Why Doctors Need To Listen To And Understand The Patient’s “Perspectives” – A True Story

Perhaps the most fundamental principle of “patient-centered care” is for clinicians to understand the patient’s perspective regarding key aspects of a care episode.

Here’s a real life example that just happened to my wife and I that should help you understand what the patient’s perspective is…and why it matters.

Definition of ListeningFor the past week my wife, who is being treated for severe recurrence of lung cancer, has developed fever and chills which present in the early evening.  I notified her Oncologist when the fevers first started.  Upon my wife’s suggestion (she is an RM) a urine sample was taken and evaluated.   She had a UTI and was put on antibiotics.  But the fever (and infection) continued.   Each episode begins with a fever and progresses to chills, coughing, vomiting and disorientation. The episodes last for an hour and then goes away after which my wife sleeps and is fine. That was until yesterday …

Yesterday, while in her oncologist’s office, the fever and chills set in very fast. I did what I could to keep her warm (which is impossible in any doctor’s office) and reassure the staff that this was a “syndrome” she experienced every day presumably as the result of a recent urinary tract infections. The doctor and staff would have none of my explanation …they said she need to go to the ER immediately.  I said “if I take her to the ER she will die … and that I would take her home instead and let the fever run its’ course” as it had up until then.

I tried to explain to the Oncologist that on 3 prior occasions when I took my wife to an ER (in a different town for other reasons) the ER doctors wanted to re-diagnose my wife’s cancer … or worse … diagnose her as being septic and having pneumonia (when she wasn’t and didn’t).   Turns out my wife’s symptoms and chest X-rays mimic those of sepsis and pneumonia.  I was afraid it would happen again if we did what the Oncologist said.  I asked the Oncologist to call the ER and give them a heads up concerning my wife’s condition and a working diagnosis.

He wouldn’t do it.  He wanted the ER to do a diagnostic work up of my wife.  In my mind this confirmed in my mind  that if we went to the ER it would be another nightmare.

What Am I Trying To Say

As my wife’s caregiver, I had a very definite, unmistakable reaction to the doctor’s recommendation that my wife be taken to the ER.  My reaction was based upon my prior ER experiences with my wife – bad experiences which began with a misdiagnosis in the ER, unquestioning acceptance of the diagnosis by hospitalists, followed by the incorrect treatment, intervention by specialists and extended hospital stays.

My reaction was to blow off the Oncologists advice.  He didn’t seem to hear me when I described how my wife’s fever came and went.  I just got the sense that the doctor want scared and wanted us out of his office.   The Oncologist did not want to hear about our previous ER experiences.  He just wanted me to do what I was told.  This doctor has a strong ego and is definitely physician-centered (versus patient centered).

Luckily I took my wife to the ER.  She had a BP of 60/40 and a temperature of 105O.  She was later admitted to the ICU with sepsis caused by an infection.

My Point?

The point of this story is that if the Oncologist took the time to listen to “our story” concerning our previous ER experiences (our health perspective) he would have better understood why I reacted to his advice the way I did.  Had he listened to and understood our story maybe he would have called the ER doctor to give him some “back story” on my wife. But he didn’t … he wouldn’t and that cause me to distrust him and his clinical advice.

Had the Oncologist even told us that my wife had a temperature of 105O or a very low BP I would have done what he recommended. But he didn’t …and I was too stressed to ask.

I’ll bet our experience is like those of many patients and family members today.

The Take Away?

I know I sound like a broken record but the solution is for physicians to become more patient-centered.  This means learning how to think about patients differently … and in turn how to talk with patient differently.

Specifically it means understanding where their patients (and family members) are coming from.  In my case, by understanding that we all come with “baggage” that shapes how we think and behave.  My comment to the effect that “if I take my wife to the ER she will die” should have promoted a “why do you say that?” comment from my wife’s Oncologist.   But that never happened and I am sure the doctor thinks I am a total moron.

I learned an important lesson as well.   Usually physicians do know what’s in the patient’s best interest.  I learned that sometime its’ better to compliant and alive than disagreeable and dead.

It’s just seems however that there has to be a better, win-win scenario than patients always needing to “go along to get along.”

Sources:

Jagosh, J., Donald, J., Steinert, Y., Ellen, M., & Ingram, L. (2011).  The importance of physician listening from the patients ’ perspective : Enhancing diagnosis , healing , and the doctor – patient relationship. Patient Education and Counseling, 85(3), 369-374.

