach to life is completely changed he searches the Internet for information he looks at all these drugs for his chronic lung physician condition he emails his physicians, his PCP and his main pulmonary specialist and he gets his chart notes the day they're released online and sends them to me and talks to me in the evening about what they showed he is what the literature would say an empowered patient and this is entirely a change for him based on technology because before that he never asked a single question and didn't have access to information so I think there are being zillions of jokes about the Internet I'm already diagnosed myself I'm only here for a second opinion because in fact patients like John have become more engaged and it's shifted the role of the physician from a source of information to a navigator of information who helps a patient take the information that they've found and think through what it means for them like combine the information that they found on the Internet the information that the doctor has and help think how to make sense of this based on the patient's values and preferences so helping make patients make choices informed by the evidence with the physician acting as an interpreter and I'd say it's a task that's easier said than done and challenges physicians again about how to do this in really short visits and then there's the effect of the electronic medical record in the exam room and this is an article that Vinny I don't think is here but she's the senior author on the paper Vinny Aurora and there have been a number of systematic reviews in this article there were 53 studies that were included by virtue of using video or direct observation of behaviors in the visit and surveys to examine patient perceptions and in general these studies find that there are some negative aspects largely related to physicians dividing their attention between the screen and the patient pausing in conversations to attend to the screen but there are also specific behaviors that facilitate patient-centered interaction by inviting the patient to look at the screen and encouraging patients to ask questions and clarify electronic medical information but skills of attending to the patient's nonverbal communication despite looking at the chart are really important and in general the literature shows that patients report no significant change in satisfaction with the encounter as a result of the EMR but it's certainly a challenge for physicians to figure out how to attend to the patient watch the patient see their emotional reactions and at the same time be integrating using the electronic chart so it's also had a profound I think impact on the relationship and then there's what people do with Mark all the time they text or call him no matter when and you know this is I mean I really think what could be more patient-centered than this you know being able to avoid missing work having childcare costs having to park and pay for parking if you can just ask your clinician some quick questions I mean I personally almost never see my primary care doctor but I do email him from time to time and I'm very impressed with my cousin John and how much his clinicians are responsive to this kind of communication outside of the doctor patient visit I think it's really being again a game changer in how how patient-centered care is delivered in fact I noticed when I was in the Mark you're in your offices or maybe in general medicine a big poster about how trainees like to text of course the downside is you know confidentiality issues but I think it's really had a fairly major impact and and then I think the other great changer is being this major change in patients being able to look at their record I think it's a great advance and it's really fits with what that patient said years ago nothing about me without me because you know physicians have been concerned that that having patients read their short notes would be complicated reveal information that might be uncomfortable that they might have to chart in a different way but I think for patients it's been a huge positive and studies show that physicians worries about chart notes haven't really borne out it really is the patient chart after all and so I think that this is another really important force that's changing the relationship so I'm only touching on a few elements of where I think the internet and EMRs have had a profound and mostly very positive effect on the doctor patient relationship but how to incorporate this in a time efficient way all these new technologies I think is challenging and I'd be really interested to hear your view of how they're affecting our ability to deliver patient centered care so I want to also talk about one other force I said earlier in the discussion that sometimes specific kinds of communication have highlighted the need to be more patient centered and I think one of the things that's happening now relates to the discussion about high value care and tests which may be unnecessary and so this is just sharing a little bit of the kind of communication work I'm presently doing through choosing wisely which you see is in English and French in Canada Schwazerevex, why that's a really nice name in French it's a double entendre it also means choosing with caring so that was the name that our French colleagues came up with but why I wanted to show it to you is because I think in Canada where the campaign has had quite a bit of resonance it is a little bit changing the conversation between doctors and patients because we're trying to teach the concept to patients that more medicine is not always better and facilitate the conversation about do I really need this test or treatment and we decided that it was a complicated kind of conversation to have with patients so we wanted simple imagery to help us we know that patients often think that more medicine is better when in