"Relationship" new buzzword in patient-centered care

When Anthony Suchman, MD, an internist in Rochester, N.Y., helped found the Highland Physicians Organization in the mid-1990s, he applied a relationship-centered philosophy -- prioritizing building strong partnerships between physicians, office staff, patients and family members -- to all of the enterprise's endeavors. He used this approach in developing practice guidelines, in the negotiation of contracts and even in budget discussions.

Through this experience he concluded that this approach led to less rivalry between specialists and primary care physicians than he has experienced elsewhere. In addition, there was a higher level of satisfaction among patients and all involved in their care.

"We were paying attention to the process of how people were working together," said Dr. Suchman, also the chair of the board of the American Academy on Physician and Patient, a medical society dedicated to patient-physician communication.

Dr. Suchman is one of a growing number of physicians advocating that the health care system step beyond patient-centeredness, which has been the focus of efforts to improve medical care in recent years. The American Medical Association's Ethical Force Program, for instance, runs a patient-centered communication initiative that aims to provide self-assessment kits for group practices and hospitals to determine how well physicians and other health care professionals deal with cultural competency, language barriers, health literacy and cross-cultural communication.

"This may be perhaps one of the most important initiatives that we have taken up," said David Fleming, MD, director of the Center for Health Ethics at the University of Missouri in Columbia and a member of the AMA project's expert advisory board. "The barriers to patient-centered care are the barriers to developing the healing relationship in many ways."

Those who advocate a relationship-centered approach see this model as the natural next step from the patient-centered concept. The hope is that focusing on how physicians and patients relate to each other will address what some see as a flaw in the patient-centered approach.

"One of the problems with patient-centered care is that the focus is only on the patient," said Paul Haidet, MD, MPH, a staff physician at the Michael E. DeBakey Veterans Affairs Hospital in Houston. "There are actually two people in the room, and often a lot of others. ... This is about all the relationships that exist around the patient and the doctor."

To advance the concept, the Journal of General Internal Medicine published a special supplement this month featuring nine papers, including pieces by Drs. Suchman and Haidet exploring various aspects of relationship-centered care and suggesting an agenda for research.

"We really wanted to bring attention to this idea of the relationship as being the key to medical care and the key to healing," said Richard Frankel, PhD, the issue's guest editor and professor of medicine and geriatrics at the Indiana University School of Medicine in Indianapolis. "But this is not just sitting around and holding hands singing 'Kumbaya.' Relationships can make a measurable difference in health care outcomes."

Recognizing all involved

The approach calls on the health care system to recognize that all individuals involved in the process of care bring who they are to the table; that emotions are an important part of illness and health; and that patients can influence physicians as much as physicians influence them.

"It's not just a trick of language," said Thomas Inui, MD, a co-author on several papers and president and CEO of the Regenstrief Institute, an affiliate of the Indiana University School of Medicine. "It's about moving away from the customer comes first and into something more focused on producing a fruitful, robust relationship."

Advocates say this allows for health care to meet a patient's needs more completely. It even can help meet the needs of physicians and other medical professionals and lead to improved outcomes, reduced costs, an elimination of disparities and improvements in the overall satisfaction of everyone involved.

"The attention to this concept will help transform the way that people are with each other and get at the healing potential of individual physicians and health care organizations," Dr. Haidet said. "Doctors and patients who can make better relationships will achieve better outcomes."

Not a new idea

In many ways, this approach is not new. At its core, relationship-centered care calls on physicians and patients to have longstanding compassionate relationships with each other -- interactions that have been a traditional bedrock of primary care and are often mentioned as a possible solution to quality issues.

But experts say the health care system moved away from this concept in the 1970s and '80s. Many doctors have been trying to get back to it ever since.

"For many years, the focus has been on disease elimination. We need to focus on the process of healing," said John Zubialde, MD, a family physician and associate dean for graduate medical education at the University of Oklahoma College of Medicine.

"But healing cannot take place without a relationship with the physician," he said. "We have to look at the complexity of a person's total experience and how it all fits together. You need to build trust and build continuity of care."

Experts say this approach is needed now more than ever. A relationship is less important in the simple, acute care setting but is crucial when dealing with chronic illness, which characterizes much of what most physicians now see.

"It's not about what happens today," Dr. Inui said. "It's about what happens over decades."