Patient-Centered Physicians Have Lower Diagnostic Testing Costs

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For many physicians, the term “patient-centered” conjures up fears of longer office visits and patients demanding expensive diagnostic tests and procedures they don’t need.

There concerns are completely understandable. After all, medical schools until recently never really taught physicians what it meant to be patient-centered…or the intrinsic benefits of being patient-centered. It doesn’t help that the only exposure many physicians have had to patient-centered care have comes from ill informed, caustic comments found all too frequently on physician websites like KevinMD.com.

But the reality is that these “perceptions”, while real to the beholder, don’t necessarily stand up to the evidence.

Take the belief that patient-centered care is synonymous with increased diagnostic costs in the ambulatory or office setting.

Several US and Canadian studies in recent years have shown just the opposite…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?

Sources:

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.

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

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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.

The Power Of Conversations Between Physicians And Patients

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People always ask me how I got started with my work in physician-patient communications.  Like so many people, I had a story that I felt needed to be told.  Much of my inspiration over the course of the last five years of writing Mind the Gap have come from my wife and my journey as we deal with her Stage IV Lung Cancer.

But there was also a video I saw back in my blog’s early days that really gave me a sense of direction.  A video featuring Maggie Breslin, at Mayo Clinic’s Transform 2009 Symposium.  (Maggie is no longer with Mayo)  At the time I was so taken with Maggie’s presentation that I pick up the phone and spoke with her about her “Power of Conversations” experiences.    Well I rediscovered that video in a recent guest blog post on Mayo Clinic’s Center for Innovation Blog.  The piece was written by by Nolan Meyer,  a student at the University of Minnesota Rochester .

Here is Nolan’s post which includes the video.  I hope it inspires you as much as it does me.

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If you were to guess why patients consistently return to the Mayo Clinic and recommend the Mayo Clinic to friends and family, what reason would you venture? Unparalleled medical expertise? Superior technology? Prestige? Tropical weather conditions?

In contrast, the number one reason is not solely due to the excellent quality of care they receive. It is not that they receive pioneering procedures at a world-class academic medical facility, nor is it space-age medical technology. It’s not that they were prescribed miracle medications that exist nowhere else.Rich conversation is the pathway to quality, to efficiency, to affordability… when we have good conversations, we are practicing individualized medicine in its most authentic—it’s most human—form.”

The reason patients return to Mayo Clinic is that providers here take the time to connect with their patients—to talk with them and ensure all their patients’ questions are answered. This connection forged between Mayo Clinic healthcare staff and their patients ensures the concerns of patients and their families are understood and fully addressed. Although the Mayo Clinic is a premiere and world-class academic medical institution, the meaningful connections made here between providers and patients are what bring people back again and again.

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

It’s Free For  Qualifying Physicians

In a time of healthcare reform, extensive regulations, standardization, and malpractice suits, when many healthcare institutions have turned to emphasize numbers of patients seen over the overall quality of healthcare delivery, the Mayo Clinic has remained steadfast in its familiar maxim: “The needs of the patient come first.”

I believe that if we make satisfying conversations and human connection the focus of our healthcare delivery development—if we make connecting people and having them talk to each other the single most important metric by which we judge all of our efforts—we will get everything else we want our healthcare system to be. Rich conversation is the pathway to quality, to efficiency, to affordability… when we have good conversations, we are practicing individualized medicine in its most authentic—it’s most human—form.”

Maggie Breslin, in a research-and-design effort put forth by the Center for Innovation’s Spark Design Lab, set out to find and address elements that enhance or impede quality of healthcare delivery. Maggie was granted access to observe healthcare interactions in various departments of the Mayo Clinic. During her time working on this project, Maggie observed thousands of healthcare interactions ranging from the mundane to the life-changing. Maggie observed everything from annual influenza vaccinations, to radiological studies, to discussions of unforeseen treatment complications, to emotionally wrenching diagnoses of debilitating conditions.