 

 

We Stop Being A “Person” And Become A “Patient” When We Walk Into The Exam Room At The Doctor’s Office

ExamRoom Door2We all play many roles in life …. spouse, employee, sibling, parent, friend, customer, and so on. Each of these roles brings with it its’ own unique set of expectations (self-imposed as well as externally imposed – can you say spouse) for how we are supposed to think and behave. One role that we all play is that of “being a patient.”

The roles and behavioral dynamics that take place in the exam room between patients and physicians gets little attention today. But they should, since the exam room is where diagnoses are made, treatment plans formulated and utilization of health care resources determined. And if outcomes are any evidence, what passes for patient communications these days, and the resulting patient behavior, is anything but patient-centered or high quality.

The Patient’s Role

Beginning with our childhood visits to the pediatrician with our mother, we have all been socialized into the “patient role.” We come seeking the doctor’s expertise. We are petitioners. Our role as patient is straightforward … answer the doctors questions … sit passively by while the doctor does their thing … and upon leaving the office, do what the doctor recommends. Doctors after all know what is in our best interest. Right?

If you do what you were told (recommended) then you care a good patient – compliant and engaged are words that clinicians often associate with good patients. If you challenge the doctor by making requests, taking up too much time, or you do not do what the doctor recommends – you are a often considered a difficult, noncompliant patient.

From the patient’s perspective, good patients get the best care … but if you are a bad patient you may not get the doctor’s full attention … or worse you could be “fired.”

The Doctor’s Role

Doctors too have a role … that of clinical expert. Many physicians will tell you that they were taught 2 things in medical school : 1) how to diagnose medical problems and 2) how to treat medical problems. To the extent that most doctors talk to you … it is for those two purposes alone. Most doctors will tell you they were never taught in medical school to get to know the patient (or person). They will also tell you they often wish patients would “shut up” after they have the information they need to arrive at a working diagnosis.

Physician Communication Styles2To do their job, physicians were taught the need to control the visit by the way they communicated with patients. Traditionally, physicians learned by watching their medical school preceptors and mentors that the way to “control the visit” was to control who the communications between they and their patients. This “physician-directed” (aka paternalistic) communication style is where the physician does most of the talking, asks most of the questions ( usually closed ended) and makes most if not all the decisions.

Here’s a comment I received recently for a decidedly Physician-Directed (Paternalistic Physician) that illustrates their role mindset: An estimated 70% of practicing physicians today employ a “Physician-Directed” style when talking with patients.

Physician-Centered QuoteOver the last 20 years, there has been a resurgence in the importance of understanding and treating the whole person … and not just their medical problems. This has lead to what is commonly referred to as Patient-Centered Care.

A patient-centered style of communications seeks to actively involve patients in the medical exam. The focus is not just on the biomedical aspects of the patient’s disease … but also how patient perceive their health issues, their ideas as to it cause as well as its treatment. It simply means that the clinician ask them for their thoughts as a way of making a better diagnosis and arriving at a better treatment plan. One they both can agree upon. A Patient-Centered style also focuses on patient psychosocial issues which are all but ignored by the Physician-Directed style.

Note : Nothing about a Patient-Centered Style suggests that physicians give patients anything they want even if they don’t need it. It means that if patients asks for something they don’t need, the clinician seeks to understand the reason for the patient request. And if unnecessary, the clinician gives the patient the courtesy and respect of explaining why they think the request is inappropriate.

Implications Of Roles and Communication Styles

Now you need to ask yourself the following questions

If 7 out of 10 physicians, including those in your provider networks, do not know how to “speak Patient-Centered”, how can you expect them to do the following:

Engage patients – How engaging is it when you doctor interrupts you, ignores or dismisses your input, or limits the number of questions you can ask …and information you receive?

Be Empathetic – If your doctors see no point in eliciting patient psychosocial issues … what makes you think you can they are doing it?

Shared Decision-Making – If you doctors just assume that patients want/expect them to make the decisions why in the world would you expect them to ask the patient what they think? They don’t solicit the patient’s input about anything else?

Missed Patient Engagement Opportunities – The average patient presents from 9 to 12 patient engagement opportunities at each visit. Most doctors miss more than 50% of these opportunities. not because they lack the time…but because their either don’t recognize them as opportunities, don’t know how to respond or simply ignore them. That comes out to almost 100 missed patient engagement opportunities per doctor per day. Remind me what the cost of an unnecessary ER visit or hospital readmission is again?

So What’s The Solution?

