I See You: Putting the Patient in the Center of the Healthcare Team

What Avatar Teaches Us About Using an Empathetic Approach to Treating Patients

In our blog post for this week, guest blogger Rebecca Bryan, DNP, adult nurse practitioner and Owner of Rebecca Bryan Consulting LLC, discusses the importance of understanding health concerns from the patient’s perspective.

My favorite moment in the movie Avatar is the love scene between protagonist Jake and Neytiri, a female Na’vi on the planet Pandora. Neytiri finds Jake’s Na’vi avatar unresponsive in the forest and realizes that his human form is in the mobile lab.

She jumps through the shattered window to find him unconscious and near death, suffocating in Pandora’s atmosphere. Desperately placing the oxygen mask on his face, she watches as Jake comes to life, looks Neytiri in the eyes, and says, “I see you.” Neytiri, who prior to this point, has only seen Jake in his avatar form, smiles and responds tenderly, “I see you.”

To appreciate the fullness of this moment, understand that humans were the enemy to the Na’vi, appropriating and destroying their sacred planet. Neytiri had fallen in love with Jake in his avatar form and was devastated when she learned he was human. This love scene was the moment when masks, paradoxically, removed, and soul saw soul, regardless of form.

Etic vs. Emic

That’s the shift in perspective from etic to emic.

That’s the paradigm that can put the patient in the center of the healthcare team.

I have been lecturing about, and helping organizations become, trauma-informed since 2013, but only recently discovered the vocabulary of “etic vs emic” as two ways to understand human behavior. This language was first coined by Kenneth Pike, a linguistic theoretician, in 1954, with etic pertaining to objective findings and emic pertaining to the meaning behind a finding.

With regard to human behavior, particularly through biomedical lens, an etic approach looks at a problem from the outside in. It relies on objective criteria to make a diagnosis, which is consistent with the traditional allopathic model.

Take cigarette smoking, for example. An etic intake would include the patient’s age of smoking onset and packs smoked per year, and the diagnosis would be ICD-10 code F17.200: Nicotine dependence, unspecified, uncomplicated.

An emic approach would respond to that ICD-10 label with a snort; is cigarette smoking ever uncomplicated?! Because an emic approach looks at things from the patient’s perspective – or, from the inside out, so to speak. An emic intake to evaluate cigarette smoking would include understanding what was happening when a patient started to smoke, the good things that smoking does for the patient (“it calms me down…it distracts me from my pain”), the barriers to quitting and the level of desire to quit. Asking patients questions like these gets to what I like to call “the root of why.” It gets to the bottom of things and can be transformative.

The Importance of Personal Experience

Trauma-informed practice calls for shifting from etic to emic, from “What’s wrong with you?” to “What happened to you?” The kind of trauma I am writing about here is relational, as compared to situational trauma like a car accident or a hurricane. While trauma can occur at any age, it is particularly impactful in childhood, and much of the science generating evidence-based practice stems from the Adverse Childhood Experiences (ACEs) studies.

ACEs are common, cumulative and strongly associated with most of the leading causes of death in the U.S., as well as health risk behaviors like smoking, disordered eating and substance abuse. ACEs impact brain development, immune and hormonal systems, and even genetic expression – across the entire lifespan.

Positive events like growing up in a loving home, living in a safe space, and getting good at something counteract ACEs, again across the entire lifespan. In other words, our lived experience becomes our biology.

Walk a Mile in the Patient’s Shoes

That’s why it’s important to understand health concerns from the patient’s perspective. Research from the Robert Wood Johnson Foundation found that 80 percent of health outcomes are the result of factors other than healthcare. Traumatic experiences and adverse community challenges play a big role in this.

When we take the time to step in the patient’s shoes, we have a better chance at understanding what is driving health outcomes – and how to intervene. After all, the patients are the experts of their own lives!

Affirming patients’ experiences and helping them connect the dots across their lives is healing and places them in the center of the healthcare team. It facilitates relationships that are empowering. It says, loud and clear, “I see you.”

Healthcare’s Future Lies in Transformation

Dr. Ezekiel Emanuel Offers a Compelling Argument

What will the future of healthcare look like? It’s an issue that public affairs commentators and policymakers across the political spectrum continue to debate.