These thousands of observed interactions qualifies Maggie to tell us what quality healthcare delivery looks like, and according to her, it looks like a satisfying conversation. According to Maggie, quality healthcare delivery is “the most human thing you’ve ever seen in your life!” Working on this groundbreaking project, Maggie became familiar with four powerful insights regarding conversation in healthcare:

  1. Conversation is how people determine quality and value.

  2. Conversation has therapeutic value.

  3. Conversation allows us to deal with ambiguity.

  4. People seek out conversation, even when we make it hard for them.

 While some of these observations may seem intuitive, they have fallen by the wayside in many modern medical institutions. The power of a simple conversation in a medical setting seems to have been deemed “nice-to-have,” but unnecessary and extraneous by many modern designers of healthcare delivery. This is an unfortunate trend, as the importance of translating advanced scientific and medical knowledge from provider to patient is more important now than ever. Maggie asserts that these satisfying conversations are not a “nice-to-have,” an extra, an unnecessary and time-consuming luxury in modern medicine. Quite the contrary: satisfying conversations are what Maggie calls “the very essence of healthcare delivery.”

Maggie relates a story in which she and her colleagues set about the hospital in search of factors which enhance or impede human connection. Her team found a startling pattern: the presence of human connection in healthcare delivery was, by and large, the result of the actions of outgoing individuals. In contrast, the absence of human connection was the result of often-unforeseen systematic hurdles. Maggie argues that in modern medicine, too many decisions are being made in the name of efficiency, standardization, legal requirements, documentation, and numbers.

All of these decisions contribute to the construction of what Maggie calls a wall between providers and patients. The inspiring thing, though, is that both patients and providers make what Maggie calls a Herculean effort to jump over that wall and find ways to connect with one another.

The Mayo Clinic’s efforts to recognize and address impediments to meaningful patient-provider interactions are an example of how it strives to provide the best patient care possible. Maggie Breslin calls on everyone involved in healthcare delivery and its design to ask themselves one question as they do their work: what kind of conversation will result from this concept? If the answer is “a better conversation,” then have that mean something!

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

It’s Free For  Qualifying Physicians

Why Would Geisinger Health Take A Paternalist Versus A Patient-Centered Approach To Patient Engagement?

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I am always a bit ambivalent about coming off as “too preachy.”    I am at an even greater loss as to when it’s OK to find fault with what others say or do when it comes to patient communications or patient engagement.

But sometimes I just have got to say something…and this is one of those times.do this

The setting was a presentation earlier this week at HIMSS 2014. The presenter was Chanin Wendling, the Director of eHealth at Geisinger Health System.  Channing was talking about Geisinger’s often-cited HIT-driven patient engagement efforts which includes their patient portal, health apps and a recent foray into “Open Notes.”

What struck me was Chanin’s description of the philosophical approach and communication style employed by Geisinger Health in the course of developing content for these engagement tools.

Here’s what she said.

“We tend to think in a paternalistic way: this is what the patient needs, versus thinking ‘What will work best for the patient?’ and ‘How will the patient relate to whatever we’re prescribing?’ And that’s extremely important because at the end of the day, if you can’t get the patient to help, if they don’t take their meds, if they don’t lose the weight, if they don’t do their exercises, there’s nothing you as a clinician can do. You need the patient to help you.”

Here are two things that jumped out at me from Chanin’s comments;

1. Geinsinger’s patient communication style is paternalistic and physician-directed…meaning that it is the direct opposite of a patient-centered philosophical approach and communication style.  You will recall that an increased focus on “patient-centeredness” was called for in the IOM”s Crossing the Quality Chasm.

A patient-centered communication style begins with an understanding of the very things Chanin says Geisinger ignores – what will work best for the patient and how patients will relate to a proposed intervention.

The evidence is clear that a patient-centered approach…not a paternalistic, “we know best” approach…is linked to increased patient engagement, better outcomes, more adherent patients, lower utilization and better patient experiences.

patient communication style continuum(1)2. Geisinger Health is not alone in its belief that patients are inherently unengaged in the health, e.g., patients won’t help clinicians unless told by clinicians what they need to do.  This same “we know best” physician-directed patient communication style is what most physicians learned years ago in medical school.  So it is not surprising that this same style of communications has it has found its way into other forms of communications like patient portals and health apps. But come on…this Geisinger Health we are talking about and they really should know better.

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

It’s Free For  Qualifying Physicians

After all,  82% of U.S. adults visit their doctor at least once a year…the average being 3 visits/year…and double that for people with chronic conditions. Why? Because “they” think it’s the right thing to do.  And yet Geisinger Health thinks that patients are “not willing to help” providers do their job?  Are you kidding me?

