Aligning care with the patient

Patient-centered, patient-centered medicine respects and integrates individual preferences, values, or needs and has grown in importance in patient care in recent years. In clinical care, it is therefore important that we enable our patients to have a say in decisions regarding their treatments, or at least to involve them in the decision-making process.

Patient-centered medicine respects and integrates individual preferences, values and needs [1–3] and has become increasingly important in patient care in recent years. In clinical care, it is therefore important that we enable our patients to have a say in decisions regarding their treatments, or at least involve them in the decision-making process [3].

During a hospitalization, daily ward rounds are the foundation of patient-centered medicine. Numerous studies emphasize the importance of rounds and show that they can contribute to better quality of care, patient safety, and improved patient outcomes [4–6]. As a meeting between patients, physicians and nurses, they offer the treatment team the opportunity to establish a relationship with the patient, to inform them about their illness, to discuss ongoing therapy or to jointly evaluate further diagnostic steps [5,7].

Decisions regarding the treatment of a patient are often made during the chief physician’s rounds. During a chief resident visit, residents usually present their patients’ medical histories to the attending treatment team. The presentation can take place either directly at the patient’s bedside or in front of the door. Both modes are common practice in clinical care.

The interdisciplinary discussion of the patient’s history directly at the patient’s bedside enables the patient to actively participate in the treatment. In addition, the patient can gain insight into their medical history through the case discussion. However, these discussions, at least from the physician’s side, are usually of an academic nature and contain medical terminology, which patients are usually not familiar with. This can lead to patients not understanding things correctly or even misunderstanding them. Also, the complexity and volume of medical information, as well as the sharing of sensitive information at the bedside, could lead to confusion, discomfort, and misunderstanding, and possibly affect patient*s knowledge [8–10]. Patient knowledge and understanding, in turn, are considered important predictors of successful treatment adherence [11–13].

If the case presentation and academic discussions do not take place directly at the patient’s bedside, a “patient-friendly” summary can be explained to the patient*s afterwards to inform them of what was discussed. Potential disadvantages of this type of visit, however, are that patients may be less involved, decision-making may be less transparent, and the care team may spend less time with the patient.

To date, few studies have examined whether patient presentation directly at the bedside during rounds has a positive or negative impact on patient-centered outcomes such as understanding, satisfaction, or perceived quality of care.

A 2019 meta-analysis that included five randomized trials failed to show a difference in patient satisfaction or patient knowledge [14]. A similar conclusion was reached in an American systematic review that compared bedside patient presentations with other types of patient presentations in internal medicine, surgical, and intensive care units and found no evidence of an effect on patient-centered outcomes [15].

However, the included studies in both papers were of low to moderate quality, showed marked heterogeneity in terms of reported outcomes, and had recruited only small patient populations. Since the evidence to date did not allow for any recommendations, the question therefore arose in clinical practice whether it is helpful during rounds to discuss all diagnostic considerations or therapeutic aspects directly at the patient’s bedside or whether this approach is more likely to cause confusion or even mistrust among our patients.

The lack of evidence led hospitals to vary the location of patient presentations during rounds based on the preference of the individuals involved [16–18].

Case presentation at the bedside versus at the door – a randomized multicenter trial and its clinical relevance.

The BEDSIDE-OUTSIDE Trial, a randomized multicenter study from Switzerland, addressed the question of how the type of patient presentation (bedside vs. outside the patient’s room) affects patient understanding as well as their perceived quality of care [19].

The BEDSIDE-OUTSIDE study was conducted at three Swiss teaching hospitals and its results were published in the journal Annals of Internal Medicine [19]. For this study, consecutive patients were included at hospital admission who had their first chief resident visit. Patients with cognitive impairment, hearing impairment, patients who could not understand the local language(s), and patients who had been previously enrolled in the study or who did not provide informed consent were excluded. Patients were then randomized to the “bedside group” (patient presentation at the bedside) or the “outside group” (patient presentation outside the patient’s room).

In the bedside group, case presentations and or academic discussions took place without prior discussion at the door, right at the patient’s bedside. In the outside group, patient case presentations and meetings took place mainly in the hallway without the patient’s presence. Afterwards, the treatment team entered the room and gave the patient*s a brief summary of the medical situation, and conducted the rest of the visit at the patient’s bedside.

