Q&A with Dr. Richard Irwin

Richard Irwin, MD, Master FCCP
Richard Irwin, MD, Master FCCP

Richard Irwin, MD, Master FCCP, Editor in Chief of CHEST®, will deliver Sunday’s keynote address titled “My Journey to Patient-Focused Care and Lessons Learned Along the Way.” CHEST Daily News caught up with Dr. Irwin for a deeper look into his journey with patient-centered care.


Was there a defining “moment” or significant event, in your career, that jump-started your journey to patient-focused care?

Yes, it was when my father passed away, and my mother’s response to that. She was very angry. He had a massive stroke and passed away when they were visiting us in Massachusetts. After she went home, my mother called the office of my father’s cardiologist down in Florida. She told the secretary who answered the call that my father had passed away, and following that conversation, my mother was expecting a call from the cardiologist, who never ended up calling. My sister and I tried to understand why my mother was so upset about this. In talking with her, we learned she was very disappointed that the physician didn’t call to say how sorry he was for the loss of my father; by not calling, he left the impression that my father wasn’t anything more to him than a chart number. This really opened my eyes to the fact that my mother had a lot vested in the health-care providers she and my father were seeing, and she thought they had a vested interest in my parents, as well. It didn’t feel right to her that the cardiologist never even called her back.

I was raised in an era, starting my career in medicine at the end of the 1960s, that was very physician-focused. The patient’s role in their care was a very passive one. When my dad died in 1981, that event opened my eyes to changing the way I cared for my patients. Unfortunately, it sometimes takes events in the life of the physician to get them to appreciate that the way we should be caring for patients is as if they were our own family members.

When you talk about patient-focused care, what are the defining characteristics?

As a movement, patient-focused care really got started in the 1950s, and all these years later I’d say we still have a long way to go. Patient-focused care embodies three “Cs,” and except for perhaps the oldest patients, it’s the way each of us would want to be cared for.

The three “Cs” include:

  • Good Communication
  • Consistency on the part of the physician: If they say, “Give me a call and let me know what’s going on,” there should be someone there to answer the phone when the patient does call.
  • Concordance of wishes: Finding the common ground between how the patient and you as a physician deal with their care.

This suggests an active role by the patient in their own care, working with the physician. This is different from the very passive role patients may have played in their own care in the physician-focused era when I started my career. It recognizes that there are multiple options to deal with a problem the patient is facing. The physician’s recommendation should include the pros and cons of what goes with each option, and this type of discussion gives the physician the opportunity to explore with the patient what the other pressures they might have in their life, for example, if they’re taking care of someone at home.

What changes did delivering patient-focused care require for you, personally?

I was the division chief at the time I started my journey to patient-focused care, and I changed both personally and helped our division as a whole change how we were taking care of people. Before “open access” became a common concept, for example, we had made that change in the early 1980s in our clinic. This wasn’t the case everywhere within our institution, at the time. But it did become the standard in our particular group. Those of us in charge led by example, and the trainees who came through understood what we meant by patient-focused care.

Around that same time, the Institute of Medicine (IOM) came out in favor of this approach to care. Then, in the late 90s and early 2000s, the IOM determined they liked the term “patient-centered care” better. Even though the IOM liked the term patient-centered care, I still preferred to use “patient-focused care” because it seemed to be more of an active term—requiring the provider to actively choose to be focused on the patient.

How does the business of medicine (ICD-10, meaningful use, EMRs, and more) get in the way of delivering patient-focused care?

I think the business of medicine has the potential to be a barrier. But I also think that the mindset of the physician can be a barrier. There are so many things going on for a physician, and sometimes all your time is spent thinking about how you’re going to get through your own day and survive. As busy as our days are, it’s really hard to also think about walking in the shoes of the people sitting on the other end of the exam table. In reality, it’s a full-time job just focusing on the patient, yet we also have so much else going on in a given day.

I would say that those of us who have had a calamitous health-care related experience with a loved one are more likely to get it and understand what patient-focused care really takes. If you have some momentous event that takes place in the lives of you and your loved ones, it’s easier for you to actually think about your patients as we would their loved ones, and to want to make sure we take time to deliver patient-focused care.

Given today’s advances in technology, do you perceive these as threats to the delivery of patient-focused care?

The threats come from new technologies that might cause the provider to be looking at the computer screen instead of the patient, when taking their history, for example. You’re focused on trying to document everything and do it right, using the tool that’s right in front of you. This can definitely get in the way of focusing on the patient.

You should be focusing on the patient who’s in front of you, spending a lot of time taking a really good history and doing a good physical examination. The bits and pieces of the patient’s story that you gather during the history and physical really are the things that give you the best place to start in their diagnosis and treatment.

If these important steps in patient-focused care aren’t done well, there’s a risk of over ordering tests. The most likely reason for over ordering tests is that the physician isn’t fully aware of everything going on with the patient and didn’t take the history as well as they should’ve.

How have you advanced the delivery of patient-focused care through your service at CHEST, leading the way for future generations of health-care providers?

Besides modeling it in our division for colleagues and trainees, I also made patient-focused care a major guiding tenet through my work at CHEST. When I was the president-elect in 2002, then Executive Director Al Lever asked me what I was going to focus on during my presidential year. I decided upon “patient-focused care.” That’s when we came up with the pledge that we now recite at the convocation every year.

That same year, when I gave my talk as president, the importance and impact of patient-focused care was the number one message that I wanted to deliver. I gave examples of things my own family members had experienced, and I emphasized what I would like to see not happen anymore.

Now, 15 years later, I realize that this is work that never ends. On a personal level, I’m just one voice that’s added to other voices, and hopefully there will be others in the audience who find my comments resonate with them. Getting this message across to one person at a time is important. There are some who will actually change and do a better job with the way they deliver care, after hearing me speak—I would feel good about that.

What other lessons have you learned along the way?

Well, this isn’t just up to me, or up to us as the doctors and health-care providers. It’s also up to each of you—as patients. In today’s age, you are more likely to be speaking up than ever before. Medical schools are now doing simulation training, and they have standardized patients; all of these things are good. We all have unfortunately bad events that have happened to our family members, and that also helps opening people’s eyes.

What is the single most important takeaway for a provider at CHEST 2018 who hears your keynote presentation?

Because everyone we treat is somebody’s loved one, we have to treat them as if they were our own loved one. After all, in the end, we’re all family, and we need to treat each and every patient that way.