Listen To Your Patient And They Will Tell You The Problem – A True Story

Patient Communicatio Skills Quote2Readers of Mind the Gap,

I apologize for my absence in recent months.  As you will see from my latest post, I have been away with my wife as she is dealing with a serious recurrence of her lung cancer.  Our recent experiences continue to underscore the need for improved physician-patient communications in the doctor’s office and hospital.

Thanks for understanding.

Steve Wilkins,  Author, Mind the Gap

We often hear how physicians seem to interrupt patients almost as soon as they open their mouth to tell their story. It’s not because they are trying to be rude. Physicians interrupt patients because it doesn’t take them long to “size up’ the patient and arrive at a working diagnosis.

Once they arrive at a differential diagnosis, physicians will tell you that there is little to be gained (from their perspective) from wasting time letting patients ramble on. As physicians often remind me, they were taught to do two things in medical school…diagnose and treat the patients’ problem…not talk to patients.

A True Story

My wife’s recent emergency room visit and hospitalization underscores “how wrong” physicians can be when they interrupt or ignore the patient’s story. Her (our) experience also underscores the costs in unnecessary diagnostic tests, pain and suffering, fear, frustration and loss of patient confidence (trust) that often accompanies experiences where physicians (and nurses) simply don’t listen to the patient.

You need to understand that my wife is a 10 year survivor of Stage IV Non-Small Cell Lung Cancer (no she never smoked). She is experiencing a recurrence of the cancer with mets to her liver which has caused a build-up of fluid in her abdomen. She is being treated by a very good team of oncologists and her cancer is responding to treatment. On the day of her ER visit, we were half way across the country from her treating physicians for the holidays. We had my wife’s medical records with us.

My wife presented to the ER physician with severe abdominal pain associated with her distended abdomen. The ER doctor quickly assessed my wife’s condition, seemed to listen to “our take” on what was wrong – excessive fluid build-up (scites) in her abdomen – and the need for an emergency paracentesis or draining of the fluid from her abdomen. Her oncologists warned us that such a procedure may be necessary at some point. For us this was that point. It was not to be the case however for her ER doctor and hospitalists.

Turns out the ER doctor was convinced that my wife had pneumonia and sepsis. The chest X-ray and CAT scan of her abdomen showed “cloudiness” in her right lower lobe of her right lung, a high White Blood Cell count, and fluid around the lungs and liver. These findings are consistent with possible pneumonia and sepsis…but they are also consistent with her history of lung cancer with liver mets. The radiology exams confirmed the cancer. Since my wife had a similar ER admission 5 months ago in the same hospital, they were able to compare the x-rays and CT scans to the same tests done 5 months prior. This hospital system also has an extensive EHR system.

Consistent with the diagnosis of pneumonia and sepsis, the ER doctor put my wife on IV fluids and antibiotics. While still in the ER, a hospitalist had visited my wife and concurred with the diagnosis of pneumonia and sepsis and the treatment plan. My wife, an RN, reminded the ER nurse that she was on fluid restriction associated with her condition…but my wife had been given pain medication and was not in a position to argue her case.

As my wife feared, her abdomen swelled up even bigger from all the IV fluids and her pain went off the charts (30 on a 10 point scale). She was having difficulty breathing and was convinced she would die before the doctors (or nurses) would discontinue the IVs and antibiotics and give her Lasix to help eliminate some of the fluids which were cause her condition to get worse. The ER nurse told me that if they did what my wife and I requested, remove the IV fluids and antibiotics, my wife could die. That’s not something I needed to hear.

By this time the original hospitalist went home and a new one came on shift. The ER nurse got the new hospitalist on the phone and the doctor reiterated to me the diagnosis of his predecessor. I suggested he actually examine my wife and listen to what we thought was the problem. The doctor eventually showed up, agreed with our story, and discontinued the IVs and ordered Lasix. The next day my wife had the fluid drained from her abdomen which greatly relieved her symptoms. She had one more paracentesis two day later removing total of almost 10 liters of abdominal fluid. She was discharged from the hospital several days later.

Big Deal – Doctors’ Are Human – Mistakes Happen

The reality is that if we had never left town (where my wife’s oncologists were located) she would have gone to the hospital ER, had the paracentesis done and be out of the hospital the same or next day. But that is not what happened.

Instead she was out of town, her doctors ignored her story, and as a result went off on a wild goose chase treating a phantom problem at considerable expense, pain and suffering. While it is true that doctors are human, that in no way excuses them from soliciting and listening to the patient’s story – their perspective of what is going on. Being busy or being pressed for time is not a legitimate excuse for misdiagnosing and mistreating patients either. Sir William Osler’s admonition to medical students in the late 19th century is applicable today, “Listen to your patients and they will tell you the problem.”

Listen to your patients and they will tell you the problem.

The Take Away?

