Healing Skills from the Underserved Patient Perspective
The purpose of this study was to identify physician actions that facilitate meaningful doctor-patient relationships, from the perspective of the medically underserved patient. Twenty-five patients were interviewed at the United Neighborhood Health Services Northeast Clinic in Nashville, Tennessee, which serves an underinsured patient population. Patients were asked to identify the qualities of engagement with their doctor that move beyond simple diagnosis and treatment. Interviews were audio-recorded, professionally transcribed, made anonymous, and analyzed by the grounded theory method of qualitative research. Six physician actions emerged as vital to the doctor-patient relationship. As presented in the words of the patient, they are: Sits down with me; Treats me like family; Cares about me as a person; Takes the time; Gets to the root of it; Will not push me away. How the doctor made the patient feel was vitally important to the clinical encounter.
Doctor-patient relationship, healing skills, communication, medically under-served, community health center
Where there is love for mankind, there is love for the art of healing.—Hippocrates
At the center of medical ethics is the healing relationship.—Edmund D. Pellegrino
The need for healing has been recognized throughout Western medicine's 2,500-year history. While most physicians intuitively realize the importance of establishing healing relationships with patients, there are few empirical studies describing the factors that enhance or diminish such relationships.1 The studies that do exist focus on general patient populations rather than on more vulnerable groups, such as the indigent or the medically uninsured.
Progress in identifying the key factors in healing relationships from a physician standpoint has been made by Churchill and Schenck. Through a series of 50 physician [End Page 373] interviews, they identified a core set of healing skills in allopathic and in complementary and alternative medicine.2 Scott and colleagues completed a similar study focusing on healing relationships in the primary care setting, elucidating three key processes to fostering healing relationships: (1) valuing/creating a nonjudgmental emotional bond; (2) appreciating power/consciously managing clinician power in ways that most benefit the patient; and (3) abiding/displaying a commitment to caring for patients over time.3 In another recent study by Mendoza and colleagues, community-based physicians were systematically asked their opinions on the components of high-quality health care. These physicians placed greatest emphasis on the relationships formed between physician and patient.4 In 2001, The Institute of Medicine released Crossing the Quality Chasm: A New Health System for the 21st Century, a report detailing six aims for improvement in American health care. Chief among these was patient-centeredness: providing care that respects and responds to patient preferences, needs, and values, allowing for the development of "continuous healing relationships."5
Our study was designed to understand healing in the understudied, medically indigent patient population. The medically underserved are those individuals who lack access to primary and specialty health care because they are socioeconomically disadvantaged and live in areas with high poverty, or because they reside in rural areas.6 Patients may also be underserved because of provider barriers such as inadequate training, or biases such as homophobia, racism, sexism, or some combination of socioeconomic status and cultural bias.
Community health centers are poised to play an even larger role than they play presently in the delivery of high-quality health care in America. Thus, it is important to understand how the quality of doctor-patient relationships affects the delivery of this health care in the medically underserved, community-based setting.
Our goal was to identify physician actions and behaviors that facilitate good doctor-patient relations, from the perspective of the patients served. Twenty-five patients were interviewed at the United Neighborhood Health Services (UNHS) Northeast Clinic in Nashville, Tennessee. This clinic was chosen because of its large patient volume serving a diverse urban population, and because the clinic administration and providers were interested in such a study. Neither author has an on-going relationship with the Northeast Clinic. Patients were asked to tell the story of their relationships with their health care providers, and in so doing, to identify the qualities of engagement with their doctor that move beyond treatment of disease. In particular, we were interested in what health care providers say or do that shows care, builds trust and confidence, and helps patients get better.
The UNHS Northeast Clinic is one of 17 federally qualified health centers (FQHCs) in metropolitan Nashville. It is staffed by two physicians, two office personnel, and one physician assistant. It serves a panel of 1,662 patients, with 49% relying on TennCare (state of Tennessee Medicaid program), 39% using a self-pay/sliding fee scale, 5% using Medicare, and 7% using commercial insurance. The patient population is 67% African American, 27% Non-Hispanic White, 5% Latino, and 1% other.7 The median income [End Page 374] for these households is $21,052, and 45% of families are rent-burdened (more than 30% of their monthly income is spent on rent).8
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Recruitment and interview guide
Twenty-five patients from the United Neighborhood Health Services (UNHS) Northeast Clinic were interviewed for this study. Participant demographics are shown in Table 1. Interviewees were recruited by letter and clinic waiting room flyers. Interviews were conducted at the clinic in a private room using a semi-structured interview guide. Each patient was asked to tell the story of his or her relationship with their health care provider. Specific questions are listed in Box 1.
