Integrative exploration of the primary care interaction: tensions and ideals in patient-centered care

Rahmer, Brian M.
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University of Delaware
Communication matters in medical encounters. Health care providers, patients, researchers and policy makers are well aware that good communication is the basis of an effective relationship between care providers and patients. In an era of dynamic health care reform, institutional strategies emphasize re-organizing health care system components and incentive structures around patient-centered care as means to improve health and lower cost. However, examination of the complexity of the association between elements of patient-centered communication and macro (policy), meso (institution), and micro (interaction) influences on such care is still relatively novel. This exploratory research explains how and why dimensions related to patient-provider communication are critical to understanding and optimizing political, institutional, and individual goals of health care reform efforts. I explored patient-provider interactions within primary care practice using an integrative social analysis framework with a primary objective of building on the theoretical understanding of how individual, organizational and political goals may produce tensions in patient-centered care. These tensions were highlighted as potential points of innovation. Results generated by the proof-of-concept methodology used in this study reaffirm the need to account for both micro and macro level influences linking patient-provider communication to broad health outcomes. Patient-centered care was critically interpreted using a multi-level approach including interaction analysis of real conversations between primary care physicians and diabetic patients as well as a novel video-elicitation method to account for context within a cultural-historical framework. Theoretical contributions include the integration of patient-centered communication patterns within primary care interactions with the elicitation of barriers and facilitators of patient-centered care. This analysis was used to recognize tensions, contradictions and ideals in patient-centered care that can be used in critical analysis of healthy policy, health system strategic planning, and practice level reforms. What does it mean to be "patient-centered" and what does this then mean about ways of improving health care systems, communication and translation of knowledge? Putting a primacy on understanding the interaction between the patient and the provider may indeed be the only way in which the quality of health care delivery is improved; especially in a reform-oriented care delivery system which emphasizes and incentivizes patient-centeredness.