The BEDSIDE-OUTSIDE Trial is the first large multicenter randomized trial to demonstrate that bedside visits do not negatively impact patient knowledge. Patients in the bedside group had similar subjective knowledge as patients randomized to the outside group (mean, ± SD) (79.5 ± 21.6 vs. 79.4 ± 19.8, adjusted difference 0.09 (95% CI -2.58 to 2.76; p=0.95) (Table 1). Objective knowledge, which was rated by the study team, also did not differ.

In terms of time efficiency, patient presentations at the bedside were found to be more time efficient than patient presentations outside the room (mean, ± SD) (11.9 ± 4.9 vs. 14.1 ± 5.7 minutes, adjusted difference -2.3 minutes (95% CI -3.0 to -1.6; p<0.001). Bedside visits were thus on average 2.3 minutes shorter, which may well be relevant for the total visit duration.

Nevertheless, direct doctor-patient contact was longer in the bedside group. In addition, patients in the bedside group estimated that their treating physicians spent about 15 minutes more per day on their treatment. Although the difference may seem small at first glance, this result may have important socioeconomic effects. Assuming a treatment team visits 20 patients*, the time difference between bedside and outside visits can add up to about 45 minutes. The core task of inpatient treatment is to provide patients with the best possible care. But especially in times of DRG and pandemic, resources are often limited and the workload high. Bedside visits seem to be a way to save time without negatively impacting the knowledge of our patients.

On the downside, patients randomized to the bedside group were significantly more likely to report being confused by the medical terminology (adjusted risk ratio 7.58 (3.67-11.49); p<0.001) or even to have been confused by the academic discussion (adjusted risk ratio 2.89 (0.30-5.49); p=0.029). These findings are consistent with results from a 1997 American study published in the New England Journal of Medicine. [20] Lehmann et al. found that there seems to be an association between the patients’ level of education and their confusion or uncertainty. Patients with a low level of health literacy in particular have difficulty understanding medical terms or contexts. A 2019–2021 Swiss survey showed that about half of the population has low health literacy. Academic discussions involving the use of medical terminology during bedside visits could cause confusion and uncertainty for these patients* in particular. A few years ago, the British Royal College of General Practitioners called for doctors to speak slowly and avoid medical jargon [21]. Even terms such as “chronic” or “positive outcomes” are not familiar to many patients and their meaning is therefore not clear. A lack of understanding of their own illness and its treatment can in turn lead to patients being admitted to hospital in an emergency more frequently or suffering serious health problems [22]. Therefore, it is elementary that we pay attention to patient-friendly expression and avoid technical terms, especially during bedside visits.

Patient-centered communication can lead to a better understanding of the patient’s health situation and thus facilitate their involvement in decision-making during rounds.

A secondary analysis of the BEDSIDE-OUTSIDE Trial showed that about 80% of patients* want to be involved in medical decisions or even make their own decisions [23]. Patients’ preference to be involved in decisions or not was an important predictor of perceived quality of care in the study. Patients who wanted to make their own decisions were significantly less satisfied with their hospital stay and had less trust in their doctors and nurses. Therefore, it is advantageous here – especially for important decisions – to work out and take into account the patient’s preference.

In addition, the BEDSIDE-OUTSIDE Trial found that sensitive issues, such as psychiatric comorbidities, lack of treatment adherence, or medical ambiguity, were significantly less likely to be addressed during bedside visits (adjusted odds ratio 0.72 (0.54-0.97); p=0.033). One might assume that during bedside visits, sensitive topics were not discussed in front of other co-patients for confidentiality reasons. However, the study found that the treatment team did not address sensitive issues even during debriefings following the visit, thus completely ignoring them. Older studies show, however, that sensitive topics such as psychological well-being or subjective illness experience are regarded by patients as priority topics of a visit and should therefore be addressed [24].

In another secondary analysis of the BEDSIDE-OUTSIDE trial, the authors* examined interprofessional communication during rounds and physician and nurse preference with regard to the type of patient presentations [25]. It was found that nurses preferred bedside visits because they felt more integrated and valued and had the impression that they could better voice their own concerns. One reason could be that Outside visits tend to be more academic and place a greater emphasis on teaching residents than on practical aspects of patient care. As a result, nurses may be less involved here, while more involved in patient-centered discussions at the bedside.

Physicians, on the other hand, favored outside visits because they felt less uncomfortable discussing sensitive topics. Communication techniques that facilitate the discussion of sensitive topics could therefore increase the confidence in dealing with them and thus the satisfaction of physicians with bedside visits.

How can communication be optimized?

