Enthusiasm for patient centricity has led to many good things. For example, the increasing use of patient reported outcome measures (PROs) has improved drug development by capturing patients’ experiences in clinical trials. And in hospitals and physician practices, many teams now use shared decision-making to arm patients with clinical evidence, so they can make informed choices about their treatment.
Yet, by continuing to focus on the patients’ disease states rather than lives lived within complex family, work, and social contexts, our healthcare system sets patients up to fail.
Instead of a patient-centric model, a new paradigm my colleagues and I call social centricity may lead to a more resilient healthcare ecosystem and greater treatment compliance on the part of patients. Under this paradigm, the medical team takes stock of the patient’s social context to aid diagnosis, increase patient engagement, and enhance prediction of treatment outcomes.
A few examples may clarify what we mean by these terms. In a patient-centric environment, a medical team may steer a woman toward a life-disrupting surgical procedure because it’s the most efficient path given her disease state. The team is unaware that a sick child or an aging parent in the patient’s home requires her constant attention. Conflicted and confused, she postpones treatment of any sort, and her doctors are unable to sway her. The patient’s social context remains muzzled, unable to testify on her behalf.
Similarly, the physician or pharmacist may reprimand a patient who fails to renew a prescription, as though he is willfully non-adherent. The medical team can’t see—because they haven’t asked—that the patient is conserving scarce funds for a family member with a more urgent condition. The team, including the payers, clings to the image of a linear patient journey, with no missed treatments. Life, however, is messy. It’s a continuous decision process, buffeted by events and hard to fathom under a disease-based, patient-centric model.
Ethnographic Research
Behavioral Insights, part of inVentiv Health Communications, recently completed a two-year ethnographic study of 30 American families to examine the social forces impacting individual health behavior. One key finding was that patients value a holistic approach to healthcare; they want a trusted physician at the center of care who treats them as a whole person, not a medical condition—someone who will listen, acknowledge their real-life challenges and speak in terms they can understand. This idea is at the heart of the patient-centric medical home, which has gained currency in recent years. The trouble is, even in the medical-home framework, providers may not be posing the right questions or asking in the most effective way.
Empathy is at the heart of a positive doctor-patient relationship—and communication is the vehicle to get there. But our study found that when it comes to quality of care, participants were least satisfied with their communication with physicians. Their disappointment isn’t surprising, as research shows the average office visit lasts just over 10 minutes. That’s hardly enough time to probe the patient’s social context or establish any emotional authenticity. Perhaps that’s one reason the majority of information provided to the patient by healthcare providers is either forgotten immediately or retained incorrectly by patients.
These factors adversely affect patients’ healthcare habits and behaviors. The American Heart Association estimates that three out of four patients aren’t taking their current medications as directed, and one study found that nearly one-third of patients never fill new prescriptions from their doctor. Even when a patient “agrees” to take a prescribed medication, he or she is often ill-prepared to take action or compliance takes a back seat to the rigors of daily life. And when healthy patterns do emerge, such as monitoring blood glucose, the behavior may be short-lived because of competing social and family responsibilities.
Social Centricity in Action
There are several ways in which hospitals, physician practices, pharmacists, pharma companies, and other stakeholders can promote a more social-centric healthcare model. One idea is to enhance the most important touchpoints for patients: The annual checkup, and the doctor’s office where a patient first describes a health issue. In either setting, the initial visit might include a short survey—perhaps just four or five questions—to illuminate social circumstances relevant to the diagnosis, or the treatment recommendation, or both. The queries would cover life-altering events such as a recent death or divorce in the family, loss of work, starting a new job, and caregiving responsibilities for a sick child or aging parent.
The survey wouldn’t be a standard clipboard-cum-checklist routine. Rather, it would involve a face-to-face conversation with a doctor, nurse, or administrator who is able to communicate genuine concern for the patient’s social context. This may sound like a burdensome add-on to a primary care workup that is already a strain for busy doctors. Yet, embedding such an interview or survey in primary care wouldn’t be unprecedented. Since 2002, the U.S. Preventive Services Task Force has recommended that primary care doctors screen patients for depression using similar questions.
