Why It Matters
Photo by Jenny Ueberberg | Unsplash
It’s not something people like to admit.
Dedicated health care providers don’t roll their eyes when they hear new ideas about how to make care more person- and family-centered. Many of us, however, may silently cringe and worry about how much time it’s going to take. What if getting to know your patients on a more personal level opens up a can of worms? Problems could arise that you can’t solve. One lengthy exchange could put you behind for the rest of the day.
Maybe that’s how you or your colleagues react when you hear people at IHI talk about shifting from asking patients, “What’s the matter?” to asking, “What matters to you?” Maybe this change seems too simplistic to make much difference.
We’re here to tell you that it dramatically changes patient care for the better. We were privileged to serve a 74-year-old gentleman who showed us how.
The ROMEO Club
Our patient, who we’ll call Mr. Smith, was a widower who lived alone with no family in the area. He had stage IV heart failure. In the past, we would just have asked him, “What’s the matter?” We would have learned that he had gained fluid and weight, which was aggravating his heart condition. Presented with a clinical problem, we would have provided a clinical response: prescribing a diuretic and a low-sodium diet.
However, when we asked Mr. Smith what’s most important to him, we learned that his first priority was to attend the ROMEO Club, which stands for Retired Old Men Eating Out. Once a week, he and his ROMEO Club buddies would go out to eat, and Mr. Smith would have his favorite meal — a hamburger and french fries. His favorite meal was, of course, loaded with sodium. Each week, he retained fluid and gained weight.
We could have labeled him non-compliant for eating these meals. Instead, we understood that eating out with his friends was what mattered to Mr. Smith. So we worked with him on how to adjust his diet the day before, the morning of, and the evening after ROMEO Club so he did not end up with excess sodium and fluid gain.
What we learned about Mr. Smith followed him throughout the whole continuum of care. We first took care of Mr. Smith in home health. But when his disease eventually progressed, we were able to address his needs when he transitioned to hospice care, where the team arranged for the ROMEO Club to come to Mr. Smith’s home and bring him a meal, even when he could only take a bite of it. After Mr. Smith died, we offered bereavement support to the members of the ROMEO Club because they were his extended family.
Convincing the Skeptics
There is no skeptic like a nurse who has been practicing for more than 30 years. They’ve seen it all. They’re understandably suspicious of anything that might be a flavor-of-the-month gimmick.
When we first introduced the concept of “What matters to you?” to one nurse in particular — we’ll call her Julie — she crossed her arms and wore a look on her face that said, “This isn’t going to make any difference.”
But we’ve learned from IHI’s quality improvement methods that you can build a cascade of success by starting with a small test of change. Even the most adamant doubters are willing to try a new idea once — if only to prove you wrong!
We invited our clinicians — including Julie — to test asking “What matters to you?” with one or two patients. Julie was working with a woman in her eighties, and she decided she would try it during their next visit. She said to her patient, “Before we get started on my list of other questions, I want to hear what’s important to you. What would you like to make sure we address today?”
The patient leaned forward and stared at her for what seemed like a long time. Then, all of a sudden, she burst into tears. Surprised, Julie said, “Oh, my goodness! I am so sorry. Are you alright? I didn’t mean to upset you."
The woman finally explained that the question initially overwhelmed her. She said, “In 84 years, I have never had a single health care provider ask me that question.” It changed the entire interaction.
During our next weekly multidisciplinary case conference, Julie shared what happened with the group. She had become a believer. Given her initial skepticism, her complete turnaround was particularly profound.
A Guided Partnership with Patients
We ask patients to do (or not do) all kinds of things. But do we always take the time to help them understand how these actions or medications are going to help them reach their goals? Are we helping connect the dots to what matters most to them?
When you ask a patient, “What’s the matter?” you elicit what’s physically wrong with them — the reason they’re seeking health care services. You get an answer that makes you as the clinician think, “What am I going to do to fix it?” It becomes an interaction that a clinician directs.
On the other hand, when you ask, “What matters the most to you?” the patient talks about their life. You learn what they truly care about. Then, you can offer your clinical expertise and knowledge, guided by the individual’s values, needs, and preferences.
We think of the clinical relationship as a guided partnership in which it’s important to start by identifying the end goal. It’s like seeing someone locate a destination on a map, and helping them determine the best route to follow to get there. You invite the patient to be the driver, and you’re the co-pilot.
What you hear when you ask this simple question might surprise you. Getting exactly where the patient wants to go may not be possible. But asking the question helps build a relationship of mutual trust and respect, and gives us the opportunity to bring our experience with evidence-based practice to support the patient all along their journey.
Beth Hennessey is Executive Director and Paula Suter is Clinical Director at the Sutter Center for Integrated Care in Fairfield, California.
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