Here is the advice I would offer any physician or physician stakeholder who cared to listen:

1) Ask the patient (or caregiver) what the problems are that brought them in – get them all
2) Be mindful and listen to what the patient and caregiver tells you
3) Discuss your diagnosis with the patient to get their thoughts and buy in
4) Work with the patient (and caregiver) to arrive at a mutually agreeable diagnostic/treatment plan

As strange as it may seem, physicians often lack the communication skills and experience needed to accomplish these seemingly basic, simple tasks…but it is true. Keep in mind that many physicians simply are not trained nor inclined to engage patients as described above. These skills however can be taught and physicians can learn how to integrate these patient-centered communication skills into their daily routines. The first step however is to recognize that there is a problem.

I know because my company works with physicians, hospitals and health plans to assess and improve their patient communication and engagement skills every day.

If You Are Doing Patient Engagement Just To Meet Stage 2 Meaningful Use You Are Going To Fail…Here’s Why

I recently came across an interview with Stephen Beck, MD, Chief Medical Information Officer (CMIO) at Catholic Health Partners. Dr. Beck was being interviewed on the subject of patient portals and patient engagement.

Here’s a quote from that interview.

“While we have many enrolled patients in our patient portal, it’s not simply the enrollment but the actual use in Stage 2 that meets the criteria. Although the threshold is fairly low, there is still ongoing concern about how we can encourage patients to use the portal regularly…. We want patients to use electronic communication rather than pick up the phone. For many patients this transition will take quite some time to achieve. I have confidence the patients will see the light — the question is: How quickly?”

No wonder Catholic Health Partners is having trouble getting 5% of their patients to “use” their portal for secure messaging, etc. They are doing patient engagement for the wrong reasons.  And as we as have seen with Mayo Clinic and others…Catholic Health Partners is not alone.Get To Know Me

There Are Two Reasons For Doing Patient Engagement

There are two reasons why an organization should get involved with patient engagement. The right reasons and the wrong reason. The use of the terms right and wrong is not intended to imply any moral connotations.  Rather it refers to the likelihood that one’ engagement efforts will succeed or not.

The Right Reason

If your engagement efforts are done principally for the patient’s benefit (patient-centered) then you are doing it for the right reason. Examples of the right reasons include:

  • Ensuring that each patient is as involved as they want in their own care,
  • Reducing patient risks of infection or injury due to medical errors or safety issues
  • Helping patients make health decisions that are right for them
  • Providing patients with important self-care skill, and so on.

You get the idea.

Could Your Patient Communication Skills Use A Tune Up?  Find Out.  Sign Up For the Adopt One! Challenge. 

It’s Free For  Qualifying Physicians

The Wrong Reason

If you are trying to engagement patients principally for the benefit of someone else (health care executives, physicians or regulators) then you are doing it for the wrong reasons…and patients will quickly sense this. Examples of the wrong reason abound and include:

  • Doing it to achieve Stage 2 MUEngagement Quote 1
  • Off-loading work heretofore done by clinicians to patients via a patient portal
  • Engaging is shared decision-making to coach the patient away from costly service requests
  • Putting a patient or two on an advisory committee as window dressing
  • Requiring that patients view their physician notes on the patient portal or health app before allowing them to find what they really want


Sure you can rationalize that everything ultimately is for the patient’s benefit but come on. Patients aren’t stupid. They know when something benefits them and when it really is for someone else’s benefit. Forcing patients to go online to use secure messaging to communicate with their health care provider instead of calling is a pretty transparent way of trying to eliminate staffing costs and achieve Stage 2 Meaningful Use. But from a customer service perspective it’s not very smart. Person-to-person interactions are much more meaningful from an engagement perspective than “going online.” Heck even the airlines let you call and speak with a reservation agent if you don’t want to book your flight online.

The Take Away?

Remember, many patients (people) are already engaged in their health albeit in ways that differ from the way providers tend to define engagement, e.g., patients doing what we provider consider to be the right thing.  Following the admonition to “do no harm” the health care providers job is to be engaging and avoid pissing off the patient and disengaging them.

Also remember that for every action there is an equal and opposite reaction – call it unintended consequences. In this case Catholic Health Partners might not only fail to achieve Stage 2 MU but also increase patient dissatisfaction in turn disengaging more patients than they actually engage.  I doubt that their patients will ever see the light as Dr. Beck hopes.   But then patients are not the one’s who need to “see the light” are they….

My advice is you do something nice for your customers – something that they find to be a benefit – you can never go wrong.

That’s what I think. What about you?

Could Your Patient Communication Skills Use A Tune Up?  Find Out.  Sign Up For the Adopt One! Challenge. 

It’s Free For  Qualifying Physicians

Patient Reactance – What It Is And Why Clinicians Need To Be Aware Of It

Can you say “reactance”?  Don’t feel bad, I wasn’t familiar with the term either until recently.  But as you will see, anyone that has ever been a patient will catch on pretty quickly as to what reactance is and how it works.

