Monday, December 20, 2010

The Human Centered Health Home: Detecting Patient Alignment or Misalignment Using "Get, Give, Merge and Go"

"One of the paradoxes of our time is that the healing relationship seems most in jeopardy at a time when we need it most.  ...A preoccupation with a disease instead of a person is detrimental to good medicine....Any physician who looks upon a sick patient as an exercise in diagnosis or treatment is not a complete is tempting for a physician to rely too heavily on his science."...G. Gayle Stephens, MD in The Intellectual Basis of Family Practice (1982)

Clinical knowledge and skills require continuous learning and practice by physicians, including frequent upgrades of clinical science.  Patients assume that we know a lot of science and medical facts.  Still, that leaves us incomplete as physicians.   The interface of physician and patient is a dynamic human engagement with elements beyond the two primary persons and their momentary roles that seek to effect a mutually beneficial outcome.  I have written before about clinical decision making in the family medicine office as a shared endeavor in which patient and physician explore, reach a level of understanding and act on a plan.

The patient has unique insights about their illness and life context (often including biological and medical knowledge) while the physician has unique insights about human biology, diseases, conditions, therapies and medical situations.  Education, experience and the internet seem to better prepare patients for clinical situations and environments.  Many physicians believe that it's more satisfying to care for patients who have information access and motivation.  Many others clinicians fear informed patients because they may feel threatened or have to vary their work flow to accommodate the (usual) extra information sharing.

Sometimes, the physician may hide behind their "white coat" to pressure the patient with important and/ or costly recommendations, leaving the patient little negotiating room.  Many physicians are trained to withhold information from the patients, who don't understand Bayes' Theorem or p-values in clinical studies because it would only confuse them.  They become coercive in pressuring patients to accept diagnostic testing or therapies that they don't adequately explain to patients.  They don't really inquire about patient values that would drive the decision in a direction other than the one chosen by the physician.  How could the patient understand the complexity of our clinical decision?

How can physicians better understand the complexity of the "illness" for the patient?  How can either communicate effectively with the other, and with themselves, in the work context where medicine lives and patients seek healing?  I still believe that it starts with two humans, equal in their humanity and their respective quests for meaning.  The mutual respect for each others humanity anchors the dyad at the starting line of health care quality and precludes the participants from "using" each other.

Disease oriented medical literature assumes a valueless patient initially for the purposes of learning.  Behavioral aspects of patient care are seen as less important.  So patient values aren't subjected to statistical analysis.

A model that often helps me in Family Medicine is "Get, Give, Merge and Go", developed by Carkhuff Associates in Amherst, MA and published by Human Resource Development Press, also in Amherst.  The Patient and Physician both use the same model, as indicated.  First "Get" the other person's perspective on what they think is happening (referring to other posts about the HCHH, this could include a SPIT differential diagnosis or Biopsychosocial analysis at least by the physician and possibly by both).  Then "Give" your perspective.  Next, seek to "Merge" the two perspectives, integrating aspects of both parties insights into the analysis after engaging and clarifying.  Lastly "Go" ahead with the mutually agreed to plan.

What do you do if the two parties can't seem to agree?  Dr. Carkhuff published a book in 2010 (Saving America) introducing:  "Get, Give and Grow".  Keep learning and growing until the "Merge" element might occur, leading to a mutually agreed "Go" step.  Examples of the place to use this model include patients and/or physicians with strongly held beliefs about immunizations or opiates.  These can be challenging discussions, but family physicians and their patients need to commit to "Getting and Giving".  The mutual human respect will allow the dyad to have a better chance to "Go".


  1. The fact that this problem has been around and festering for 28 years says a great deal about the will, or lack thereof, to make change happen. What needs to happen to get us unstuck?

  2. As a PhD student in need of a thesis topic (on the power relationships between physicians and patients), please let me know if you see a research question in this topic that hasn't been explored!