Patient Centered Care Lecture MCPHS 2025 PDF

Patient-Centered Interviewing Patricia Cerreto, MS, PA-C [email protected] Objectives ❖ Describe the differences between the definitions of “clinician centered”, “patient centered care” and “relationship centered care” ❖ Describe the components and sequence of a full patient assessment...

Patient-Centered Interviewing Patricia Cerreto, MS, PA-C [email protected] Objectives ❖ Describe the differences between the definitions of “clinician centered”, “patient centered care” and “relationship centered care” ❖ Describe the components and sequence of a full patient assessment ❖ Identify examples of positive and negative nonverbal communication ❖ Describe why the medical interview is important as well as why the patient centered component of the medical interview is particularly important ❖ Describe the core skills of patient centered interviewing including open ended, emotion seeking, and empathizing skills ❖ Describe each of the “Steps 1-5” of the Smith’s Patient Centered Interview Lecture Road Map ❖ History: Clinician Centered, Patient Centered & Relationship Centered Care ❖ Overall Patient Assessment ❖ Medical Interview Clinician vs Patient Centered ❖ Patient Centered Interview Skills ❖ Patient Centered Interview: The Steps Clinician Centered Care History  “The start of the 20th Century was an exciting time. Discoveries were being made. Discoveries that A CORE CURRICU LUM FOR TEACHING THE would build the foundation of modern medicine. MEDICAL INTERVIEW TO INTERN AL MEDICINE RESIDENTS PATIENT CENTERED Discoveries that would help improve diagnosis and CARE MEDICINE Michael and Enid Dr. Mack Lipkin & Society for Research in Education in NATIONAL INSTUTE RELATION SHIP Balint 1969 COMMUN ICATION disease and decrease human suffering. 2” In addition to trying to discover a Primary Internal Medicine 1984 OF MEDICINE 2001 SKILLS Cho & Cooley BIOMEDICAL MODEL. localizable iles s, th e Names Patient 2018 ACADEMY OF RELATION SHIP Disease is fully patient has to be “The potential CENTERED CARE Centered Care as One COMMU NICATION IN benefits of a of Six Sims to accounted for by examined a s whole deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.”  1940 “The Magic Bullet” https://archive.org/details/dr.-ehrlichs-magic-bullet  1908 1928 1928 1921 1901: Blood Types ABO identified: blood transfusions increase 1908: Paul Ehrlich: idea of introducing substances into the body to fight disease 1904: EKG-William Einthoven, ultrasound (1963), CT scan (1971) 1921: Frederick Banting: co-discover of insulin 1928: Alexander Fleming discovers penicillin 1937: Introduction of general anesthesia 1954: First organ transplant “’Biomedical approach’” to care, which is focused on diagnosing and treating or curing symptoms and diseases—where these are understood to be faults in a body or in bodily function.”. “Physicians were driven to only appreciate information that contributed to a purely physical explanation of disease process.” “They were seeing the disease or the injury only, not the person.” Clinician Centered Care Clinicians take charge of the interview and to focus on acquiring details on the symptoms of disease to determine disease/diagnosis. The balance of power is generally centered on the preferences and values of the clinician The use of closed ended questions when taking a patient’s history is common, seeming somewhat like a patient interrogation. The patient’s experience of illness was often ignored or even discouraged preventing most personal info, emotions and feelings from emerging Essentially, a detached perspective developed… “find the broken part & fix it” Patient Centered Care History  In contrast, there is another way of medical thinking which we call “patient-centered medicine”. In addition to trying to discover a localizable illness or illnesses, the doctor also has to examine the whole person in order to A CORE CURRICU LUM form what we call an 'overall diagnosis'. FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS BIOMEDICAL MODEL. Disease is fully 1969 In addition to trying to discover a localizable illn ess , the patient has to be ACADEMY OF COMMU NICATION IN Medicine 1984 “The potential RELATION SHIP CENTERED CARE 2001 Names Patient Centered Care as One Cho & Cooley 2018 accounted for by examined a s whole benefits of a of Six Sims to deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.” Balint E. The possibilities of patient-centered medicine. J R Coll Gen Pract. 1969 May;17(82):269-76. PMID: 5770926; PMCID: PMC2236836 “In 1950, we started advertising in the medical press in London that we proposed to hold seminars on the psychological problems in general practice”  We are frustrated. We don’t have the proper training or time to incorporate this into our patient visits. Our patients need a formal course of psychotherapy and this takes a 50-minute interview.  