Patient Saying NoReactance is how we respond to something that threatens to limit or eliminate our behavioral freedom.  I recently experienced reactance in the course of “prepping” for a colonoscopy.   The day before the colonoscopy you cannot eat anything except clear liquids.  Then you have to drink this horrible tasting “stuff” to clean you out…you get the idea.

Sure I understood the need for having the colonoscopy.  But the whole ritual made me feel really imposed upon by everyone involved – the doctor, hospital where I had the procedure, and the makers of the “stuff” I had to drink.  I thought of lots of counter arguments for why I needed food more than a colonoscopy.  Remind me what’s wrong with virtual colonoscopy?

Compared to being diagnosed with cancer, diabetes or some other life-changing condition, the “loss of l freedom” associated with a colonoscopy is insignificant.  I cite my example only to illustrate what reactance is and how it works.

If you think about it, reactance is an inadvertent by-product of the way much of health care is organized and delivered.   Who hasn’t felt that waiting 45 minutes to see their doctor isn’t an unfair restriction on their time and behavior?  Or who hasn’t felt that the hospital admitting process is all about protecting the hospital and does nothing for the patient other than hold them captive as some clerk reads through 30 minutes of legal mumbo jumbo.

The author of the Health Influence – Persuasion Blog suggests that reactance typically follows the 3 step process:

Step 1.  People perceive an unfair restriction on their actions.

The key word here is, “unfair.”  People can accept restrictions, but they must feel that the restriction is reasonable, equal, and just.  When the restriction is unfair (they don’t know why it was applied, or it only applies for some people, or it is too tough), the next stage occurs.

Step 2.  A state of reactance is activated.

Reactance prompts a cognitive and emotional response in people.  Cognitively, we come up with counter arguments for why what we are being asked to do is unreasonable, unfair or not worth doing.  Emotionally, people can feel wronged and that they “aren’t going to take it anymore.”  Reactance is important to understand because it has strong motivational properties and leads to the final stage.

Step 3.  The person must act to remove the reactance.

The motivational qualities of reactance are so strong that the person must do something about it.  They must either “right the wrong” or get around the restriction. In the case of health care, reactance may manifest itself in the form of non-compliance, anger, poor satisfaction scores and so on.

How Can You Minimize Reactance in Your Health Organization?

The best way to minimize the risk of reactance,  according to researchers, is to make sure that there is a reasonable balance between what providers ask a patient to do (take a medication, get a colonoscopy, or wait 45 minutes) and the reasonableness and fairness of the request as perceived by the patient.

Waiting 45 minutes to see your physician for 7 minutes, and then feeling rushed and limited to 1 question, may seem like an unfair exchange to some patients.   Asking a newly diagnosed patient, who doesn’t fully understand the severity of their condition, to start taking a medication against their wishes, may seem unreasonable to patients as well.

Lack of time often works against providers when it comes to preventing reactance.   With limited time, providers are not always able to make a strong or believable case for why patients should do get a test or take a new medication.   Weak arguments and unrealistic threats of unlikely consequences from providers only tend to increase reactance in patients.

Do you have any good examples of “reactance provoking “requests that  your organization routinely makes upon patients?

That’s my opinion. What’s yours?


Rains, S. A., & Turner, M. M. (2007). Psychological Reactance and Persuasive Health Communication : A Test and Extension of the Intertwined Model. Human Communication Research, 33, 241-269.

Need Help Meeting The 5% “Patient Use” Stage 2 MU Requirement? Try This…

A lot of physicians are having problems meeting Meaningful Use Stage 2, particularly the requirement which calls for 5% of patients to view/download/or transmit their online, personal health information. According to CMS and ONC, only 1 percent of eligible providers and 3 percent of eligible hospitals have attested to Stage 2 to as of July 8, 2014.

Providers are being told to look to social media to drive patients to portals where they can get secure access to their personal health data.   But as I discussed in an earlier post,  a provider’s best bet for getting patients to access their data is to talk to them where they already are – in their doctor’s offices.

Stage 2 MUTelling patients about portals, how to use them, and how they will benefit, is essential to building enough “critical mass” to achieve 5% use of their data.

Unfortunately, physicians don’t talk to patients much during the exam room portion of the office visit about the patient portal or the potential benefits to be had by the patients.

The responsibility for communicating with patients about patient portals, secure messaging and the like has been delegated to the front office staff. ..and that is a mistake.

Patient on LaptopIf Physicians Were To Integrate The Patient Portal And Secure Messaging Into The Medical Exam Dialogue With Patients They Would Breeze Through MU Stage 2 Attestation.

In my work with the Adopt One! Challenge, I listen to a lot of audio-recordings of physician-patient exam room conversations. In the course of these exam room dialogues, patient are forever giving “cues” to physicians regarding health concerns, fears, beliefs, requests and expectations.  many of these cues involve patient requests for  information.  Each of these cues represent opportunities…teachable moments if you will…for the physician to engage, educate and exceed patient’s expectations.  Most physicians however fail to respond to such patient cues.  Perhaps the physician didn’t recognize them or they recognized them but decided not acknowledge them due to time, lack of tools, etc.

