Patients Are Often More Engaged In Their Health Than Providers Think

Patients often don’t get the respect they deserve. Take the subject of patient engagement.  Just about everywhere you turn in the health care literature these days we are told how physicians and other providers need to do a better job getting patients involved in their own health.

But is that really their role?

Patient Engagement Is Not The Job Of Health Care Providers

Why?  Because by the time a person (aka patient) presents for care in the primary care physician’s office…they are already engaged in their own care to some degree…albeit now necessarily in the way providers expect.   Here’s what I mean.

People consult with their doctor when they have a need or concern which they believe needs to be addressed.  Often times before they make an appointment to see the doctor, people will do their own home work to see if a doctor’s appoint is really necessary.   Many of us for example will talk with a friend or family member or consult our favorite health website before deciding to see a doctor.  A recent Wolters Kluwer poll on Health found that of all people who go online for health information, 50% do so before seeing their doctor.

Next we must pick up the phone and make the appointment which itself requires time and dedication given office hold times.  Then we must actually keep the appointment…telling ourselves that we are seeing the doctor for a good reason.

By the time we walk through the front door of the doctor’s office we are already engaged in our health as manifest by the cognitive involvement and expenditure of time involved with:

1)    Deciding that we need to see a physician,

2)    Making and keeping their doctor’s appointment despite the self-talk that we will get better on our own.

3)    Preparing a mental list of issues/question that we want to discuss with the doctor.

Given that people 50 years and older see their physician and average of 3-4 visits a year, they are already engaged in their own health…at least up until the time they walk into the physician’s office.

What happens in the doctor’s office plays a big role in determining whether the patient’s level of engagement grows, or is diminished if not extinguished.  Physicians that are prepared for the visit, ask patients for their input, solicit patient expectations, beliefs and previous experiences, and where possible honors them, are demonstrating traits that patients find engaging, e.g. traits which encourage patients to persevere in their get involved in their health.  Physicians who appear rushed, “not present,” not prepared, or who fail to solicit the patient’s input often have the opposite effect.

So What Is The Role Of Providers When It Comes To Patient Engagement?

Given that patients is the office are already engaged, albeit perhaps not is ways providers think of as engagement, the role of the provider is not so much one of needing to engage but rather being “.”  By engaging I mean creating an atmosphere which facilitates, cultivates, and builds upon the level of engagement which patients bring to the office.  This is accomplished when the physicians and provider staff consistent employ patient-centered communications with all their patients.

That is what I think…what’s your opinion?

Patent Portals. PHRs, & On-line Decision-Support Tools Alone Will Not Lead To Greater Patient Engagement

Patient engagement is getting a lot of attention these days, particularly in the health information technology press.   Anticipation of Stage 2 Meaningful Use criteria is certainly is driving much of the “talk.”  So too are the promises of improved patient outcomes and satisfaction associated with the adoption of patient engagement tools like EMRs, PHRs, web portals, and on-line decision support tools.

But if the mere availability of such health information technology was all there was to engagement…member use of health plan web portals, which have been around for years, would be a lot higher than they are now, e..g., often < 10% of members.

Patient Engagement Begins With The Patient-Physician Relationship Not Technology

If you were to take everything you read at face value, all physicians and hospitals need to to engage patients is patient or member web-based portal.  I guess the idea is if you build it…they will come. But there is a HUGE FATAL FLAW in that logic:

 Successful patient engagement is predicated upon the existence of a strong, trusting, mutually satisfying relationship between the patient and their physician.

Strong, trusting physician-patient relationships are becoming harder and harder to develop and maintain these days…for both patients and providers.   Poor physician communication skills, e.g., physician-directed communications, have been cited in the literature over last 30 years as a major barrier to more satisfying and productive physician-patient relationships. Poor communications also tops the list of patient complaints about their doctors.  Not surprisingly,  many patients find it easier to “get by” in an OK relationship with a primary care provider than seek a provider with a more engaging demeanor

What Are The Three Traits Patients Find Most Engaging In Their Provider?  Check out our latest White Paper

The Link Between Patient Use Of Engagement Tools And The Physician-Patient Relationship
So What Does A Strong, “Engaging” Physician-Patient Relationship Look Like?

Here’s my short list;

• Patients and providers like, respect, and trust each other
• Patients and providers are interested in and take the time to listen to where each other is coming from, e.g., their beliefs, concerns, etc.
• There is a high degree of agreement between patients and providers as to the visit agenda, diagnosis, treatment, and self-care options.
• Providers’ employ patient-centered communication skills

Imagine yourself in a relationship with a provider who simply doesn’t seem to dedicate much time or place much importance on the above traits. How likely would you be to spend your valuable time-sharing personal health information with someone who has never exhibited any interest when you attempted to share the same information in the past?

The Take Away

Don’t get so wrapped up in the promise of the latest health information technologies that you lose sight of what’s really important to patient engagement, outcomes and patient/provider satisfaction – the physician-patient relationship

That’s what I think…what’s your opinion?

What Are The Three Traits Patients Find Most Engaging In Their Provider?  Check out our latest White Paper

Challenge #1 For Health Care Providers – Way Too Much Information And Way Too Little Communication With Patients

One of the biggest problems with health care today is that there is way too much information and way too little communications going on between providers and patients.