fact unnecessary care has risks and costs they think that screening and early diagnosis is always good and really over darkness can be harmful we know that they think benefits of treatment outweigh harms when really we're talking about marginal benefits and improvements they often think that denying treatment is rationing but we think it's rational and they often still defer to doctors when really it's about shared decision making and so we thought well how can we take these kinds of complicated concepts and make them simple and this is what we do we have a big campaign in Canada that to teach that more is not always better and this hot dog which looks just completely disgusting this poster is in almost every family doctor's office in Canada we have we sent this out to the 31,000 family doctors it's there here's another image we use and just to say that Mark mentioned that choosing wisely is spread kind of internationally so here's what Norway does they have posters of this which translate into more is not always better so we also have these questions which the ABIM foundation who created choosing wisely and in Canada we actually just use the first four because how much it costs is not relevant to us and we have a poster that also like this has been sent out to all the family doctors in Canada and is in many family physicians office waiting rooms and in the exam rooms to the best of my knowledge there's not been research to study whether this helps to create a more patient centered interaction in Australia where they have very similar questions they use three questions about options benefits and harms and how likely these things are to occur and there have been some interesting studies using unannounced standardized patients in family medicine where the intervention arm had the patients ask these questions and the other arm did not ask the questions and the study showed much increased information given by family doctors and increased patient involvement in making decisions so I think this is an example where a specific kind of communication in this case reducing unnecessary care is having the side effect of leading to more patient centered communication but I would ask you overall to think before I talk about the future briefly how you think we're doing in being patient centered not just in academic medical centers but beyond in the community in the US in general so I think the next big change which I think is not fully here yet in the future relates to AI and the transformation of our understanding of patients illnesses based not only on their genetic information but the role of many other factors psychological social and environmental and in the years that come I think the concept of the reductionistic view of disease is just completely different now with our deeper understanding and I want to show you something I really like that I found on the internet actually from Catherine Lucy who's at UCSF about the breast the model of what causes might lead to breast cancer in a visual way I want to show this to you now let's see because this is a model of all the factors and so you can think about the biopsychosocial model kind of on steroids that lead to breast cancer causation and as you look at this you might think well what is the role of the physician and the healthcare team in this because here are the biologic relationships and factors which influence breast cancer so all the genetics age of menarchy and things that we've thought about for many years but here are the behavioral issues that influence breast cancer physical activity, BMI alcohol, age of first birth and parity here are the social factors race and ethnicity and here are the physical factors that also influence sleep disturbance environmental tobacco and all of these in this model the thicker the line the stronger the relationship but when you look at this you kind of think wow this is very far away from our original model of biomedicine and it's it's an incredibly rich model of the biopsychosocial extended model and it does make you the authors of this said that often scientists look at just one factor at a time when they investigate the causes of breast cancer but in reality many factors need to be considered at the same time the model demonstrates the complexity of this disease and it makes you think about how we not only care for the patient but prevent disease in the future let me escape back oops I want to go back to my slides you want to grab that for me I just want to show you one other model yeah thank you great that's it so this is another one just to show you another example of childhood obesity and adult metabolic syndrome and you know I think we not just the biomedical factors now we understand more about the gut and the microbiomes in the gut there's things about c-sections and how they affect the microbiome environment there's a lot of information about early exposure to childhood violence there are factors of uterine growth retardation and things which happen in uterine and even early childhood education I mean again the complexity of thinking about what this disease is really due to and how we can intervene to prevent it so I think that you know looking at all these factors you can ask yourself the question what does it mean to care for a patient thinking of the population of patients and the forces that can affect disease George Engle on steroids so lastly you know I kind of think about the future and AI by which I mean machine learning, natural learning language learning, expert systems of decision making and what its impact is going to be on the physician-patient relationship in the future and while I'm sure like Toronto this is probably a huge area of interest I put it in the future category because I think we're really just at the early stages of understanding the implications of AI for clinical care but the capabilities of AI to care will undoubtedly bring