The point is that these cues (averaging between 9 to 12 cues per visit) give physicians a tangible reason to recommend to patients that they use their portal.   Each cue represents an opportunity for physicians to prescribe an “information therapy referral” to patients directing them to the portal URL containing the desired information.  Once there, the links to their qualifying personal health data can be made thus increasing the likelihood of achieving the 5% view/download/transmit requirement.  The details of the information therapy referral could be incorporated into the post Visit Summary given or emailed to the patient at the end of the visit  – check off two more MU Stage 2 requirements.

Medication Nonadherence – A Candidate For An Informational Therapy Referral Program

Medication nonadherence is a great example of how physicians could employ an information referral strategy to meet MU Stage 2 requirements and satisfy patients’ needs and desires for information (think cues).

The Problem

When prescribing a new Rx medication, the average physician spends <60 seconds explaining to the patient why they need the new medication, how to take it, safety and efficacy, what to do about side effects and so on. Many physicians also forgo performing periodic, recommended medication reconciliations designed to keep the patient’s medication history up to date.  nearly every patient over 50 years will be taking at least one Rx medication for a chronic condition.  Of these up to 70% will be nonadherent.  Three quarters of nonadherence is intentional because patients do not agree with the need for, safety, or efficacy of the drug.

Info Therapy RxThe Solution

Imagine if every patient prescribed a new Rx medication were given an information therapy referral by their physician to their patient portal with two objectives in mind: 1) to have the patient review the accuracy of the list of medication in the EHR or PHR and 2) use their medication list to link patients to information about the medication, including instructions for use, side effects, etc.

Not only would this address the 5% requirement for Stage 2 MU but it would also potentially decrease medication nonadherence and its associated costs, e.g., preventable ER visits and rehospitalizations.

Using audio recording of actual exam room conversations, we teach physician participating in the Adopt One! Challenge how to recognize and respond to a wide range of “cues” given by patients, including those pertaining to adherence and health IT.  We also show physicians how to integrate information referrals to their patient portals into the medical exam as described above.


For an information therapy referral model to work, the patient portal needs to offer more than convenience services like lab test results, appointment scheduling and Rx refills. The portal must offer information that is relevant to what patients want and need to know.  Whether the information provided by vendor patient portals is relevant or not is the topic for another time.

Physicians cannot delegate responsibility for “talking up” the portals to their staff.  Patients may be comfortable talking with office receptionists and MAs about some things but how and why to use the patient portal about detailed medical conditions is not one of them.  There are simply too many benefits for both physician and patient to merit delegating such an important conversation to someone else.

Take Aways

Physicians need to make lemonade out of the lemon that is Meaningful Use.  By implementing an information therapy referral program as described here, physicians can:

  1. Derive real, quantifiable benefits from actually having a portal that patient will find useful.
  2. Be better positioned to meet the more challenging MU Stage 2 requirements like the one requiring that “at least 5 percent of all patients in the case of Eligible Providers (EPs,) and 10 percent for Eligible Hospitals (EHs) should be able to view, download or transmit their health information to a third party.”

Effective Communication Between Physicians And Patients Is Not Optional…And Cannot Be Delegated Away

I was talking with my sister recently about physician-patient communications. She is administrative lead in charge of the hospitalist physicians where she works – a large hospital in the Midwest. Not surprisingly, given her responsibility and her loyalty to her docs, she often comes across as an “apologist” when it comes to doctors and their patient communication abilities. Doctors after all are busy. They barely have time to talk to patients while rounding. To expect them to be good communicators is just asking too much.

This attitude isn’t limited to hospitalists or their managers.  Practice administrators and physician office staff are just as likely to make excuses for why their docs shouldn’t be held up to too high a standard when it comes to their patient communication skills. Office staff in primary care settings, e.g., Medical Assistants and Nurses, are being asked to take on more responsibility for communicating with patients. It’s all part of a move to get office staff to “practice up to what their license” will allow.

But implicit in the physician apologist’s mindset is the belief that Physician Apologistthe ends justify the means. In other words, the fact that physicians are busy justifies in the apologist’s mindset that  cutting corners is OK for physicians when it comes to something as seemingly unimportant as “talking with patients.”

This notion that your physicians can “get by” with sub-optimal patient communication skills (for whatever reason) is wrong… both for patients and the rest of the organization. Effective patient communication skills are as essential to the practice of high quality medicine as a physician’s clinical expertise. Good patient communications skills are not optional. Nor can the physician’s responsibility for communicating with patients simply be delegated away.