Hospitals, ACOs, Medical Groups and Health Plans should work with physicians in their provider networks to do the following:

  1. Commit to adopting patient-centered communication best practices – they do exist, there are 30+ years and hundreds of published studies linking patient centered communications to increased patient engagement, better outcomes, lower costs and better patient experiences.
  2. Profile and benchmark your physicians’ patient communication and engagement skills against established best practices. Audit how many patient engagement opportunities are being missed by physicians in your provider network and at what cost.
  3. Conduct patient communication and engagement skills training programs tailored to the individual needs of your physicians.

Stephen Wilkins, MPH, Principal

Mind the Gap Academy

www.mindthegapacademy.com

Conflict of Interest: My company works with hospitals, ACOs and Medical Groups to assess and benchmark physicians’ patient communication and engagement skills. We also offer online physician training in patient-centered communications and engagement.

Sources:

Roter, D. L., Stewart, M., Putnam, S. M., Stiles, W., & Inui, T. S. (1997). Communication Patterns of Primary Care Physicians. JAMA (277), 350-356.

Joseph-williams, N., Elwyn, G., & Edwards, A. (2013). Knowledge is not power for patients : A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Education and Counseling.

Levinson, W., Stiles, W. B., Inui, T. S., & Engle, R. (1993). Physician Frustration in Communicating with Patients. Medical Care, 31(4), 285-295.

Alexander, J. a, Hearld, L. R., Mittler, J. N., & Harvey, J. (2012). Patient-physician role relationships and patient activation among individuals with chronic illness. Health services research, 47(3 Pt 1), 1201-23.

Levinson, W. (2011). Patient-centred communication : a sophisticated procedure. BMJ Quality And Safety, 20(10), 823-826. doi:10.1136/bmjqs-2011-000323

Is Trying To “Convince” People To Use Health Apps They Don’t Want The Right Approach To Patient Engagement?

If patient-centered care is supposed to be about “respecting the patient’s perspective” where possible… as well as an measure of high quality health care … then why are RWJF and the Center for Connected Care teaming up to “convince” people to do what they have shown they don’t want to do? That’s provider-centered care (aka beneficent paternalism) not patient-centered care. I am confused…someone help me out here.Paternalistic vs Patient CenteredIn a recent announcement, the Robert Wood John Foundation announced a $468,000 grant to the Center for Connected Health to develop an “engagement engine” to “convince” consumers to use health and activity trackers and other health apps.

Why? According to the announcement:

Few [consumers] are using them [health apps] beyond a couple months. And that’s why providers are hesitant to jump on the bandwagon

The marketing logic is clear enough. RWJF and Connected Health believe they need to get more patients to use health apps…in order that they will then tell their doctors about the apps..in the hopes that doctors will then recommend the apps to other patients. What is not clear is why is RWJF and Connected Health “doubling down” on health apps in the first place. It is not like the consumer market is tripping over themselves to use them …with the possible exceptions of the quantified self users.

Does RWJF or Connected Health really believe that “putting new wine in old wine skins”, e.g., an engagement engine, is somehow going to make all these discarded or unused health apps more desirable to consumers and physicians? Isn’t it just possible that maybe consumers have good reasons for not wanting/using health apps, reasons like lack of product relevance, lack of product value/usefulness, ease of use and so on?

Let’s consider the issues of relevance and usefulness:

Relevance - Many providers believe that most people (patients) today are generally “unengaged” in their health. Why? It is because patients don’t do what they are told to do by providers. After all, doctors have the best interests of their patients in mind when they tell them to exercise, lose weight, etc. When patient are nonadherent…it’s because they don’t care…they are unengaged. By extension…developers of health apps – who often include physicians – think about patients the same way. It never occurs to providers or developers that patients might have good reasons for their nonadherence, i.e., they don’t agree with treatment recommendation, don’t understand what the doctor told them to do, can’t do or afford to do what the doctor recommended and so on.

I would go even further in saying that many provider (and health app developers) have disdain for patients and their cognitive ability to understand things pertaining to their own health.

Consider the following quote from Joe Kvedar, MD, of the Center for Connected Health Care, which is the beneficiary of the RWJF grant:

In healthcare, we can’t just give people what they want. The challenge in healthcare is that, though we [physicians] know what patients/consumers need to do to improve their health, most of them don’t want to hear about it.”

Privately, in meetings and conferences about patient engagement, we have all heard how patients (that us folks) are fickle, dumb, lazy, unengaged, or otherwise incapable of understanding what it is they should be doing when it comes to their health and health care. This line of thinking shouldn’t come as a surprise to anyone. This paternalistic, “I know best” style is how most doctors communicate with and relate to patients today. It’s how doctors were taught in medical school to relate to patients .