The problem today is not that patients are unengaged…but rather that many providers aren’t very engaging.   Sure 50% of patients are non-adherent…but 20% of patient non-adherence has been attributed to poor physician communications, e.g., paternalistic, physician-directed communications.  Sure less than 10% of patients visit the average patient portal in a year…but when portal contents and functionality treats one like an uncooperative child why would anyone expect a higher level of adoption?

The Take Away?

Unless and until provider organizations like Geisinger philosophically come to grips with the fact that patients, aka people, are often already engaged and knowledgeable, albeit in ways that are different from how providers expect…nothing is going to change.

The solution? Become more patient-centered in the way you think about, interact with and communicate with patients.

That’s my opinion. What’s yours?

 

Some Practical Advice For HIMSS 2014 Attendees…

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HIMSSHIMSS14, the big conference for all things dealing with health IT, is right around the corner. It’s a great conference – wish I could attended this year. But my wife’s health keeps me close to home these days.

Since I can’t be there on my soap box, I want to share here a few thoughts for HIMSS 2014 attendees to reflect upon as they wander the conference and exhibit halls. Some first principles to help you “keep some perspective” as speakers and exhibitors attempt to dazzle and maze you with promise of what HIT can do for you.

Let’s get started…

First Principle #1

There’s a big difference between what people tell survey researchers they will do or what they want (80% for example say they want and would use a service that enabled them to email their doctor)…and how people actually behave in real life (less than 10% of patients/plan members with aces to secure email on their patient portal routinely use it).

First Principle #2

Patient engagement may be next “blockbuster drug” as Dave Chase said but like any drug you need a trusted doctor with good patient-centered communication skills to prescribe it. Put another way, the vast majority of health “care” is delivered in the context of a trusting physician-patient relationship. If a patient-facing HIT solution purports to cut the doctor out by talking directly to patients…walk away.

One of the big reasons that PHRS and patient portals are going nowhere is because physicians were not included in their development (nor patients for that matter) and are not inclined to tell/recommend that patients use them.

First Principle #3

Patient-facing HIT cannot compensate for a clinician’s poor patient communication skills or bad bedside manner. Absent a strong doctor-patient relationship and good patient-centered communications, patient portals, health apps and SMS texting will not increase patient satisfaction or improve patient experiences.

First Principle #4

It’s about the message not the technology. Sure patient-facing technologies like SMS texting can deliver a message to the right person…but what if the message is wrong? Before you “buy” into patient-facing technology look for the “Patient Inside” logo…you know proof that real people (aka patients) were intimately involved in crafting and testing the messages to be deliver.

First Principle #5

Pushing more information at patients (regardless of how vital you think the information is) will not change people’s health behavior. That’s not how behavior change works. Rather, people need to know they have a problem, they (not you) need to believe the problem is serious, they need to know that they can fix the problem by doing X and finally there needs to be a cue or call to action. Technology can but absent a diagnosis and appreciation as to its severity…information alone is just digital gobble dee goop.

Finally, if you forget everything else, just remember that 85% of people still want the ability to be able to see their doctor “face-to-face” regardless of how many patient-facing HIT solutions you put in front of them

Oh and don’t forget…like doctors…patient-facing health technologies should do no harm to anyone…patient, family or providers.

Have a great conference!

Thanks my opinion. What do you think?

Doing Patient Engagement For The Wrong Reasons Doesn’t Work

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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 engagement 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

We Have Been Socialized From Childhood To Be Passive When A Patient – But That Doesn’t Mean We Are Not Engaged

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socialized to be passiveIn a recent email exchange, the physician I was corresponding with wrote “many people [that] go to see doctors are not engaged in their health.”  My normal reply would have been “what do you mean not engaged…these people wouldn’t be in the doctor’s office if they weren’t engaged.  Instead, I thought about what is that would suggest to a physician that the person on their exam room table was unengaged.

Then I remembered – it probably is the passive sick role we patients assume when entering the doctor’s exam room.  

As people we all assume multiple roles throughout our lives. We are husbands, wives, friends, parents, bosses, and employees. And at some point or another, we are all a patient sitting on a paper-covered exam room table in some doctor’s office.

Each of the roles we assume come with a corresponding set of “rules” that help define how we are supposed to behave. Wives are always right…and husband wrong. Children are supposed to obey their parents and not talk back. Don’t argue with a police office when pulled over for a traffic ticket. And when called into the doctor’s office exam room we automatically assume a passive “sick role” opposite the clinician’s role as expert.

