Why Patient-Centered Care May Not Be the Best Kind of Care
But, isn’t it always about the patient?
Of course it is. But, it’s also about you.
To be sure, patient-centered care—an approach to healthcare that emphasizes the patient as a whole person who has needs that extend beyond just physical ones—is important. Not only can it leave patients and their families feeling more satisfied with their clinical encounters, but it is also a critical (and overdue) corrective to the overly-paternalistic medical care of the mid-20th century when some patients were left in the dark about their diagnosis and treatment plan and were expected to unquestioningly follow “doctor’s orders.”
Despite the very real benefits of patient-centered care, what seems to be glaringly absent from most of the work around this movement is the lived experience of the clinician—the way clinicians are inevitably affected by suffering, healing, pain, joy, frustration, loss, and love.
Most models of patient-centered care—despite their emphasis on shared decision making and building therapeutic partnerships—fail to recognize the clinician as a whole person who is affected by clinical encounters and who bears witness to suffering, death, and health injustice much more often than those outside of healthcare. Whether the ubiquitous emphasis on patient-centered care is the result of pressure from healthcare executives to promote “consumer satisfaction” or the beliefs of an individual clinician who was trained to believe their emotions are unimportant, one thing is true: overlooking clinicians’ experiences can leave them feeling as if there is no place for their own feelings of exhaustion, disappointment, or grief.
So, rather than patient-centered care, we might instead promote what clinician scholars have called relationship-centered care. Like patient-centered care, relationship-centered care highlights the importance of seeing patients as whole people, but it also stresses that the relationships clinicians have with each other, with their community, and with themselves are critically important and morally valuable. In fact, relationship-centered care is founded upon four principles:
1. Personhood matters—the personhood of the patient, their loved ones, and members of the care team
2. Affect and emotion are important
3. Relationships do not occur in isolation
4. Maintaining genuine relationships is necessary for health and recovery, and it is morally valuable
The second principle—the importance of affect and emotion—is worth emphasizing. In medical practice and training, affect and emotion are often framed as distracting at best and intolerable at worst. Medicine is frequently described as an objective practice—an “applied science”—and thus emotions are seen as a threat to the “objectivity” needed for sound medical practice. Indeed, medical school often reinforces this belief, as students learn to emotionally detach themselves in order to dissect donor bodies, to sacrifice relationships in order to endure the rigors of the curriculum, and to compartmentalize their own emotions as they “focus on the patient” and try to impress faculty to receive good evaluations during their clinical training.
There are certainly situations in which maintaining clinical distance is necessary (during an emergency or trauma, for instance), and a level head and sound judgment are necessary in virtually all situations. And yet, this does not mean that clinicians are unaffected by their experiences. Nor does it mean that objectivity is the foundation of good medicine. Empathy and compassion, two pillars of good medical care, require clinicians to feel. Indeed, the Latin root of compassion (passion= the suffering of pain and com= in combination or union together) quite literally means the suffering of pain together. In order to be compassionate, we must be able to feel some of what the other person is feeling—not to “feel bad” for them or to assume we know exactly how another person is feeling, but to allow ourselves to feel some of their pain. And this is something we are unable to do if we are not in touch with our own pain and are unable (or unwilling) to tap into it.
For these reasons, proponents of relationship-centered care, like Drs. Mary Catherine Beach and Thomas Inui, argue that relationship-centered care “challenges the notion of detached concern, in which stepping back to maintain affective neutrality breaks the bond that holds people together. Rather than remaining detached or neutral, clinicians ought to be encouraged to empathize with patients, because empathy has the potential to help patients experience and express their emotions to help the clinician understand and serve the patient's needs, and to improve patients' experience of care.” Said simply, compassion requires vulnerability. Compassion requires us to look at ourselves, to be in touch with our own emotions, and to connect with others through the shared experience of being human.
Patient-centered care fails to fully capture the shared human experience or acknowledge how deeply many clinicians are affected by what they do every day. And while patient-centered care has fortunately helped to recapture the patient’s voice in the clinical encounter, its time might be nearing an end. Embracing emotion and investing in relationships is healing—for both patients and clinicians. Let’s stop normalizing detachment, compartmentalization, and objectivity in the name of “patient-centered care.”