Now juxtapose this paternalistic, physician-centered “view” of patient engagement with the patient’s perspective, e.g., patient-centered perspective.

Fact: Over 80% of US adults see their doctor at least once a year – the national average is 3 visits/year – double that for patients with a chronic condition.

Now what is it about these statistics that “screams” unengaged? Why would so many people who are so “unengaged” spend so much time making and waiting for an appointment to do something they care so little about? They wouldn’t!

Fact: Patient have their own ideas of what constitutes “health” and they have their own ideas and preferences for how best to achieve their health goals.

But since providers seldom solicit the patient’s perspective, the patient’s beliefs and motivations tend to get lost during the medical exam. Health apps are no different. A patient that doesn’t like to take pills will balk at a recommendation to take an Rx medication. A person who lives in an unsafe neighborhood will cringe at being to walk the dog around the block to lose weight. You get the idea.

Is it any wonder that health apps designed from a paternalistic, physician knows best point of view do little more than disengage consumers that consider themselves knowledgeable and engaged?

Usefulness – How many of us have been asked by our physician at one time or another to record some aspect of our health behavior like our blood pressure? I know I have and I also know how it felt when the doctor never asked to see the results at a follow-up visit? What a waste of time.

Patients know from experience that physicians will probably never pay any attention to the data collected by a health tracking app. If my doctor never bothered to ask about my BP that I recorded (at his request) so diligently on an Excel spreadsheet…why will they care about the data captured by Fitbit?

Physicians, for their part are already overwhelmed with more data than they know what to do with. Since many doctor’s EMRs don’t “play well” with the hospital’s EMR system is it little wonder that physicians are not terribly excited about paying to add more health app interfaces to their EMR?

Unless and until the data from health apps can be seamlessly integrated into the patient visit record…and physicians actually do something with the data for the patient’s obvious benefit…both physicians and patients will fail to see the usefulness of health apps (and portals).

My suggestion to RWJF and Connected Health is to step back and consider the relevance and usefulness of health apps from the consumer’s perspective before trying to “convince” or “sell” consumers of their value. Also, lose the “doctor knows best” message in favor of a “patient knows best” message that acknowledges the patient’s ability to decide what’s best for themselves. Telling your target market how dumb they are is never a good marketing strategy.

If you need help…you know where to find me…

Patient Engagement & Health IT – Disillusionment Sets In Poll Shows

This week, the 2015 HIMSS Patient Engagement Summit is taking place in sunny, warm Orlando. According to HIMMS, conference attendees will learn how “leading healthcare organizations” are successfully using health IT and other strategies to engage patients in their care.

Portal Not EngagementWhat I suspect attendees will not hear much about at the Summit (particularly from speakers and exhibitors – one in the same?) is the growing “disillusionment” with the ability of patient portals, EHRs/PHRs and smart apps to actually engage patients at all. One only need look at the dismal adoption rates of these technologies (in the very low double digits if that) within most provider organizations, Kaiser, Group Health and Geisinger being notable exceptions.

What disillusionment you may ask?

Recently I conducted my own informal poll on LinkedIn’s HIMSS Group by ask the following question:

 

Untitled-1

If a patient chose NOT to use your patient portal, PHR or smart health apps do you consider them to be “unengaged” in their own healthcare?

The question was prompted by all the “over the top claims” by HIMSS (See their Patient Engagement Framework) and EHR and Health IT bloggers that patient portals, EHRs and smart apps are what drive patient engagement.  Come on now.

If that were true, that would mean that prior to the World Wide Web in the early 1990’s it was impossible for people to be engaged in their own healthcare.  That is simply not true!

Who doesn’t recall Healthwise’s big old health handbookHealthwise Handbook.  It must have weighed 5lbs! Or who doesn’t remember “Ask A Nurse” – that ubiquitous 1-800 number you could call at 3:00 AM a health question? And of course there was always the doctor, family member or friend you could discuss your health concern with. To this day, more health conversations among seniors probably occur in McDonalds over morning coffee than on some EMR or health app.

But I digress…

So what were the results of my informal poll?

Take a look for yourself. Below are snippets from some of the 70+ responses (and counting) I received from members of the HIMSS Group which consists of developers, venture capitalists, informatics, vendors and clinicians.

What surprised me the most was how few “good things” people had to say about health IT in general…not just with regards to patient engagement.