So, we assembled a dozen of our most experienced general practitioners and asked them if they would like to co-operate with us in a research into how much 'patient-orientated medicine' can be done in the ordinary run of their practices. “Six-minute psychotherapy”  “At the end or our study we found that doctors are beginning to feel that they are not endangered if they allow their patients to tell them what they want in their own time and in their own way and they find that they are not turned into psychotherapists if they do this”. “In my experience what prevented them from doing this in the past was not because it involved a new way of thinking but because they feared that if they let the patient loose, so to speak, they would be overwhelmed; patients would get too close to them and would become unbearably dependent and demanding.”  Psychoanalyst Enid Balint In her 1969 address to the UK Royal College of General Practitioners, spoke of a new approach to medical thinking—patient centered medicine— in which doctors try to understand their patients’ illness within the context of the whole person, the ‘unique human being,’ before them. A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS BIOMEDICAL MODEL. Disease is fully 1969 In addition to trying to discover a localizable illn ess , the patient has to be ACADEMY OF COMMU NICATION IN Medicine 1984 “The potential RELATION SHIP CENTERED CARE 2001 Names Patient Centered Care as One Cho & Cooley 2018 accounted for by examined a s whole benefits of a of Six Sims to deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.” Mitchell P, Cribb A, Entwistle V. Vagueness and variety in person-centred care. Wellcome Open Res. 2022 Jun 16;7:170. doi: 10.12688/wellcomeopenres.17970.1.  George Engel explained that the development of 1977 disease (and health) is complex, not just a result of biological factors but a result of a complex interaction of biological, psychological, and social factors. A CORE CURRICU LUM FOR TEACHING THE He appreciated the impact of the mind on one’s MEDICAL INTERVIEW TO INTERN AL MEDICINE RESIDENTS PATIENT CENTERED CARE MEDICINE Michael and Enid well being. Dr. Mack Lipkin & Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. localizable illn ess , the 1984 Names Patient 2018 ACADEMY OF RELATION SHIP Disease is fully patient has to be “The potential CENTERED CARE Centered Care as One COMMU NICATION IN benefits of a of Six Sims to accounted for by examined a s whole deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.” Biopsychosocial Model, 1977 1977, “The Need for New Medical Model: A challenge for biomedicine”, Science Biomedical model is flawed because it does not consider the whole person and cannot account for individual differences in perceived illness. The development of illness is a complex interaction of biological factors, psychological factors, and social factors George Engel, MD  1986 A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. localizable illn ess , the 1984 Names Patient 2018 ACADEMY OF RELATION SHIP Disease is fully patient has to be “The potential CENTERED CARE Centered Care as One COMMU NICATION IN benefits of a of Six Sims to accounted for by examined a s whole deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.” Patient Centered Care, History “The United States has the finest in technical health care, but its citizens are not getting the humane treatment they want.” Harvey Picker & Jean Sovatkin, 1946 History: Picker Institute, 1986 http://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care  2001 2001: National Institute of Medicine defines patient centered care “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. localizable illn ess , the 1984 Names Patient 2018 ACADEMY OF RELATION SHIP Disease is fully patient has to be “The potential CENTERED CARE Centered Care as One COMMU NICATION IN benefits of a of Six Sims to accounted for by examined a s whole deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.”  A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & SMITH’S PATIEN T Michael andCENTERED Enid Society for Research RELATION SHIP Balint 1969 INTERVIEWING SK ILLS in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS 1996 In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. Disease is fully accounted for by 1996 1S T edition localizable illn ess , the patient has to be examined a s whole ACADEMY OF COMMU NICATION IN HEALTHCARE 1984 “The potential benefits of a RELATION SHIP CENTERED CARE Pew Fetzer Tas k Names Patient Centered Care as One of Six Sims to 2018 deviations from the person understood as successful interview Improve the Quality FOUNDED Force 1992 norm of measurable as a unique huma n curriculum are of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.”  