In many practices, patients also are asked their preferences regarding shared decision making—a process that involves even more elaborate, face-to-face interactions between patients and practitioners than what we have proposed. Weaving a social-centric routine into this existing fabric would be practical as well as productive. What might practitioners learn from such an exercise? To give just one example, they might find out that a patient’s concerns about drug side effects are linked to family responsibilities at particular times of day. A mother may explain that she can’t be battling nausea while preparing her children for school, but she would be willing to take the same medicine at night and put up with side effects after the kids are in bed.
Better Medical Messaging
Taking a social-centric view might also help us navigate complicated straits related to medical language and messages. In today’s healthcare settings, patients are bombarded by instructions and reminders from care providers, payers, manufacturers, and marketers with different specialties and agendas. In the familiar patient-centric model, each is doing his job as long as the focus is on the patient’s disease state.
In contrast, the social-centric model calls for a new type of cross-stakeholder collaboration. Marketers, regardless of the brand, would soon learn that if they can help the patient with any piece of the puzzle, including issues in the family and work context, they will be promoting the patient’s health and perhaps earning his or her trust. Under this paradigm, the most effective way for a pharma company to earn the loyalty of a physician and patient may not be to distribute an informational brochure. Instead, it might be to fund and develop the social questionnaire used in the physician’s office, as well as the training program—neither of which would contain any reference to the company’s brands. Acknowledgement, if any, would come in the form of tasteful, italicized print at the bottom of the survey, similar to the “thanks to our sponsors” messages used on public broadcast programs.
Adverse reaction to brand promotion isn’t the only sensitivity stakeholders must worry about in a social-centric model. All public communications, including advertisements and marketing brochures, are designed to engage populations, not individuals. With the best of intentions, marketers use phrases such as “patient journey” that stamp individuals into a mold. This under-represents the uniqueness of their experiences, and perhaps downplays the chance that they’ll have a better-than-average outcome.
Kristin Ainsworth, Vice President of Marketing for Tesaro, relayed a particularly vivid anecdote along these lines when we discussed social-centricity at a recent industry roundtable. As part of a research program conducted by Tesaro, she had a chance to hear how women who are bravely battling cancer react to the use of one-size-fits-all medical language. One patient told her: “Please don’t give me a ‘welcome kit’ when I take your drug, because I don’t want to be ‘welcomed’ to recurrent ovarian cancer. And don’t talk about my cancer as a ‘journey’ because then you’re telling me there’s an end. I get that, and it’s probably true, but I don’t want to be reminded.”
Understanding the social context for today’s health consumers can help us understand patients as unique individuals and address them in more meaningful language. It may also help us discover new ways to encourage patients toward healthy behaviors while still managing the family’s multiple, shifting priorities. A social-centric approach can enable stakeholders to begin coordinating and connecting messages and action in a way that enhances trust. And there is a chance that trust will extend to the brands that support the larger, social-centric healthcare experiment, as I have described. Social centricity challenges us to leverage all the factors influencing behavior—the family, the healthcare system, society, and language—toward more effective patient engagement.
References:
1. Behavioral Insights, “Health in America.” 2016.
2. Verilogue. “Physician-patient Communication: By the Numbers.” http://visual.ly/physician-patient-communication-numbers. March 2, 2012. Accessed November 9, 2016.
3. Sandler DA, Mitchell JR, Fellows A, Garner ST. “Is an information booklet for patients leaving hospital helpful and useful?” BMJ. 1989;298:870-874.
4. American Heart Association. “Medication Adherence – Taking Your Meds as Directed.” September 2, 2016. http://www.heart.org/HEARTORG/Conditions/More/ConsumerHealthCare/Medication-Adherence—Taking-Your-Meds-as-Directed_UCM_453329_Article.jsp#.V9bspldLV4E. Accessed November 10, 2016.
5. Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. “The incidence and determinants of primary nonadherence with prescribed medication in primary care: a cohort study.” Ann Intern Med. 2014;160(7):441-450.