In the run-up, it was also discussed on the medical-political level that the lack of communicative skills on the part of physicians is mainly due to a “deficient study program, which is too somatic, fact- and performance-oriented” [26].

In numerous European countries, the course of study “human medicine” has been reformed in recent years as part of the Bologna Process. The medical faculty of the University of Basel took advantage of the change to a Bachelor/Master structure to implement a longitudinal curriculum “social and communication skills” [27]. From the first bachelor’s to the first master’s year, communication skills are taught longitudinally in conjunction with clinical content. These include patient-centered (space-opening) techniques such as ESC (Waiting, Repeating, Mirroring, Summarizing) or addressing emotions using the NURSE model (Naming emotion, Understanding, Respecting, Supporting, Exploring) as well as physician-centered techniques such as explicitly structuring the conversation. In addition, the communication techniques “Shared decision-making”, “Motivational Interviewing” and “Breaking bad news” are taught in lectures and practical workshops. The goal of the curriculum is that patients are not only experienced as somatic “disease cases”, but students also understand the meaning of the disease for the individual and learn to address emotional issues and aspects. Numerous studies in the field of undergraduate education show that communication skills can be taught and the skills of future physicians can be improved [28].

The importance of communication in medicine was underscored by a landmark status report on communication in the UK healthcare system supported by the Marie Curie Foundation [29]. The report stat that deficient communication in healthcare exerts a negative impact on medical treatment quality and patient outcomes. In addition, the authors found that poor communication skills waste resources, the damage of which the authors estimated at £1 billion/year in the UK. Furthermore, communicative skills are not only able to increase the satisfaction of our patients, but also to reduce the burnout rate of medical staff.

Communicative skills are considered by many professional societies to be a core medical competence, which has led to the fact that teaching content on communicative competencies is now part of the obligatory catalog of subjects at medical universities in Switzerland. Physicians in advanced training in hematology/oncology must complete several days of communication training in order to obtain their specialist title, as communication and addressing the psychosocial needs of patients is considered an elementary component of high-quality care for cancer patients [30]. In contrast, continuing education for other health care workers is often less clearly circumscribed.

Regular communication training for all medical staff, which takes up typical examples from everyday clinical practice (such as conversations during a ward round), could make an important contribution to reducing misunderstandings and increasing patient satisfaction. Further evidence is also needed here in clinically relevant communication-challenging areas to incorporate this appropriately into teaching and training. With regard to visit communication, a particular focus should be placed on more patient-centered communication during visits in order to avoid confusion and uncertainty and to give patients space to talk about topics and questions that are relevant to them. On the part of the treatment team, it is also important to develop techniques that make it easier to address sensitive issues professionally without unsettling or snubbing patients, especially during bedside visits.

Take-Home Messages

• Rounds are an elemental foundation of patient-centered care.
• Bedside patient presentations are more time effective, but can cause more confusion and uncertainty.
• Communication skills training can contribute to improved patient care, making it a core medical skill that can be learned.

Literature:

1. Daschle T, Domenici P, Frist W, et al.: Prescription for patient-centered care and cost containment. N Engl J Med 2013; 369(5): 471–474; doi: 10.1056/NEJMsb1306639.
2. Stewart M: Towards a global definition of patient centred care. BMJ 2001; 322(7284): 444–445; doi: 10.1136/bmj.322.7284.444.
3. Bardes CL: Defining «patient-centered medicine». N Engl J Med 2012; 366(9): 782–783; doi: 10.1056/NEJMp1200070.
4. Zwarenstein M, Goldman J, Reeves S: Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009; 3: CD000072; doi: 10.1002/14651858.CD000072.pub2.
5. O’Mahony S, Mazur E, Charney P, et al.: Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med 2007; 22(8): 1073–1079M; doi: 10.1007/s11606-007-0225-1.
6. Pucher PH, Aggarwal R, Darzi A: Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014; 259(2): 222-226; doi: 10.1097/SLA.0000000000000376.
7. Royal College of Physicians RCoN. Ward rounds in medicine: principles for best practice. 2015 (London: RCP, 2012.).
8. Chapple A, Campion P, May C: Clinical terminology: anxiety and confusion among families undergoing genetic counseling. Patient education and counseling 1997; 32(1–2): 81–91.
9. Hadlow J, Pitts M: The understanding of common health terms by doctors, nurses and patients. Soc Sci Med 1991; 32(2): 193–196.
10. Chapman K, Abraham C, Jenkins V, et al.: Lay understanding of terms used in cancer consultations. Psycho-oncology 2003; 12(6): 557–566; doi: 10.1002/pon.673.
11. DiMatteo MR, Giordani PJ, Lepper HS, et al.: Patient adherence and medical treatment outcomes: a meta-analysis. Med Care 2002; 40(9): 794–811; doi: 10.1097/00005650-200209000-00009.
12. Conn VS, Ruppar TM, Enriquez M, et al.: Patient-Centered Outcomes of Medication Adherence Interventions: Systematic Review and Meta-Analysis. Value Health 2016; 19(2): 277–285; doi: 10.1016/j.jval.2015.12.001.
13. Clarke C, Friedman SM, Shi K, et al.: Emergency department discharge instructions comprehension and compliance study. CJEM 2005; 7(1): 5–11; doi: 10.1017/s1481803500012860.
14. Gamp M, Becker C, Tondorf T, et al.: Effect of Bedside vs. Non-bedside Patient Case Presentation During Ward Rounds: a Systematic Review and Meta-analysis. J Gen Intern Med 2019; 34(3): 447–457; doi: 10.1007/s11606-018-4714-1.
15. Ratelle JT, Sawatsky AP, Kashiwagi DT, et al.: Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf 2019; 28(4): 317–326; doi: 10.1136/bmjqs-2017-007778.
16. Gonzalo JD, Chuang CH, Huang G, et al.: The return of bedside rounds: an educational intervention. J Gen Intern Med 2010; 25(8): 792-798; doi: 10.1007/s11606-010-1344-7.
17. Stickrath C, Noble M, Prochazka A, et al.: Attending rounds in the current era: what is and is not happening. JAMA Intern Med 2013; 173(12): 1084–1089; doi: 10.1001/jamainternmed.2013.6041.
18. Peters M, Ten Cate O: Bedside teaching in medical education: a literature review. Perspect Med Educ 2014; 3(2): 76–88; doi: 10.1007/s40037-013-0083-y.
19. Becker C, Gamp M, Schuetz P, et al.: Effect of Bedside Compared With Outside the Room Patient Case Presentation on Patients’ Knowledge About Their Medical Care: A Randomized, Controlled, Multicenter Trial. Ann Intern Med 2021; 174(9): 1282–1292; doi: 10.7326/M21-0909.
20. Lehmann LS, Brancati FL, Chen MC, et al.: The effect of bedside case presentations on patients’ perceptions of their medical care. N Engl J Med 1997; 336(16): 1150–1155; doi: 10.1056/NEJM199704173361606.
21. Rimmer A: Doctors must avoid jargon when talking to patients, royal college says. BMJ 2014; 348: g4131.
22. Berkman ND, Sheridan SL, Donahue KE, et al: Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011; 155(2): 97-107; doi: 10.7326/0003-4819-155-2-201107190-00005.
23. Becker C, Gross S, Gamp M, et al.: Patients’ Preference for Participation in Medical Decision-Making: Secondary Analysis of the BEDSIDE-OUTSIDE Trial. J Gen Intern Med 2022; doi: 10.1007/s11606-022-07775-z.
24. Köhle K, Raspe H: Das Gespräch während der ärztlichen Visite. München-Wien-Baltimore: Urban & Schwarzenberg 1982.
25. Gross S, Beck K, Becker C, et al.: Perception of physicians and nursing staff members regarding outside versus bedside ward rounds: ancillary analysis of the randomised BEDSIDE-OUTSIDE trial. Swiss Med Wkly 2022; 152: w30112; doi: 10.4414/smw.2022.w30112.
26. Geisler L: Kommunikation bei der Patientenvisite – Ausdruck unserer ethischen Werthaltung 2003 [Available from: www.linus-geisler.de/vortraege/0314patientenvisite.html, accessed October 5, 2022].
27. Kiessling C, Langewitz W: The longitudinal curriculum «social and communicative competencies» within Bologna-reformed undergraduate medical education in Basel. GMS Z Med Ausbild 2013; 30(3): Doc31; doi: 10.3205/zma000874.
28. Smith S, Hanson JL, Tewksbury LR, et al.: Teaching patient communication skills to medical students: a review of randomized controlled trials. Eval Health Prof 2007; 30(1): 3–21; doi: 10.1177/0163278706297333.
29. McDonald A: A long and winding road: improving communication with patients in the NHS. London, 2016.
30. Adler NE, Page AEK, eds. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington (DC) 2008.

HAUSARZT PRAXIS 2022; 17(11): 10–14