precision to many medical problems allowing us to tailor care to the individual patient it will likely increase our diagnostic acumen by allowing us to incorporate so many factors that our human brains couldn't synthesize at one point at one time it'll again change I think the role of what a physician is to become more of an interpreter of complex information putting it in a context and helping patients make decisions it will require really complex skills of communication like we've discussed before but it could help us perhaps understand the complexities of that patient with breast cancer or metabolic syndrome by pulling together things from so many domains that into a synthesis for that individual Abraham Vergesi recently wrote in JAMA that systems that augment the article was called humanizing AI systems that augment the diagnostic and scientific task of treating disease are exciting and wonderful but is it possible to invent and discover applications that can enhance the human capabilities in clinicians to better engage in caring for the patient at its core medicine will always be enacted through the relationship between the clinician and patient where the caring and compassion for a human being who is concerned who is concerned and suffering Abraham Vergesi asks whether these AI technologies might help clinicians provide more humanistic care because at its heart medicine past present and future is based on being patient centered or as Francis Peabody said in 1925 the secret of caring for the patient the secret of the care of the patient is in caring for the patient and that was in 1925 when yes sir that's my baby just came out so I'm gonna stop there and I'm very interested in your reactions I'm curious about your views of where we are in being patient centered and I just welcome your questions David if you go back to the Greeks you can find the same thing there's a very long tradition in medicine of the emphasis on knowing the patient and I wonder a little bit whether in fact that history is in fact much more dominant even now than might be recognized by the perspective of what sees sitting in an academic I can't help but think of the Pickers being in Boston a place that probably epitomizes that view of what American medicine is Toronto reminds me very much of Boston in that regard and I guess I'm curious whether we know much about what medical practice looks like outside of those walls and whether in fact what we see in academic medical centers is really representative of what we see in all of medicine not that there isn't truth in learning from that but there's probably some perhaps broader human centeredness in sort of community practice perhaps in the world I would just say from my own experience the most meaningful work in medicine with patients was the longitudinal work with patients over time being in primary care or in geriatrics where you work with people that you get to know over a long period of time and you understand some of their context and their values and preferences it's a very rewarding kind of work I think it's rewarding to the clinicians in addition to the physicians but I mean I don't know do you think I mean I think as time pressures have gotten huge and technology has gotten bigger and you know we've sort of replaced some of that with technology I think I'll just share the experience we've had developing CCP and working with some of the doctors at Ingalls community hospital we see doctors who still practice this way and not a small number of them and meaningful so I don't dispute the art of change but I think there might be a lot more by looking at variation I think that's a good point and maybe community hospitals have stayed more true to some of that Marshall? Thanks Wendy for the great trip down memory lane both history wise as well as your work so I don't hear that like education of clinicians in communication and the relationship is a necessary prerequisite but insufficient for there to be the actual change in practice and you raise issues of for example the system and the structural design of healthcare clinics and what not and staffing and the economics and so part of this issue of like truly society feeling this is an important thing that they're going to basically support it and demand it and so what ways do you see forward in terms of both the structural and economic support for this type of care and do you see a way forward that we can go from where we are now to this actually being the reality of what's valued? Well it's interesting I mean I think medical schools used to not teach it right and now I think medical schools do teach communication skills as part of their curriculum but you know I think we're still not there yet in our residency training and in practice I mean I have one other slide medical schools need to revise the ethics and humanity aspects of their curriculum so when do you think that was written? This is a newspaper article it was written last week in the leading Canadian paper and I thought to myself whoa this is making it into the leading Canadian newspaper I would have thought it was 35 years ago so I guess in answer to your question like I think we we've integrated into residency into medical education for medical students in some residencies it's taught but in some residencies I don't think it's taught or modeled at all I think we still teach a very medical model dominant if you show that breast cancer model to most oncologists I don't think they would be thinking about all the factors that lead to breast cancer I think we're far away from it really Mark? I have three related questions uh-oh three Mindy has her hand up too Mark what aspects of the doctor-patient relationship do you think are timeless and enduring and which are likely to change with time and with increased technology the second question which relates is what do you see as the biggest challenges of the increase