Here’s a great quote that explains what I mean:

The two words information and communication are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through.

Sydney Harris,  Journalist

I was reminded of this and the quote from “Cool Hand Luke” quote in an exchange I had with a primary care physician on LinkedIn recently.   In that exchange, which dealt with long-term physician-patient relationships, I hypothesized that intentional non-adherence may be the by-product of situations in which physicians and patients in long-term relationships simply grow to distrust each other.

The good doctor commented as follows:

“In the end, it is the patient’s decision to be compliant or not, yet many physicians continue to care for these patients because someone must. Would the patient comply better with a new doctor? I doubt it. “

I replied to the good doctor’s comment as follows:

“True…the decision to comply or not is up to patients.  But the evidence shows that compliance is not a product simply of bad patient behavior. Non-compliance is an outcome for which both physician and patient have shared responsibility.

I suggest that most people would be a lot more likely to comply if they: 1) understood and agreed with the need for the prescription and 2) believed that the benefits of taking the medication outweighed the risks and concerns. But these issues are seldom brought up by the physician or the patient, due to limited time, provider attitudes and beliefs about patient, and so on.”

Then he dropped the A-bomb – a move intended to silence anyone who would dare challenge physician authority and learnedness:

A professional who deals with this on a daily basis can explain meds, conditions, etc. very quickly and to the satisfaction of the patient.

That’s when it occurred to me…too much information and not enough communication

No doubt most providers today are proficient at quickly giving information to patients (including telling them what to do).  What most providers (and people in general) are not good at is effectively communicating, e.g.,  getting through, with patients (or each other).   Anyone who has ever been married knows the difference between information giving and communicating.

And how would the good doctor know that his patients understood the information he gave them…not to mention their being satisfied with it?   Surely he’s not banking his revenue going forward under P4P on his patient satisfaction surveys alone.

If anything, the weight of evidence suggests that his patients probably do not understand the information he quick doles out and probably are not particularly  satisfied with it.   Like many of us, his patients probably do not want to confront the good doctor choosing instead to ignore his recommendations or seek advice elsewhere, e.g., no-adherence.

But as with any good relationship, effective spouse-centered (I mean patient-centered) communications is key.   To truly engage the other party, you have to know where they are coming from, what’s important to them and never, never ask them to do more than they are willing and able to do.  I had to say that since my wife “proof reads” my blog posts…lol).

That’s what I think…what’s your opinion?

Why Patients Don’t Always Do What’s In Their Best Interest

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.

Reactance 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.

Can Long-Term Physician-Patient Relationships Be Bad For Your Health?

I wonder how many problems like non-compliance, usually attributed to “poor patient behavior,” actually stem from long-term physician-patient relationships in which both parties have just given up.

You know what I mean…physicians who have treated certain patients long enough that they believe they are just plain never going to do what they are told…and patients with expectations for care and service from their physician that never seem to be met.

Like any long-term relationship, people become used to one another and develop coping mechanisms to avoid an outright breakdown.  People in long-term become complacent with one another’s “quirks.”   We are all too willing to settle for the things as they are and not push the boundaries of the relationship hoping to improve it.

But there is a long-term cost to the patient and physician when we ”settle” and try to just get by as the graphic below suggests.

At face value, most physicians and patients don’t do a great job when it comes to communicating with one another.  Take patient expectations .

Most people have certain basic  expectation for what we want to happen when we consult our physician.   At a minimum we expect to have the time and opportunity to tell the doctor why we are there.   After all, if we are concerned enough to make an appointment we want to be heard.  Maybe we also have an expectation for a specific service – say a test, a referral or a new medication.

Quite often however, patient’s expectations, reasonable or not, often go unmet.  According to researchers, physicians failed to ask for patient’s full reason for their visit in 77% of visits.   Maybe the physician has little time to allow the patient to ramble on or maybe the physician has already arrived at a diagnosis already.

The reality is that the patient’s expectations were unmet perhaps resulting in disappointment and perhaps frustration.  Unfortunately, as Avedis Donabedian, MD, once said, “patients are overly patient with their physicians” and are willing to put up with a lot without saying anything (or reporting it on patient satisfaction surveys).

Not every patient request for a test, referral or medication is appropriate.  Physicians have an obligation to deny inappropriate patient expectations.  But again, depending upon how well the physician explained their reasoning for the denial, some patients will be disappointed and perhaps even angry.   Another study found that 56% of patients expressed an expectation for a specific service – a test, referral or medication… with 50% not getting what they asked for.

Now imagine playing this scenario playing out between patient and physician 2 or 3 times a year over a number of years.   I have to believe that in situations like this patients continually lower their expectations of their physicians…and along with it their trust, willingness to share information, and a willingness to comply what the physician recommends.  Physicians for their part probably reciprocate these feeling in some way.

The point is that settling and being complacent can be bad for the patient’s health and very unsatisfying for the physician.   Too bad we don’t measure patient and physician complacency…it could probably explain a lot.

That’s my opinion…what’s yours?

Sources:

Dyche, L. et al.  The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns.  Journal of General Internal Medicine. 2005; 20:267–270

Peck, B. et al.  Do unmet expectations for specific tests, referrals, and new medications reduce patients’ satisfaction? Journal of General Internal Medicine, 2004; 19(11), 1080-7.