What Does This “Passive Sick Role Behavior” Look Like?

From the physician’s perspective, passive sick role behavior looks like we don’t care very much about our health…at least not enough to:

  • Do as we are told with respect to our health
  • Ask the doctor relevant questions
  • Ask the doctor for information
  • Challenge the doctor on diagnosis or treatments
  • Demand that we engage in shared decision making

 

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

It’s Free For  Qualifying Physicians

A couple of key concepts typify passive sick role patient thinking and behavior as we sit in the waiting area and exam room:

Minimization of our problems and concerns

  • That person looks a lot sicker than me
  • That frail old woman deserves a lot of time and care
  • I don’t need to bring up all my problems or concerns at this visit

Respectfulness and understanding of the demands placed upon our busy doctor

  • I’ll whittle down my list of questions to one or two – surely the doctor will be too busy to answer my questions
  • I’ll just wait until I get home and look up what I want to know on the internet
  • I guess if I were as busy as my doctor I would limit patients to one question just like I have read about
  • Poor guy/gal…he/she is way too busy for me

Memories of previous experiences visiting doctors going back to childhood

  • Doctors never remember who I am – as long as he/she covers the basics I will not make a fuss
  • Doctor wants to be the boss so I will sit her and just listen
  • The last time I asked a question the doctor laughed at me
  • I read somewhere where doctors can “fire” patients if they don’t like them
  • My friends say not to act like you know more than your doctor…they don’t like it

So Why Do We (Patients and Doctors) Behave This Way?

That’s simple. Just as we were socialized into our role as a child, sibling and parent, we learned very early on how we were supposed to behave in the doctor’s office. I guess we can all blame our mothers.  After all they were the ones that took us to the pediatrician…and we never saw them question or challenged the doctor.

Don’t blame physicians either. They were taught to behave the way they do in medical school. In other words people come to a physician with a bio-medical problem (think acute) and you are supposed to diagnose and fix the problem. That’s it. You are not supposed to fix people’s lives, heal their marriages or hold their hands. The disease-oriented, physician-directed communication style still employed by the majority of physicians is an artifact of the “doctor as expert role” they were taught in medical school.

These Roles And Social Conventions Are Major Barriers To Fixing What’s Wrong With Health Care

Thirty years of evidence documents the following trends:

  • Patients ask very few important questions of their doctors out of fear (looking stupid, not wanting to appear difficult, because they are limited to the number of questions they can ask.
  • Patients often are very selective in terms of the information they are willing to share with their doctors
  • Patients give doctors the benefit of the doubt where it comes to poor communications and service.
  • Patients are afraid to challenge doctors for fear of being fired or branded as “difficult.”
  • Patients often disagree with their doctor’s diagnosis or treatment plan but will not raise the issue directly with the doctor out of fear.
  • Doctors assume that patients know more than they do about their health and patients feel doctors are too busy to ask for information.

Put another way, the roles and social conventions discussed here are a  major barrier to:

  • Patient engagement
  • Patient-centered care and communication
  • Reducing medical errors and improving safety
  • Improving patient adherence
  • Better patient health outcomes
  • Reducing preventable ER and Hospital Use
  • Improving patient experiences

What Is The Solution?

  1. Acknowledge the problem
  2. Look to high performing physicians that have “figured it out.”
  3. Get your physicians to talk about their own communication skills
  4. Conduct an assessment of your physicians’ patient-centered communication skills
  5. Offer training (in person/online) to help your physicians develop new patient-centered communication skills
  6. Teach patients how to behave and talk with physicians in today’s Brave New World

 

That’s my opinion. What’s Your?

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

It’s Free For  Qualifying Physicians

 

Satisfaction With Provider Communication In Recent Study Is Lower In Patient Center-Medical Homes (PCMH) Than Non-PCMH

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A recent blog headline on the Patient-Centered Primary Care Collaborative (PCPCC) recently caught my attention.  It was entitled Patient Satisfaction With Medical Home Quality High.  I was intrigued.  I asked myself high compared to what?  Non-PCMH practices?