Audio-recordings of each interview were professionally transcribed and anonymized, following which transcripts were reviewed independently by both investigators for core themes and content, and a code book was established. Disagreements were resolved through rereading the transcripts and further discussion. Both process coding, to denote the action described by the interviewees, and in vivo coding, using the interviewees' own words, were priorities. Grounded theory was the principal methodological guide for the study.9 The basic thrust was inductive, building from analysis of individual reports to develop more abstract theoretical categories, without a priori commitments about how to code and categorize the findings. In this way, the theoretical constructs of our study emerged in our analyses of the transcripts. The Institutional Review Board at Vanderbilt University Medical Center approved this study. All participants gave informed consent before being interviewed; each participant received a $25 Walmart gift card upon completion of the interview.
Six physician actions, as named by the majority of patient interviewees, emerged as vital to the doctor-patient relationship; they are summarized in Box 2. Staying true to the patients' thoughts and feelings, these actions are presented in the patients' own words. [End Page 375]
. INTERVIEW QUESTIONS
1. Tell us the story of your relationship with your provider…
• How long have you had your current health care provider?
• How did you decide to make your first visit?
• What was going on in your life at that time?
2. What does your provider do that makes you keep coming back?
3. Tell us some of the things your provider has said or done that showed care and concern, or helped to build your relationship with them?
4. Can you describe one or two of the most important moments or significant events that show what your relationship with your provider has been like?
5. What would you say that your provider has done during the time you have been seeing her that has most helped you deal with illness and move towards healing?
6. How is your life different now that this clinic is your primary care provider?
7. Do you currently have health insurance?
• If no, how long have you been without health insurance?
• Has health insurance status affected your relationship with your provider in any way? Please explain.
8. Are there other things about your relationship with your provider that we have not asked about that you would like to share?
1. Sits down with me
Small courtesies of communication, such as eye contact, physical touch, and sitting down with a patient turn out to be highly significant. Body language is a powerful indicator of care and concern.
My doctor always gives me a hug. She is sincere about what she says. Like when she said, 'I am going to take care of this,' looking me in the eye and truly meaning it.
Engaging with a patient face-to-face, even hugging a patient, helps to initiate healing.
The doctor sat right there with me, and she grabbed my hand and said a prayer for me. Then she gave me hug. No doctor's ever said a prayer for me or given me a hug, and you know, wished me luck. It stopped my heart.
Sitting down with a patient and openly communicating also fosters a sense of trust and reduces stigma.
I have depression. The doctor sits with me and we talk about it, and I now understand that depression is nothing to be ashamed of.
2. Treats me like family
Patients find comfort when a physician can be professional as a doctor yet personal like a family member.
As soon as I left the office, I felt so comfortable that I called my daughter and I said, "Oh I finally found a doctor that I'm so comfortable with." [End Page 376]
. SIX PHYSICIAN ACTIONS THAT PROMOTE HEALING RELATIONSHIPS IN THE MEDICALLY UNDERSERVED
Sits down with me
Treats me like family
Closeness and warmth
Cares about me as a person
Kindness and compassion
Takes the time
Receptive and responsive
Gets to the root of it
Effective help and follow-through
Will not push me away
This closeness allows patients to divulge sensitive information in a non-judgmental fashion.
She's always thinking about her patient, what's going on with you, and if you slip, it's okay. Like I told her I wasn't taking my blood pressure pills, and she was like, "It's okay." I just couldn't come to nobody else, I told her, because you know me, and I know you. I just wouldn't feel comfortable with another person.
Building a relationship of trust and mutual respect, as one would do with a family member, encourages patients to feel safe and welcomed.