in technology and the third one is what are the great opportunities from increasing technology well I think it's what David said this is part about caring for the patient is the enduring part I think it's what Abraham for Daisy said like can we get technology to help us with that like could we get some of these startup companies to help with some emotional intelligence recognition system you know you would be watching the patient and some little I'm not I don't know what it would be but like can we can we get technology to help us be more patient centered like not how can we get better at understanding patients values and preferences their emotional needs in a way that we can implement in practice without just you know what are the technologic facilitators of that I don't know what they could be but I mean we're very good at creating new technologies could we apply them to understanding how to make this part of care better so that not that we you know then we're doing both we're developing genetic new immunotherapies that are genetically you know tailored but we're also honing this piece that is so important to patients but that I think we still devout under value thank you Mindy and Dan I said anyway I think this is an absolutely fascinating discussion because it hits on many levels I think one of the things I when I hear patient centered care I think about two things I think about one is patients as consumers okay and as you were talking about the background of the other the landmark articles I was thinking about you know our bodies ourselves as like you know a movement of women to take back their bodies or Elizabeth Kubler Ross on death and dying so this is happening in a milieu of both narcissism consumerism and increasing finance I mean the big elephant in the room and it's so funny that David's talking about like these doctor patient stuff and I'm talking about economics but you know I mean just on a practical level so much of our care is now a function of whether we actually order certain tests because that's how we as doctors are graded not whether we discuss the test or like in this case yeah may not be good to have a mammogram or somebody may have a decision why they don't want to do a preventive health care thing but the fact that patients are consumers I think is problematic because I think it's not like selling lipstick in Macy's you know and and you talked about that a little bit so I think there's a couple of other things and the big issue and the other elephant in the room is academic medical centers privilege procedures technical stuff highly compensated things and that's the milieu where we train many medical students as well as the whole debt issue you know that there are many things so intrigued by this but I think the one thing we need to think about is that patient-centered care doesn't occur in a vacuum a medical vacuum there's a cultural changes that have really been you know cataclysmic I'm glad you raised this because we have none of the same financial problem issues in Canada problems in Canada I was going to say and we have all of the same issues of communication I mean we don't have the cost question because patients don't pay out of pocket but so they're not consumers and Canada don't consider but all of these things are just the same and what's been so interesting to me in doing the choosing wisely campaign in all these countries in the world ranging from Japan and South Korea to Brazil all the European countries the Scandinavian countries choosing wisely and having these it's the same everywhere and we have all these different reimbursement systems the context you would say is completely different but the act of talking to patients about what they value about working with it's universal it's really the essence of being a caregiver in the healthcare system and it transcends culture so I don't think it's about the consumer environment I think it's about it's influenced by the environment work but at its core it's just about being doctors and patients yeah thanks a lot Wendy I really appreciate your talk in terms of where do I begin you know I think part as we talk before the part of the problem is the standard of care which is follows this technological imperative in which technology and procedures are privileged in terms of what doctors do and I think the standard of care even though we have different ways of reimbursing care all over the world I think the standard of care has developed a lot of it has developed and then it permeates the rest of the world so I think even though they don't follow the same sort of reimbursement system that the standards that we developed here have permeated a lot of what's going on one of my concerns with patient-centered care now is that I think it's become sort of a marketing slogan for a lot of hospitals and so you know they use you know you go to any meeting with administrators and they'll use this patient-centered care thing and they're you know as this is this idea that you know for for selling their care and so I think that can really take the substance out of what it really was supposed to mean in the first place which was reaction I think to the technological imperative and also this the you know the surveys they do now you know the hospitals are really in you know they're spending a lot of money on these surveys and we have commercials up now in the hospital you should go over there and look at these and you know they speak a very corporate response to how to make things better which I think may not be working that well I agree with many things you said I mean I think when hospitals tried to be patient-centered initially what they meant was timely access to care and parking I mean it was sort of the instrumental things and not about what happened in the exam room it is actually good to be patient-centered if you'd make parking cheaper and easier or easier access to getting