The study, which appeared in the November-December 2013 Annals of Family Medicine, asked 4,500 patients (2009 Health Center Patient Survey) of federally-support health centers (not all accredited PCMH) their perceptions of a number of “patient-centered quality attributes,” including the following measures which the study authors defined as patient-centered communication:Quotelowbar

  • Clinician staff listened to you?
  • Clinician staff takes enough time with you?
  • Clinician staff explains what you want to know
  • Nurses and MAs answered your questions?
  • Nurses and MAs are friendly and helpful to you?
  • Other staff is friendly and helpful to you?
  • Other staff answered your questions?

 

Observations About The Study

The first thing that struck me was that compared to patients in the 2012 CHAPS survey (AHRQ) website, patients in the 2009 PCMH study actually reported lower levels of 1) patient satisfaction with their clinicians’ patient-centered attributes (including communication) (81% in study versus 91% in CHAPS) and 2) lower in willingness to recommend their providers (84% study versus 89% in CAHPS).

The second thing I was reminded of is that patients themselves are so used to clinicians’ paternalistic, physician-directed communication style that simply allowing them to ask just one question puts the clinician in the top 5% of patient-centered communicators.  Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition?  Until recently I never have been and I suspect few if any people in the study cited here have either.

Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition?

The final thing that struck me was that none of the quality measures used in the study captured the “essential and revolutionary meaning of what it means to be patient-centered.” As health communication experts Street and Epstein point out, patient centered communication is about inviting the patient to get invDont Tripolved in the exam room conversation.

As articulated in hundreds of studies over the years, patient-centered communication skills include:

  • Soliciting the patient’s story
  • Visit agenda setting
  • Understanding the patient’s health perspective
  • Understanding the whole patient (biomedical and psychosocial)
  • Shared decision-making
  • Empathy

 

Nothing remotely close to these skills are included in the 2009 PCMH study.

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

It’s Free For  Qualifying Physicians

We Need To Raise The Bar For Patient-Centered Medical Homes (PCMH)

Studies like the one cited here set the quality bar (and bragging rights) way too low for PCMH. Patient-centered care has to be different than the paternalistic, physician-directed care we all seem so willing to accept. Such studies trivialize what it means for physicians and their care teams to be patient-centered in the way they relate to and communicate with people (aka patients). Patient-centeredness is a philosophy or care…and does not require team care, extended hours or care coordinators. These are great added features, but to equate such services with patient-centeredness misses the boat…something which professional groups like the PCPCC, NCQA, Joint Commission, and URAC should recognize by now.

The Take Away?

Here’s some thoughts:

1) We need to set the bar higher for PCMHs when it comes to how we define and measure patient-centered communication.

2) We need to find better ways to asses patient-centered communications in actual practice. Patient rating of a clinician’s patiient-centeredness are simply not enough.  As part of the 2014 Adopt One! Challenge, we will be using audio recording of actual physician-patient exam room conversations to measure and benchmark clinicians’ patient-centered communication skills.

3) We should stop celebrating being average whether it be in PCMH setting or hospitals when it comes to physician-patient communications.

That what I think. What’s your opinion?

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

It’s Free For  Qualifying Physicians

Sources:

  • Lebrun-Harris et al.  Effects of Patient-Centered Medical Home Attributes On Patient’s Perception Of Quality In Federaly-Supported Health Centers. Annals of Family Medicine. 2013; 11:6; 508-516.
  • Street et al.  The Value and Values of Patient-Centered Care. Annals of Family Medicine. 2011; 9; 100-103.

The Typical Physician Misses Hundreds Of Opportunities To Engage, Empower & Excite Patients Every Day

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Did you know that on a typical day in the office seeing patients, the average physician misses hundreds of opportunities to engage, activate patients and excite their patients?

Why?  It’s not because they are too busy.   Research shows it is because physicians don’t have the right patient-centered communication skills and know how.

During the course of a typical office visit, patients provide clinicians with a great many verbal and non-verbal cues indicative of what they are thinking or feeling.   “A cue, whether verbal or nonverbal, is always an indirect signal that a patient uses to try to alert the doctor to a question or concern.  The cue’s value depends upon whether the doctor recognizes and understands the cue.

These cues maybe be relative obvious such as when a patient tells the doctor I am depressed.   But more often than not, many cues are not so obvious but rather hinted at as in their facial expression or body posture.  However expressed, each of these cues represents an opportunity for the physicians and their staff to engage the patient and in turn empower them and excite them.