Here’s A Few Reasons Why Physician-Patient Communications Is So Important

The Accuracy Of The Physician’s Diagnosis And Treatment Is Completely Dependent Upon Their Ability To “Get The Patient To Open Up And Tell Them What’s Wrong”

As Sir William Osler, the founder of modern medicine once said, if you listen to the patient they will tell you what the problems is. Osler teaching underscores the importance of the physician’s ability to talk and listen to the patient’s story. The same can be said for the sharing of information, the asking of questions, expressing empathy and support and shared decision making throughout the medical interview. How can anyone – physician or administrator – think for a moment that it’s OK for physicians, not matter how busy they are, to just “get by” with anything but great patient communication skills? Even worse, how can apologist managers think for a second that such “patient communications” functions as the diagnosis or treatment can be delegated away to a nurse or MA?

Arriving At a “Shared Mind” Between Doctor and Patient Is Key To Patient Adherence

Patient adherence is directly dependent upon the degree to which patients agree or disagree with the physician’s diagnosis and treatment…also called shared mind. If patients don’t agree with the necessity for treatment due to a disagreement with the doctor’s diagnosis…or if the patient does not believe the recommended treatment is safe or effective… patient adherence will not occur. Arriving at a “shared mind” between physician and patient therefore is not optional for physicians…building consensus cannot be delegated to a nurse or MA. A shared mind is between physician and patient is essential to the successful treatment and the patient’s long term adherence.

Trust Between The Patient And Their Physician Is Essential

Patients need to trust their clinician. While a PA or NP may one day earn the same level of patient trust that a physician commands, that’s not usually the case for hospitalists whom the patient meets for the first time upon being hospitalized. Trust according to the research is a function not only of one’s credentials but also their personal attributes, particularly the clinician’s bedside manner, e.g., their ability to communicate and relate to patients. Earning the patient’s trust, even via albeit brief conversations before an emergency procedure, is not optional for physicians.


Rx Medication & TrustThe Take Away

The strange thing is that many of the doctors I talk to acknowledge a need to work on their patient communication skills. They just don’t want to have to go back to medical school or spend a week in class away from their busy practice to have to do it. As such, physicians I believe don’t need nor want apologists to shelter them from what apologists perceive to be unwarranted demands on the physician’s time. Instead of helping their docs, I wonder if physician apologists may actually end up hurting their docs, their patients and their organizations by keeping performance expectations low and foregoing opportunities for much needed physician training and improvement.

So the next time you are asked about whether your physicians might benefit for a new initiative…try and avoid the knee jerk reaction to say “my docs are too busy.” Rather, give serious consideration to the need for what is being proposed…both from the patient’s perspective as well as the clinician’s perspective.

That’s my opinion….what’s yours?

Patient Nonadherence – A Rational Reaction To Sub-Optimal Physician-Patient Communication

Medication nonadherence among patients is and has been a “gigantic” problem for the health care industry over the last 20 to 30 years… and not just for pharma.

Between 30% to 70% of U.S. adult patients, including many with chronic conditions, are or will be not fill, pick up or take a prescription Rx as recommended by their doctor.  An estimated 75% of this mediation nonadherece will be intentional.  Patients outcomes suffer and health care cost sky rocket as nonadherent patients fill ER and hospitals across the U.S.

C. Everett Koop, MD, a former Surgeon General, “summed up” the problem when he said:

"Drugs don’t work in patients who don’t take them." 


So Why Don’t Patients Take Their Medications?

There are two schools of thought with respect to medication Rx Medication smallnonadherence. The first holds that nonadherence is a patient behavior problem. Whether it’s because they are stupid, lazy or unengaged…patients just don’t take their medications as directed by their physicians.

The second school of thought holds that nonadherence is often a rational response on the patient’s part when faced with a recommendation to do something they don’t agree with – namely take a medication. There’s even a name for such behavior – it’s called intentional nonadherence. The best example of intentional nonadherence is when patients leave their doctor’s office or are discharged from the hospital and never fill, pick up or take the prescription.

How Can Nonadherence Be Considered Rational Behavior?

I can see how clinicians would feel this way. After all, doctors are acting in the patient’s best interest and prescribe medications because they believe they are necessary. The unfortunate reality however is that patients often fail to see eye to eye with their doctors on the necessity for or the benefits of taking any given prescribed medication.

According to the research, up to 50% of us as patients disagree at one time or another with our doctor regarding:

  • a diagnosis
  • the severity of a condition
  • the safety or efficacy of a particular treatment

Because most patients are loathe to challenge their doctors out of fear of being labeled difficult, they don’t say anything to the doctor.  Rather, patients - you and I -just don’t do what the doctor recommend, e.g., don’t fill, pick up or take our medication.

Researchers have shown that, when faced with having to make a health decision, we employ a kind of cost/benefit analysis in our heads. Based up our knowledge at hand – that which we have via our own personal experiences and that which we learn from the doctor, internet, etc. – we assess the “necessity” for taking a recommended action and balance it against any “concerns” we may have as a result of taking the recommended action. If our perceived necessity is greater that our concerns we take the medicine. If our concerns win out….then we don’t take the medicine.