A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. Disease is fully accounted for by 1996 localizable illn ess , the patient has to be examined a s whole ACADEMY OF COMMU NICATION IN HEALTHCARE 1984 “The potential benefits of a RELATION SHIP CENTERED CARE Pew Fetzer Tas k Names Patient Centered Care as One of Six Sims to 2018 deviations from the person understood as successful interview Improve the Quality FOUNDED Force 1992 norm of measurable as a unique huma n curriculum are of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.”  A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. Disease is fully accounted for by deviations from the 2019 localizable illn ess , the patient has to be examined a s whole ACADEMY OF COMMU NICATION IN HEALTHCARE 1984 “The potential benefits of a successful interview RELATION SHIP CENTERED CARE Pew Fetzer Tas k Names Patient Centered Care as One of Six Sims to Improve the Quality 2018 person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.” Patient Centered Care NIOM: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.” Patients are seen as individuals, clinicians aim to understand patient concerns, emotions and life challenges Patients are encouraged to express what is important to them and to recognize the importance of patient’s expressions of personal concerns, feelings and emotions Relationship Centered Care History  “Relationship centered care can be defined as care in which all participants appreciate the importance of their relationships with one another” A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. localizable illn ess , the 1984 Names Patient 2018 ACADEMY OF RELATION SHIP Disease is fully patient has to be “The potential CENTERED CARE Centered Care as One COMMU NICATION IN benefits of a of Six Sims to examined a s whole 1992 accounted for by deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BI OPSYCH OSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.”  A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. Disease is fully accounted for by deviations from the 2019 localizable illn ess , the patient has to be examined a s whole ACADEMY OF COMMU NICATION IN HEALTHCARE 1984 “The potential benefits of a successful interview RELATION SHIP CENTERED CARE Pew Fetzer Tas k Names Patient Centered Care as One of Six Sims to Improve the Quality 2018 person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BIOPSYCHOSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019 biological, psychological an d con cern s a nd comforts of patients.“ 4T H edition social factors.” Relationship Centered Care An expansion of patient-centered care, and a direct outgrowth of the biopsychosocial model Takes into consideration that all illness, care, and healing processes occur in the setting of relationships—relationships of an individual with self and with others It expands focus beyond the patient to include The relationship between caregivers and the patients & families they serve The relationship among members of the health care team The caregiver’s relationship with self Relationship Centered Care Four Principles of Relationship Centered Care 1. Relationships in health care ought to include the personhood of the participants 2. Affect and emotion are important components of these relationships 3. All health care relationships occur in the context of reciprocal influence 4. The formation and maintenance of genuine relationships in health care is morally valuable.  A CORE CURRICU LUM FOR TEACHING THE MEDICAL INTERVIEW TO INTERN AL PATIENT CENTERED MEDICINE RESIDENTS CARE MEDICINE Dr. Mack Lipkin & Michael and Enid Society for Research RELATION SHIP Balint 1969 in Education in NATIONAL INSTUTE COMMUN ICATION Primary Internal OF MEDICINE SKILLS In addition to trying Medicine to discover a 2001 Cho & Cooley BIOMEDICAL MODEL. localizable illn ess , the 1984 Names Patient 2018 ACADEMY OF RELATION SHIP Disease is fully patient has to be “The potential CENTERED CARE Centered Care as One COMMU NICATION IN benefits of a of Six Sims to accounted for by examined a s whole deviations from the HEALTHCARE successful interview Pew Fetzer Tas k Improve the Quality person understood as FOUNDED norm of measurable as a unique huma n curriculum are Force 1992 of the American biological variab les being” 1978 enormous” Health Care System 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 BI OPSYCH OSOCIAL Harvey Picker 1986 SMITH’S PATIEN T MEDICINE Picker Institute. CENTERED George Engel 1977. “Althoug h the INTERVIEWING SKILLS American healthcare 1996 “The development of system was disease is complex, 1ST edition not just a result of technologically and biological fa ctors bu t scientifically SMITH’S PATIEN T outstanding, it was CENTERED a res ult of a complex not adequately INTERVIEWING SK ILLS interaction of sensitive to the 2019