Take the following physician-patient exam room exchange:

Just in this brief conversation about the patient’s knee, there were at least 4 cues verbally expressed by the patient.  These 4 cues in effect represent 5 opportunities for the doctor to:

  1. demonstrate that they were mindful and listening to the patient
  2. demonstrate an understanding of what the patient expected of him/her
  3. relate to and empathize with the patient
  4. teach patient why an MRI is not necessary at this point
  5. collaborate on a diagnosis and treatment plan the patient can buy into

 

The intermediate potential patient “fall out” from the way the doctor responded to the patient’s 4 cues includes:

  • Loss of trust
  • Feeling their concerns were ignored/dismissed
  • Feeling that the visit was a waste of time
  • Problem not resolved

 

Long term potential outcomes might include:

  • Non-compliance in which case problem gets worse
  • Patient dissatisfaction
  • Patient holds back important health information from physician in future visits
  • Patient decides to visit the ER rather than see his physician

 

Let’s conservatively estimate that the average patient office visit generates 10 such cues…and that the physicians identifies and acknowledges 50% of them.  That leaves 5 missed opportunities per patient visit which translates into 110 missed opportunities every business day (assuming 22/visits/day), 440 a week and 22,880 missed opportunities a year/physician.

 

Number of Physicians # Of Missed Opportunities To Engage. Empower & Excite Patients & Members Per Year
1 22,880 Missed Opportunities/Year
10 228,800Missed Opportunities/Year
25 572,000Missed Opportunities/Year
50 1,144,000Missed Opportunities/Year
100 2,288,00Missed Opportunities/Year

 

Now think about the impact physicians in your provider network could make upon patient engagement, empowerment and the patient experience if they were to some basic communication skills which would enable them to be mindful of, acknowledge and respond to these cues/opportunities in patient-centered fashion.  Turns out that investing in improving the patient-centered communication skills of the physicians in your provider network could have quite a significant impact.

The Adopt One! Challenge

An examination of patient cues given…and the physician’s recognition/acknowledgement and response …will be included in the baseline communication skills assessment perform for individual participants in the Adopt One! Challenge.  Be sure to sign up for the Adopt One! Challenge Newsletter.

Caveat:

Nothing in this post should be construed to suggest that not every request for service (as in the MRI) needs to be agreed to. All I am suggesting is that clinicians should take advantage of such request to turn an inappropriate or unnecessary request into a teachable and memorable moment.

Source:

Lussier, M.T. Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice and a narrative review of methods and correlates. ., Canadian Family Physician. 2009 December; 55(12): 1213–1214.

Hall, J. Clinicians’ accuracy in perceiving patients: Its relevance for clinical practice and a narrative review of methods and correlates. Patient Education and Counseling. Vol. 84, Issue 3, September 2011, Pages 319–324

It’s Time To Stop Blaming The Patient And Fix The Real Problem – Poor Physician-Patient Communications

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Yet another in a seemingly endless series of articles blaming patients for all that’s wrong in health care is running in Modern Healthcare.  The 3-part series entitled Channeling Choice looks at how patients (people like you and I) just aren’t making the kinds of choices and engaging in the kinds of behaviors experts think we are should.

doctor patient communication2Like so many of these articles, the Modern Healthcare series shares war stories of chronically ill people making poor health choices despite the well-intentioned efforts of local health care providers to “fix” them.  One such story bemoans how a heavy-set, low-income, congestive heart failure patient named Mary, paid more attention when grocery shopping to what something cost than its salt content…despite “being advised by her doctor” to do so.  Like so many “Marys and Martys,” the Mary in this story ended upon with multiple hospital admissions over a short period of time.  If only Mary had heeded her doctor’s advice.

It Takes Two To Tango – Mary’s Side Of The Story

In an ideal world, I could buy into Modern Healthcare’s conclusion that Mary’s choices and behavior were to blame for her condition and her outcomes.  Under the right circumstances I would even go so far as to suggest that Mary’s hospital and physicians not be financially penalized for her non adherent behavior and subsequent preventable hospital readmission.

Mind you I said under the “right circumstances.”  What would the right set of circumstances look like?

