Internal Medicine Residents’ Experience Performing Routine Assessment of What Matters Most to Patients Upon Hospital Admission

Abstract

Problem

Failure to elicit patients’ values, goals, and priorities can result in missed opportunities to provide patient-centered care. Little is known about resident physicians’ direct experience of eliciting patients’ values, goals, and priorities and integrating them into routine hospital care.

Intervention

In 2017, we asked resident physicians on general internal medicine wards rotations to elicit and document a “Personal History” from patients upon hospital admission, in addition to a traditional social history. We defined a Personal History as documenting “what matters most to the patient and why.” The purpose of the Personal History was to understand and consider patients’ values, goals, and priorities. We then conducted qualitative interviews of the resident physicians to understand their experiences eliciting and integrating patients’ values, goals, and priorities in routine hospital care.

Context

We performed this exploratory intervention at a large high-volume urban hospital. Two teams from general medicine wards participated in the Personal History intervention. We conducted voluntary interviews of eligible residents (n = 14/15; 93%) about their experience after they completed their general wards rotations. Using the coproduction model, our aim was to explore how patients’ self-expertise can be combined with physicians’ medical expertise to achieve patient-centered care.

Impact

Four major themes were identified: 1) Taking a Personal History had value, and eliciting patients’ self-expertise had the potential to change medical decision making, 2) Situational and relational factors created barriers to obtaining a Personal History, 3) Variability in buy-in with the proposed intervention affected effort, and 4) Meaningful Personal History taking could be an adaptive and longitudinal process. Perceived benefits included improved rapport with patients, helpful for patients with complex medical history, and improved physician-patient communication. Barriers included patient distress, lack of rapport, and responses from patients which did not add new insights. Accountability from attending physicians affected resident effort. Suggested future applications were for patients with serious illness, integration into electronic health records, and skills taught in medical education.

Lessons Learned

Resident physicians had generally positive views of eliciting a Personal History from patients upon admission to the hospital. Overall, many residents conveyed the perceived ability to elicit and consider patient’s values, goals, and priorities in certain situations (e.g., patient not in distress, adequate rapport, lack of competing priorities such as medical emergencies or overwhelming workloads). External factors, such as electronic health record design and accountability from attending physicians, may further promote residents’ efforts to routinely incorporate patients’ values, goals, and priorities in clinical care. Increasing familiarity among both resident physicians and patients in routinely discussing patients’ values, goals, and priorities may facilitate patient-centered practice.

Keywords:

• resident physicians
• patient-centered care
• coproduction
• values
• goals

Acknowledgments

Jeffrey Lankowsky, MD contributed to conceptualizing the PH project and consulted on developing the PH pocket card. Kelly Michelson, MD, MPH contributed critical review of an earlier version of this manuscript. Julie Johnson, MSPH, PhD contributed to the presentation of our methods and frameworks used.

Disclosure statement

The authors have no conflicts of interest.

Ethical approval

Ethical approval has been waived by the IRB at The George Washington University.

Prior or related presentations and publications

Burstein DS, Chretien K, Aivaz M, Kaboff A, Puchalski CM, Tuck M. Assessing patients’ values and goals upon admission to the general medicine internal wards services: Experiences & Applications. Oral Presentation. The George Washington University Hospital Innovation Day. Washington, D.C., December 6, 2017.

Burstein DS, Chretien K, Aivaz M, Kaboff A, Puchalski CM, Tuck M. Routine assessment of patients’ values and goals upon admission to the general medicine internal wards services: Experiences & Applications. Poster. Society of General Internal Medicine Annual Meeting, Denver, CO. April 13, 2018.

Burstein DS, Chretien K, Aivaz M, Kaboff A, Puchalski CM, Tuck M. Routine assessment of patients’ values and goals upon admission to the general medicine internal wards services: Experiences & Applications. Poster. AAMC Continuum Connections, Orlando, FL. April 28, 2018.

Additional information

Funding

This work was funded by the GW Center for Hospital Innovation and Policy Research (CHIPR) through the GW Hospital Innovation Award.