in the hospital and not having physical barriers those are parts of being patient-centered but I think they never tackled the communication between clinicians and patients because that was kind of in our world and our culture and our medical education domain and really it was hard to tackle that and a lot of clinicians just weren't very interested in that unless they got patient satisfaction feedback I mean how many people in the audience have specific personalized patient satisfaction feedback compared to peers do you guys I mean I think it's good to I mean it's helpful potentially to read what our own patients think what do you think David I just wanted to comment on I was actually having a similar thought to Dan's when we had the picture talking about the press gaining surveys and the check box you know one of the problems with that is sort of everyone gets a vote and not everyone's vote I think should count the same you know you check a box and says you know I'm a healthy person I went to go get my whatever checked it was a minor thing they were very nice to me that's a check okay another person you know spends three months in the hospital dealing with incredibly complex problems it changes the life of theirs and their family and if they survive to answer the survey and if they're educated you know and they get mail because mail is even delivered to their house then they answer right but mostly they don't and so one of the things I worry about it's much like the measures of quality of care and he does some other things you know the industry controls these things and the industry by that I do not only mean for profit I mean including professional societies including you know our beloved ABM and so I really worry that this sort of approach to measurement creates this lowest common denominator phenomenon where we're not really getting at what matters ultimately if we can sort of look at ourselves you know a hundred years from now on what was our experience so I completely agree I'll tell you in my experience over all these years I have a view about what the very best way to improve your doctor patient your communication is and that is to audio tape yourself a little record your iPhone on and ask a patient if you could record the visit just so you listen to it after if you listen to it after you go wow I didn't know I fill in the blank didn't know I talk that quickly didn't know I interrupted the patient didn't know I use so much jargon the second best even better thing is if you can ask permission to play that recording with a colleague because if you listen see you Anna she's going to her daughters to Washington with her daughter who's testifying in front of the house judiciary committee right Mark so you know if you take that iPhone and you listen with the colleague and you say I'm trying to improve my communication with patients and would you listen with me and hear how I you know give me some suggestions because those are way better than patient satisfaction surveys but I mean I I don't know how many physicians are willing to do it yeah there's somebody in the back with their hand up the Bucks bomb Institute has this part of medicine program that has a woman who's kind of equate to like an executive coach but she comes into clinic and observes us seeing patients and provides feedback both constructive and constructive feedback and that's what I did which I thought was really valuable to reinforce how I was being patient centered but also what I could do to maybe improve it to I think real valuable program that's really terrific so you actually have a person who will come and observe you and give you feedback I think that's terrific and I really appreciate you said that she told you what you do at the medical school doing what we do day in and day out you know Mac Lipkin who is one of George Engels disciples used to say that our most common procedure was the medical interview that you know you might do 50 in a week thousands in a year and X number of thousands over a lifetime and yet we never actually get feedback or learn how to hone our this our most common procedure but I think it's really neat to hear that you have someone who actually goes in and watches and tells you what you do well that's really terrific I was wondering do doctors feel crunched for time in Canada yes so the difference in the healthcare financing doesn't affect that because that's a very nonpatient centered thing yeah I mean we're very they're all very crunched for it's you know physicians are still paid fee for service in most settings not primary care doctors they're paid in a salary but specialists are still paid fee for service and also you know in very sophisticated areas there's a shortage of physicians so they will tell you they have to see a lot of patients because someone could be waiting for a long time for that TAVI procedure if they don't get to them for all kinds of reasons yes they're extremely still extremely pressured for time so I think all these things are true in many cultures I don't know if you remember this but the first time I met Wendy was in Portland and we were seeing patients we were seeing patients together and Wendy had recorded as I recall more than a thousand encounters between you and your outpatients and we started a little study about how frequently conflicts emerged between the doctor and the patient using these tape recordings of many many patients it was quite an extraordinary study but there were so many other studies that followed from that I worked on and published on so it was a great experience for me to understand how much information can derive from something like a tape recording of an encounter well I can't thank you enough for this lovely talk and it means so much to us as we think about the doctor-patient relationship in its evolution and changes in the 21st century this is really important thank you for having me