Glad you asked.  In the ideal world at a minimum here is what I would expect to happen:

  • Mary and her doctor would be in agreement as to what is wrong, e.g., the diagnosis
  • Mary’s doctor reviews her treatment options with her and they engage in a shared decision as to the course of treatment
  • Mary’s doctor would validate Mary’s understanding of the above by employ basis “teach back” communication methods

 

Please take note of the importance of the physician’s patient communication skills in the ideal world.

Unfortunately Mary (And The Rest Of Us) Do Not Live In An Ideal World

In the real world, physicians’ patient communication skills are often anything but ideal. Here’s what I mean.

Mary and her doctor would be in agreement concerning the diagnosisPatients have usually formed a hypothesis about their medical problem before seeing the doctor.  Agreement concerning the diagnosis at face value would appear to be a prerequisite to patient adherence (i.e. medication and dietary recommendations) and desired health outcomes.

It goes without say that in order for physicians to know where patients are coming from concerning their complaint they need to ask the patient.  But that is not happening.   A recent study found that only 16% of physicians admitted to routinely asking patients their “perspectives” regarding their condition.

It should come as no surprise therefore that in a separate study of patients in a Cardiology Clinic over half (55%) of patient diagnosed with Congested Heart Failure were unable to accurately recall or agree with their physician’s diagnosis of CHF.

It is extremely unlikely therefore that Mary’s doctor sought her perspective concerning her condition opening the door to a lack of  agreement as to the diagnosis and what to do about it.

Mary’s doctor reviews her treatment options with her and they engage in a shared decision as to the course of treatment Shared decision-making is a communication skill typically associated with physicians that routinely employ a patient-centered communication style with patients throughout the medical exam.   The evidence suggests that the majority of physicians today employ the same physician-directed communication skills they learned years ago in medical school.   Consistent with this trend, another study reveals that only 37% of physicians admitting to routinely engaging patients in shared decision-making (in whatever form that takes) meaning that again the odds are against Mary having been engaged by her physician in shared decision-making.

Demonstrates her understanding of the above by the physician’s use of “teach back” - Patient teach-back is a communication technique where the clinician asks the patient to repeat back what they were told to make sure the patient understood what was said by the clinician.   A 2012 study found that to the extent that patient teach-back is sporadically employed and only then in instances where the physician and patient were of a different culture, ethnicity or language.

In particular, patients who speak a language other than English, are of Black/African-American race/ethnicity, those with advanced age, and those with fewer years of formal education were more like to experience patient teach-back than their counter English-speaking, white, educated counter parts. Giving Mary’s clinicians the benefit of the doubt, let’s assume she had a 50-50 chance of have benefits from patient teach-back at some point in her treatment.

The Take Away?

The reality is that, like the rest of us, neither Mary nor her hospital or treating physicians live in an ideal world.  As such, one can make a strong, evidence-based argument that hospitals and physicians are just as culpable as patients, if not more so, for failing to employ the kind of patient communication skills needed to promote patient engagement, activation and effective self-care at home.

The health care industry over the last 100 years has done a great job of socializing people to assume the passive sick role when we seek care. In that role we are not expected to challenge physicians or question their decisions…in fact many patients are fearful of being labeled as difficult when they do take on such behaviors.

If hospitals, health plans and physicians expect patients to change their behavior, they themselves have to change the way their think about, communicate and relate to patients (aka people).   They themselves have to become truly patient-centered more engaging to patients…from the patient’s perspective!

As a first step, I suggest that hospitals, health plans and physicians stop blaming patients for everything that’s wrong with health care today.  Maybe then we can make some progress at collaboratively building on all that’s right with health care.

To learn more about the patient communication skills of the physicians in your provider networks or practices sign up to sponsor or participate in the 2014 Adopt One! Challenge.

As part of the Challenge, physicians will will receive a comprehensive baseline assessment of their patient communication skills across 10 different dimensions,  see how their communication score compare to best practices, and receive access to an online learning collaborative where they can work on developing one new patient-centered communication a year beginning in 2014.

Sign up for the Adopt One! newsletter for more information.

Sources:

Sarkar, U., et al.   Patient- Physicians’ Information Exchange In Outpatient Cardiac Care: Time For A Heart To Heart?.  Patient Education And Counseling.  2010.

Jager, A. , et al. Who Gets a Teach-Back? Patient Reported Incidence of Experiencing a Teach-Back.  Journal of Health Communication: International Perspectives. 2012. 17:sup3, 294-302.

Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.