When I first came to this clinic, the doctor sat down and talked to me and told me about everything. She gave me my medicine for free. She signed me up for Bridges [End Page 377] to Care and was just real helpful. I didn't know her and she didn't know me but she just treated me like family. I trust her and that's why I come back, because at first I was scared; I thought I was going to be turned away like everywhere else I go.
A mutual closeness develops from this comfort and understanding. Patient and doctor connect on a level of higher trust, which further strengthens their relationship.
3. Cares about me as a person
Caring for someone as a person was described by our interviewees as a distinct kind of care. One patient summed it up this way:
My doctor here cares about me as a person, not as a victim or a patient, but as a real person.
Often being cared for as a unique person comes across as undivided attention in the examining room.
I came in and I was telling her about how I forget things, like putting the laundry into the dryer. Then I just teared up. And you know, she noticed that I was upset. Some doctors, they don't notice stuff like that. She did, and said we're gonna get you help with your depression.
Caring for patients as people correlated with a "feeling of togetherness" between doctor and patient. This feeling, coupled with a strong sense of trust, helped patients deal with illness and take positive steps to improve their health.
I was given high blood pressure pills. I've never taken those pills, never. That's because when you don't believe or trust in a doctor, you won't do it. So the doctor at this clinic told me, "Your blood pressure is high." And I was like, "Oh, really?" I'd never heard it like the way she said it. There was concern in her voice. And she says, "Yeah, we're gonna have to do something about that. Let's do this. Let's get this blood pressure down." And I was like okay, cool. It was like a together thing. Let's do this together.
Togetherness is a two-way encounter, with open-mindedness on both sides of the examining table.
I can be open and honest here. I can be honest enough to the point that if what the doc is trying isn't working, I can say, "Hey it's not working. So what's plan B?"
4. Takes the time
Every patient interviewed commented on the relational quality of time: time to listen, time to explain, time to answer questions. Patients wanted time. In a busy medical practice, time is precious. Yet for patients, it is extremely important to feel that there will be enough time.
She gives absolutely no impression of being rushed, which is key. Actually, it felt almost luxuriant that she would give the time to really delve deeply into what was going on. Very easy conversational style, I think we hit it off the first visit.
Time to reassure and explain helps patients understand, so they know what is going on with their bodies. [End Page 378]
She spent time just going over everything with me. It was a lot of time, not like what I call doc-in-the-boxes that come in and within five minutes write a prescription, and then leave and there's no interest or time spent finding out what's going on.
For patients, taking time means listening.
My doctor listened. It wasn't no 30-minute thing. She sat there. She went over my chart. She actually listened and I'm not used to that. So whenever I find a doctor like that I try to hold on to them.
Time was also seen as important to answering all the patients' questions.
I like the doctors here because they answer questions and they try to find out what's wrong with you, not just stick you on medicine and send you home.
Time also surfaced as important for solving problems.
She took the time to get me the specialists I needed. Most doctors I've been to don't do that. She took time to work on my problems and I appreciate that.
"Takes the time" was cited as the number one physician action that helped patients understand their state of health and move forward from it.
5. Gets to the root of it
By taking the time to hear the patient, the clinician is enabled to get to the why behind the clinic visit. Listening frees patients to say things they might not normally say.
She was interested in the things that I was telling her about my body. She was making sure that she would send me to get the proper tests done, x-rays, MRI, and blood work to find out exactly what was going on. She did that, and made me feel important. She got to the root of it and when she took care of it, I was treated for it.
Patients appreciate a persistent doctor. In reference to high triglycerides, one patient noted,
The doctor set out a plan, and we tried it. It didn't work the first time, or the second time. But we kept trying, and she just took ownership and said, "We're gonna do something about this." And together we've found something that works.
While patients are attuned to getting problems solved, they also understand that even competent doctors cannot fix everything.
I'm a diabetic, and my doctor makes sure that my sugar is under control. She checks my blood pressure. She gives me medicine for the proper stuff that I need for the body. If there's anything she can fix, she'll fix it. If she can't, then she'll send me somewhere else.
My whole entire life is different. Now I have somebody, a doctor, who I can go and talk to. Even if she can't help, I still can talk to her, and she understands. [End Page 379]
6. Will not push me away
Patients were asked about health insurance status and how this affected their decision to seek care at the clinic. Patients were either uninsured (14, 56%) or receiving Medicaid (11, 44%) and most did not have a regular primary care doctor before visiting the clinic.