The Role Of Physician-Patient Communication

For the patient’s necessity/concerns calculus to work, patients have to understand and accept that they: 1) have a medical problem, 2) understand that the problem will be serious if left untreated and 3) belief that the recommended treatment is safe and effective. This means that their physician has to take the time to communicate these salient facts to patients in a way they understand and can accept.

There’s the rub. The average primary care physician spend less than 60 seconds explaining such “ins and outs” to patients during the office visit. Figure 1 shows a breakdown of physician “talk time” by topic during visits in which a new medication was prescribed. To complicate things, patients seldom ask questions of their doctor when prescribed a new medication.

Figure 1

New Rx Talk Time

The net result of these limited exam conversations is evident in a 2011 study of low income patient being seen at Cardiology Clinic:

  • 55% of patients diagnosed with heart failure “did not recognize” nor agree with their doctor that they had heart failure.
  • 85% of patients diagnosed with hypertension disagreed with their doctor’s diagnosis.
  • 41% of patients disagree with doctor’s initial diagnosis of a psychological problem

For patients such as those in the 2011 study, given their disagreements with their doctors, the results of their necessity/concerns calculus does not bode well for their being adherent patients should medications be prescribed.

The Take Away

Physicians tend to overestimate the amount of health information they give patients and underestimate patients’ desire for information.

Clinicians and provider organizations interested in improving patient adherence and reducing preventable ER visits and hospital admissions (and readmits) should invest in assessing and improving their patient communication skills as well as those of the physicians in their provider network.

The evidence suggests that patient medication adherence could be improved 10% - 20% with such interventions. This translates into much improved patient outcomes and significant cost saving.

That’s my opinion…what’s your?


Ho, P. M., Bryson, C. L., & Rumsfeld, J. S. (2009). Medication adherence: its importance in cardiovascular outcomes. Circulation, 119(23), 3028–35.

Sokol, M. C., Mcguigan, K. A., & Verbrugge, R. R. (2005). Impact of Medication Adherence on Hospitalization Risk and Healthcare Cost. Medical Care, 43(6), 521–530.

Tarn, D. M., Paterniti, D. A., Kravitz, R. L., Heritage, J., Liu, H., Kim, S., & Wenger, N. S. (2008). How much time does it take to prescribe a new medication? Patient Education and Counseling, 72, 311–319.

Sarkar, U., Schillinger, D., Bibbins-domingo, K., Na, A., Karliner, L., & Pe, E. J. (2010). Patient Education and Counseling Patient – physicians ’ information exchange in outpatient cardiac care : Time for a heart to heart ?

Physicians That Employ A Patient-Centered Communication Style Have Lower Diagnostic Testing Costs Copy

Some physicians have the mistaken impression that being “patient-centered” is synonymous with giving patients whatever they want whether they need it or not.  If the patient wants an MRI they get one.  If they want a new drug they saw advertised on TV, their doctor orders it.  This definition of patient-centered care couldn’t be further from the truth…and not what this post is about.

Rather, in this post I am taking about physicians that employ a style of communication with patients  that is patient-centered.

A Word About Being Patient-Centered Patient-centered Communication

A patient-centered style of communications differs from the traditional physician-directed (aka paternalistic) communication style in the following ways.

In the physician-directed communication style, the physician is all about efficiently getting at a diagnosis and treatment of the patient’s presenting compliant.  This style of communications focuses on understanding the disease a patient has with little attention given to the voice of the patient.  Physicians employing this communication style do most of the talking, make most of the decisions while the patient assumes a passive sick role.

Physicians that employ as patient-centered communication style focus of the patient with the disease as well as the disease itself.  Patient-centered physicians actively solicit the patients voice and involvement throughout the visit including when it comes telling their story, setting the visit agenda, sharing information, asking questions, collaborative decision making, being empathetic and so on.

Being Patient-Centered Is About More Than Soft, Feel Good Fluff 

Several recent US and Canadian studies have shown that being “patient-centered” is about more than “soft, feel good fluff.”   These show that physicians with a patient-centered communication style ordered fewer diagnostic tests resulting in significantly lower diagnostic costs. The cost trends shown in Figure 1 are representative of the trends found in these studies looking at the relationship between diagnostic costs and physician patient-centeredness.

Dx Cost and patient CenterednessCompared to physicians with the lowest patient-centered rating, e.g., Lowest Tercile, (aka the highest physician-directed rating), physicians in the Highest Tercile (highest patient-centered rating) reported 10.4% lower diagnostic costs followed by physicians in the Middle Tercile who reported a 9.7% lower diagnostic costs.   

In a 2011 article Is Patient-Centered Care Associated With Lower Diagnostic Costs, noted researcher Moria Stewart et al. projected a 30% savings in diagnostic testing costs across Canada if all physicians there were as proficient in their patient-centered communication skills as those physicians in the top performing quartile of their study.

So Why Are Diagnostic Costs Lower For Patient-Centered Physicians?