  • I am in healthcare IT and I still have not used my EPIC portal for scheduling an appt, view results, etc. because it is has been too much trouble to access.
  • Are they “unengaged” if they do not use these tools? Absolutely not. [ . . .] I actually consider patients who use the portal, PHR or apps and are NOT having direct contact face-to-face or by telehealth as being “unengaged”. Patient engagement is a very personal and individual decision made by the patient and can change drastically at any given time.
  • It seems we too often try to use technology to replace human interaction. Patient engagement requires human interaction and collaborative work between the provider and patient.
  • Until the portal becomes a) easy to use and relevant, b) doesn’t have 20 pages of legalese and c) can converse with you via email, txt, Instant Messages or phone; there will always be a substantial portion of the population that won’t use them.
  • Ok, [patient portals]not normally a big deal until you read the terms of service which, paraphrasing the legalese, said “If we are breached, it is your fault. We are not responsible for losses you might incur. If it is determined that the entire system was compromised through your account you will be responsible for our costs to remedy the situation”.
  • Match […]the technology to the message. I am aware of HIPAA secure phone mail systems that get 83% of patients using the system to listen to messages left for them by a clinician within 24 hours. We are all used to voice mail and using the phone.
  • Engagement should be defined by the level of interaction with a provider, and the resulting outcomes. So, no, I think assessing level of engagement by use of the technology is pretty limited.
  • If you want to know why patients and physicians do not use portals, it is because they are designed by EHR companies that design them as poorly as they design EHRs. Combine that with Byzantine security procedures, and you get a somewhat useless system.
  • The assumption that a percent of users accessing data on a portal = patient engagement is where we fail! A percentage of people will access a portal for various reasons, and they will also NOT access a portal for various reasons. The real question should be…. what can we do to make the info easier to access and easier to understand.
  • Point me to a portal that you believe is patient friendly, put on your flak jacket and give me 30 minutes to make you understand that the portal smells worse than pig effluent.
  • Why would I be forced to go through all of the userID creation (I have somewhere around 250 of them in my Google profile) etc. just to give doctors access? Why can’t I tell the people at the radiology site that Drs A, D, V & Z can have access? I am extremely engaged in my health as a nearly 30 yr Type 1 Diabetic. But what you just described sounds like more PITA administration that I have ZERO interest in.
  • You cannot force adoption, it comes to good products and causes bad ones to fail.
  • I am committed to health (as opposed to healthcare) and I take an active approach to wellness. [ . . . ] Since my hospital-employed PCP implemented EPIC, my relationship with that office and my doctor has significantly degraded. The implementation of EHR and its patient portal caused me to disengage, not engage.
  • Meaningful Use is the worst government policy since the Vietnam Conflict. Over 75% of doctors have stated that MU is a disaster and patients are waking up to this fact.
  • EPIC and others have developed their EHR to generate revenue for the healthcare providers and they are forced to create patient portals due to regulations.
  • Whatever use case you can think of, the patient MUST gain value in issuing a portal (I hate this 15 yr out of date term…) or you’re causing them pain and suffering just to cut administrative costs for the provider.
  • We have to address “what is in it for me?” [when I comes to patient use].  The point is that barely nobody is engaged towards tools
  • Give me a bad patient outcome and an EMR primarily designed to bill, that allows cut and paste, and populates differential diagnoses without requiring the provider to rule each out, and I will show you a lost med mal case.
  • We are looking to technology to fix a human problem… taking their health for granted.
  • Providers, use the portal to tell your patients how they can help you be most efficient. Have your EHR builders “put your heart in your letters” why this is a valuable resource, that you support it also.
  • If the providers don’t trust it, neither will the patients, and then it [patient portal] truly is useless.

Take Aways?

No surprises here. When people in the business are honest about it, based upon my limited, informal sample, many just don’t buy into the patient engagement-Health IT hype.

Of the 70+ responses

  • No one “believes” that health IT actually “creates or drives” engagement where it did not already exist.
  • Many recognize that patient engagement occur between patients and their physicians – HIT is just useful medium for supporting that relationship.
  • There are lots of problems with patient portals beginning with:Their purpose
    • Who really benefits (clinician-patient-payer)
    • Terms and conditions of use, e.g., legalese
    • Relevance
    • Usability
    • Interoperability
    • “Byzantine” Sign In and User ID Practices
  • Some believe that portals actually caused them to “disengage” rather than engage
  • How one “rolls out” their portal to patient and physicians is critical

The bottom line when it comes to portals I would offer the following advice:

  1. Be clear about why you are implementing a patient portal
  2. Involve patients (and clinicians) in the planning and development
  3. Enroll clinicians to introduce portal to their patients
  4. Be clear about what constitutes success, including how you will measure it

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.

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?

 

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?

Sources:

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.

Caveats?

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?

Sources:

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 ?