In 1994, the late Dr. William Kissick, a professor emeritus at Wharton and the University of Pennsylvania Schools of Medicine and Nursing, identified three competing issues that the healthcare industry has struggled to address effectively. These issues – access, quality and cost containment – what Dr. Kissick called the “Iron Triangle of Healthcare,” continue to perplex policymakers and healthcare decision-makers to this day.

Recently one of the nation’s leading healthcare policy experts, Ezekiel J. Emanuel, MD, PhD, Vice Provost for Global Initiatives and Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, offered some important insights into where the national healthcare system is heading, and what it might mean for the Philadelphia region. In part he rejected the conventional notion that it is possible for health care systems to only achieve two of the three parts of the Iron Triangle.  He argued all three had to be achieved together. It was all part of a symposium on “Shaping Health Care” sponsored by the Chamber of Commerce for Greater Philadelphia and The Wistar Institute.

Lowering Costs

Finding a way to provide high-value care for all Americans – namely care marked by high quality and low costs with universal coverage – is a goal shared by providers and policymakers alike. According to Dr. Emanuel, “the only way to lower healthcare costs is to change the delivery system to ensure high quality care.”

Traditionally, one of the most significant contributors to the high cost of healthcare has been the combination of providing unnecessary services and inefficiency in how necessary healthcare services are delivered.   One example is standardization of practices so everyone – from physician to nurse to medical assistant – handles the same complaint according to agreed-upon guidelines. For instance, physicians in one local oncology practice were treating mouth sores after chemotherapy in different ways.  The practice standardized to one optimal practice that everyone followed.

Another common example is the fact that some health care groups allow their physicians to control their schedules, leading to double-booking, limited hours, and an inability to work around no-shows or walk-ins.

Creating Efficiencies

Dr. Emanuel identified 12 transformational practices that he says can help physician practices and healthcare organizations improve the quality and cost of care they provide to their patients:

  1. Scheduling
  2. Registration & rooming
  3. Shared decision-making
  4. Performance measurement
  5. Standardization
  6. Chronic Care management
  7. Site of service
  8. De-institutionalization
  9. Behavioral health management
  10. Hospice
  11. Community interventions
  12. Lifestyle interventions

Many of these practices will improve  efficiencies – lowering per unit costs by finding ways to improve a healthcare process or system, or working in collaboration with partners in a way that benefits all involved parties. Others will eliminate unnecessary and undesired services – lowering total costs.

Even seemingly minor changes can show major results. For example, streamlining scheduling practices can offer several benefits: 1) It allows practices to accommodate walk-ins without long wait times instead of sending them to the more expensive emergency room; 2) it increases provider efficiency, as physicians no longer double book or adjust schedules; and 3) it decreases the amount of time wasted due to missed appointments.

Similarly, Dr. Emanuel noted that transformational organizations are providing more services, such as palliative care, in the home. This care is initiated well before a patient becomes terminally ill and is ready for hospice. This approach elicits patients’ preferences for life-sustaining treatments, such as respirators, ICU admission, or dialysis, and tries to keep them at home for the last year of life. It also makes transitioning to hospice in the last weeks of life less abrupt. All these changes lead to care that is both less costly and more in accord with patients’ wishes.

Performance Measures

The pathway for healthcare providers to truly transform also involves the use of real-time performance measures, Dr. Emanuel said. Standardizing clinical practices and treatment procedures based on measurable qualitative data is vital to reducing costs and improving outcomes.

While some physicians may insist that “their” way is the best, organizations need to convince them to adhere to guideline-driven standards. Paradoxically, one effective way to persuade doctors to adapt to standardized measures is to task them with developing the standardized practices and encourage adherence through financial incentives.

At the same time, organizations need to improve their risk adjustment skills in order to continue to improve their healthcare management practices. Risk adjustment is defined as “a statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their healthcare outcomes or healthcare costs.”  This ensures physicians who see sicker patients are not penalized.

The ultimate goal is to transform the U.S. healthcare structure into a truly patient-centered, efficient and cost-effective system.  Dr. Emanuel notes that the Philadelphia region is a leading example of how organizations are learning to work together to achieve those goals. He said he is confident that by 2030, the entire world will be looking at the United States to understand how healthcare transformation is accomplished.