This clinic and the doctors here are really a shining light of how people who've read and understood the Hippocratic Oath should respond. Prior to this experience, health care was really just as I could afford it and normally only to deal with problems as they surfaced. I had no preventative care, no regular check-ups, none of that. So, I've really benefited from this clinic.
With limited monetary resources, patients commented on the difficulty of finding both affordable and compassionate health care.
The doctor made me feel welcome. Regardless of my circumstances, I can still come here. She said, "You know, don't even worry about the pay. We'll straighten that out later." She just let me know that it's not about the money. It's about my care. She said, "Hey, don't even worry about it. We'll handle it. We need to see what's going on with you first." But before then money was such an issue, that's why my health got to that point, because I couldn't find a person that would work with me.
Most patients initially came to this clinic because of inability to pay elsewhere, and finding it to be such a caring environment, returned regardless of cost or insurance status.
If I had insurance I would still come if they would take it. I'd like to keep her.
From this kindness, caring, and advocacy, a bond of loyalty develops.
This study confirms the notion that the healing relationship comprises an essential element of medicine, and perhaps especially so for the medically underserved. When asked, "Why do you keep coming back to this clinic?" patients unequivocally stated that the doctor made them feel comfortable, at ease, and welcome. Patients felt a personal connection to the clinic through their doctor, a bond that transcended the medical science, reaching into the quality of the relationship. Clinicians gain trust from patients by caring for the suffering of the whole person, treating patients with respect, and building trust in a healing relationship.
The Affordable Care Act has made community health centers central to the provision of medical services for the underserved. Hence, the features of care that motivate underserved patients to return to their doctor and see their care as effective over the long term will depend on the kind of clinician traits and experiences described above. Identifying the important components of the doctor-patient relationship from the perspective of the underserved patient can be an important component of FQHCs efforts to encourage patient-valued interactional skills in their practitioners, thereby delivering the most effective care possible. In summary, our research provides greater [End Page 380] understanding of how medically underserved, low-income patients experience and understand their relationships with practitioners and how such an understanding can improve patient care.
Limitations of the study
While we repeatedly encountered similar patterns of response to the questions asked, our findings are preliminary and we were working with a relatively small, selected sample who responded to our mailing and/or clinic flyer. Self-selected patients may have a vested interest in this clinic and may not be representative of the entire patient population at this clinic, some of whom do not follow-up for care or may only be seen once. An additional limitation is that the healing skills identified here refer primarily to only two clinicians, who may not be representative of providers in other clinics caring for the underserved.
Interview data have the inherent limitation of dealing with the reported perceptions of those interviewed rather than with direct observations. Physician interviews and perspectives were not included as part of this study, and they could have revealed a different set of core themes. A longitudinal study with direct observation of the clinician-patient encounter at several FQHCs would serve to expand the generalizability of our pilot study. Still, we believe that our interviews point to a sound preliminary portrait of core relational skills from the medically underserved patient perspective.
Hippocrates, the father of Western medicine, reminds us that the art of healing emerges from a core motive of love for mankind.10 Twenty-six centuries later, Pellegrino reaffirms that the healing relationship remains central to the ethical practice of medicine.11 Relationships between physician and patient serve as the major driver of healing and continuity of care within the medically underserved patient population. Encouraging relational skills between patient and practitioner will provide long-term fulfillment for both parties and in so doing, reaffirm the medical profession as a healing art.
KATHLEEN M. NEMER is affiliated with the Division of Dermatology at the Washington University School of Medicine in St Louis, Missouri. LARRY R. CHURCHILL is affiliated with the Center for Biomedical Ethics & Society at Vanderbilt University Medical Center in Nashville, TN.
We thank The Arnold P. Gold Foundation for financial support. We are indebted to Mary Bufwack, PhD, Morgan McDonald, MD, and Jule West, MD for their assistance with this research. We also express our gratitude to the patients who so generously shared their stories of healing with us. This study was funded by a grant from The Arnold P. Gold Foundation to Dr. Nemer, entitled "The Arnold P. Gold Foundation Student Summer Fellowship."