To understand the answer to this question one first must understand the difference between a patient-centered communication style and its opposite, a physician-directed or paternalistic patient communication style.

A patient-centered communications approach begins by trying to understand the person behind the medical problem. The focus is on inviting the patient (and family members) into the exam room conversation. This is accomplished by asking patients questions designed to encourage them to open up and share their perspective, e.g., this includes their reasons for the visit (visit agenda), their expectations, fears and health beliefs. Patients’ opinion are sought and their participation in health treatment decisions is encouraged and welcomed by clinicians.

In contrast, the physician-directed communication style focuses on the biomedical facts behind the patient’s presenting problems. The physician is in charge of the visit, does most of the talking and makes all the decisions. The patient is expected to assume what for years has been referred to as a passive sick role…their role being to answer the doctor’s questions and do as they are instructed by the doctor.

Not surprisingly, a patient-centered communication style is preferred by many patients, at least after having been exposed to it (many of us have never experienced it). Not only is it associated with greater patient engagement, but it also is associated with a higher level of patient trust in their physician. And trust in one’s physician is what helps explain why diagnostic use/costs are lower for patient-centered physicians than their physician-directed counterparts.

Patients with physician trust issues (over 50% of US adults have moderate to low trust in medical professionals), are more likely to go into the office visit with requests and expectations for specific lab tests or procedures. For whatever reason, some patients over time come to distrust that their doctor always does the “right thing” or always has the patient’s best interests at heart.

To protect themselves, distrustful patients drop subtle hints about what they want…and in some case come right out and demand the lab test or procedure regardless of what the physician thinks. And physicians, often concerned about upsetting patients by denying their request, acquiesce to at least the less onerous requests thereby driving up costs.

This is not to say that patients that trust their doctor do not make requests for service. They do. But patients who trust their doctor are much open to seeking out and comply with their physician’s recommendation than their less trusting peers.

The Take Away?

As I have discussed in other posts, most physicians today employ the same physician-centered, physician -directed patient communication skills they learned years ago in medical school. Put that together with the fact that over 50% of US adults only have a moderate to low level of trust in medical professions and you have a kind of “perfect storm” when it comes to patients requesting and physicians agreeing to expensive and unnecessary diagnostic tests. A situation that is only made worse by incentivizing physicians to worry more about satisfying patients (giving them what they want) than collaboratively deciding what the patient really needs.

The simplest and most cost effective answer lies in promoting the adoption of new patient-centered communication skills by physicians and other members of the health care team. And the easiest way and most affordable way to accomplish this (heck it’s free to many) is by getting physicians across the US to sign up for the 2014 Adopt One! Challenge.

That what I think…what’s your opinion?


Stewart, M. et al. Is Patient-Centered Care Associated With Lower Diagnostic Costs. (2011) Health Care Policy. Volume 6 No. 4.

Stewart, M. et al. The Impact Of Patient-Centered Care On Outcomes. (2000) Journal of Family Practice. Volume 49 No. 9.

Epstein, R. et al. Patient-Centered Communication And Diagnostic Testing. (2005) Annals of Family Medicine. Volume 3.

The Secret To Patient Engagement – More Engaging Physicians

I was the keynote speaker recently at a national Patient Engagement Symposium   I opened my presentation by asking the audience how many considered themselves to be engaged in their health.   You know…just a show of hands.   Everyone in the room appeared to put their hand up….and no one admitted to not being engaged in their own health.


waiting room b&wWhen asked how to describe “how they are engaged in their health”, true to form most people responded by saying they “I try to take care of myself” by doing X, Y and Z.

The evidence bears this out. 82% of U.S. adults have a regular doctor who their visit at least once a year with the average number of doctor visits being 3/year – double that for people with chronic conditions.

You would think that this level of patient engagement would be music to the ears of physicians, administrators and health IT vendors everywhere…but you would be wrong.


You would be wrong because physicians, administrators, health IT vendors and the like each have their own definition as to what constitutes patient engagement.

Here’s how these groups tend to define and measure patient engagement.

Physicians/Providers Definition Of Engagement

Simply “showing up” for their appointment, even if it is 6-7 times a year, interspersed with copious amounts of self-care, does not constitute patient engagement from the physicians’ perspective. After all, patients often don’t do what they are told by physicians – many patients are non-compliant. 

Since many physicians tend to equate patient engagement with patient compliance today’s high non-compliance rates (30%-70%) suggest to them that most patient are not engaged.  What clinicians are often unaware of is that up to 20% of non-compliance is a function of poor physician-patient communications (disengaging communications) not a lack of engagement.

Health IT Professionals and Vendors

Neither “showing up” nor “the patient’s level of compliance” count for much when it comes to how health IT professionals define or measure patient engagement.  The HIMSS (NeHC) Patient Engagement Framework leads you to believe that the true path to patient engagement is all about the use of health information technology and the achievement of Stage 2 Meaningful Use.  As long as patients use the right health IT tools they are engaged. 

What Health IT folks often ignore is the fact that 85% of patients want the ability to meet face-to-face with their doctor when they feel the need..  They don’t want health technology to get in between they and their doctor which is what some health technologist seem to believe is the answer.

The Challenge For Physicians And Health IT Professionals Is Not How To Engage More Patients….But Rather How To Be More Engaging To The Majority Of Patients Who Are Already Engaged

Let’s face it. Health care is still about everyone except the patient. Most physicians still relate to patients using a paternalistic, physician-directed communication style where the clinician knows best, does most of the talking and makes all the decisions for the patient. Patients are not supposed to be engaged – rather they are supposed to be passive and compliant.

Health IT tends to treat patients as stupid and superfluous when it comes to engagement. Health IT folks turn a deaf ear to the fact that 85% of adults want to be able to meet with their physician face-to-face when they want despite their “willingness” to use secure email, patient portals, open notes, etc. People aren’t stupid – they know you want to insert technology in between themselves and their doctor. They are already complaining about the introduction of laptops and computers in the exam room and how it is interfering with the doctor-patient relationship. How is that supposed to be engaging to patients?

Patient Engagement Is Not Hard

So what is the secret to improving patient engagement? Try being more engaging to patients. That means being more patient-centered versus you centered in how you think about what you do to/for patients, how you talk to/listen to patients, design products and services for patients and what you measure when it comes to assessing patient engagement. It means soliciting the patient’s story…their health beliefs, fears and concerns, understanding their health information needs and interests, understanding their previous health experiences and so on. It means giving the patient credit for having a brain as well as already having a stake in their own health.

That’s what I think.  What’s your opinion?

What Makes A Good Doctor…And Can We Measure It?

The following is a authorized re-post of a recent piece by Ashish Jha, MD from his blog An Ounce of Evidence.  

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change. We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay.

doctor patient communication2But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes. Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:

Twitter- what makes a good doctor

Over 200 answers came rolling in. Listed below are the top 10. Top answer? Having empathy. #2? Being a good listener. It wasn’t until we get to #5 that we see “competent/effective”.

What Makes A Good Doctor

Even though the survey results above come from those I interact with on twitter, I suspect the results reflect what most Americans would want. As I read the discussions that followed, I came to conclude one thing: most people assume that physicians meet a threshold of intelligence, knowledge, and judgment and therefore, what differentiates good doctors from mediocre ones is the “soft” stuff.

It’s an interesting set of assumptions, but is it true? It is, at least somewhat. Most American physicians meet a basic threshold of competence – our system of licensure, board exams, etc. ensure that a vast majority of physicians have at least a basic level of knowledge. What most people don’t appreciate, however, is that even among this group, there are large, meaningful variations in capability and clinical judgment. And, of course, a small minority of people are able to get licensed without meeting the threshold at all. We all know these physicians – a small number to be sure — that are dangerously ineffective. We, the medical community, have been terrible about singling these physicians out and asking them to get better – or leave the profession.

In the twitter discussion, there was a second point raised by John Birkmeyer and that was likely on the minds of many respondents. He said “I’d want different things from my PCP and heart surgeon. Humility. Over-rated for the latter” John was raising a key distinction between what we want out of a physician (an Internist or a family practitioner) versus a surgeon. Yes, in order to be “good”, humility and empathy are important, even for cardiac surgeons. But when they are cutting into your sternum? You want them to be technically proficient and that trait trumps their ability (or lack thereof) to be empathic. Surgeons’ empathy and kindness matter – but it may not be as critical to their being an effective surgeon as their technical and team management skills. For Internists, effectiveness is much more dependent on their ability to listen, be empathic, and take patients’ values into consideration.

A final point. My favorite tweet came from Farzad Mostashari, who asked: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” In all the discussions about being a good doctor, we heard little about effective use of beta-blockers for heart disease, or good management of diabetes care. That’s the stuff we measure, and it’s important. We use them as part of the Physician Quality Reporting System (PQRS). But I’m not sure they really measure the quality of the physician. They measure quality of the system in which the physician practices. You can have a mediocre physician, but on a good team with excellent clinical support staff, those things get done. Even the smartest physician who knows the evidence perfectly can’t deliver consistently reliable care if there isn’t a system built around him or her to do so.

So, when it comes to thinking about ambulatory care quality – we should think about two sets of metrics: what it means to be a good doctor and what it means to work in a good system. In measuring doctor quality, we might focus on “soft” skills like empathy, which we can measure through patient experience surveys. But we also have to focus on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, such as the ability to collaborate and effectively lead teams – and we don’t really measure these things at all, erroneously assuming that all clinicians have them. For measuring good systems, we could use our current metrics such as whether they achieve good hypertension and diabetes control. We need to keep these two sets of metrics separate and not confuse one for the other. And, alas, for surgeons, we need a different approach yet. Yes, I still believe that humility and empathy go a long way – but these qualities are no substitute for sound judgment and a steady hand.