Patient Engagement From The Patient’s Perspective

I apologize for my absence over the past month.  I was side-lined with two detached retinas in December both of which required major eye surgeries and downtime.   

For health care professionals, patient engagement is the holy grail of health care.  It is the key to patient adherence – a prerequisite to achieving better outcomes, fewer ER visits and hospitalizations and more satisfied patients.  It is easy to recognize an engaged patient – they do what their health care providers recommends…what their health care team knows what is right for them.

But Doesn’t Engagement Depend Upon Your Perspective?

In a earlier life I spent a lot of time looking at health behavior.  Among the many things I learned were the following:

• We all define health within the context of our own lives and in our own way
• We all are satisfied with different levels of health

Providers and Patients Often See Things Very Differently

Admittedly there are patterns of health behavior or archetypes which can be used to segment health populations.  One such archetype is characterized as 1) placing a high priority on achieving a high level of personal health, 2) being very proactive in terms of achieving and maintaining their above average health, and 3) having a moderate to high distrust of the medical professionals.

Not surprisingly, people who shared this pattern of health-related thinking demonstrated lower levels of physician visits, fewer hospital and ER visits, lower health care costs.  They get sick and develop chronic conditions like everyone else, but because of their health proactivity , they tended to the healthiest relative to all other patterns of health thinking and behavior.   Because of their trust issues with their providers and willingness to experiment with new health alternatives, these patients are “mavericks” doing their own thing when it came to self care (when sick) and staying healthy .  In other words they may not be the most compliant of patients from the providers’ perspective…and therefore would be considered “unengaged” in their health care.  

People Can Be Engaged In Their Own Health And Never See A Doctor, Visit A Hospital, Or Take A Rx Medication

If you were to tell these independently healthy folks that they were “not engaged” in their own health they would likely scoff and say “what do you expect…the health care industry doesn’t take the time to understand the patient’s perspective.”  In truth, aren’t people like this doing a better job than the health industry when it comes to “engagement” and staying healthy?

The point is that we as health care professionals need to start looking at things like the definition of health, health goals, compliance, and outcomes from the patient’s perspective.  We need to incorporate the patient’s perspective into outcome and satisfaction measures.   Only then do we have the right to “judge” whether a person (aka patient) is engaged, activated, or empowered.   Once the health industry gets past this paternalistic, “we know better than you do” attitude then we can expect to see real change in health behavior and outcomes.

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

How Are Patients Supposed To Be More Involved And More Responsible For Their Health When The Playing Field Is So Uneven?

Guest Post by Anne Polta author of the blog HealthBeat.  Thanks for covering Anne while I am off having my third Vitrectomy to repair yet another detached retina.

To be clear, there are lots of great clinicians out there. I’ve met many of them and I know them to be hard-working, dedicated and caring.

If the focus of this discussion is on doctors, perhaps it’s because this is the relationship that’s central for most patients and one that they view as important.

I think a lot of this really does come down to medical culture – the attitudes, values and beliefs that have become so engrained that they’re not even visible to many clinicians, let alone questioned. For starters, look at the language that’s used – “problem list,” “chief complaint,” “doctor’s orders,” “the patient failed treatment” and so on – all tending to reinforce the patient’s role as subordinate/supplicant. Whether we realize it or not, perceptions shape the words we use, and the words we use are at least partially shaped by our perceptions and attitudes that the patient isn’t equal to the clinician.

Here’s another example: information-sharing. Do you routinely share the specific details of test results with patients, or do you tell them “everything was normal” and then wait for them to ask for the details? How often do nurses take the patient’s vital signs and silently write down the results without sharing them? There is a difference between “we’ll share the information if the patient asks for it” vs. “we’ll routinely volunteer the information because the patient has a right to know” and it lies in the mindset that there’s a presumption from the get-go that the information will be shared.

Don’t even get me started on the whole issue of adverse events and disclosure. I have unfortunate personal experience with this, and I’ve had to accept the fact that no one is ever going to tell me what really happened. How are patients supposed to be more involved and more responsible for their health when the playing field is so uneven?

It doesn’t take more time to make some of these changes. You could develop a policy that patients will automatically receive complete test results. You could streamline your processes to make it easier for patients to obtain copies of their medical record. You could post signs at the reception desk or in the exam room, or slip a notice in with the bill, informing patients of what the process is to obtain their medical information. It’s about being more transparent and sending a message that it’s OK, and even encouraged, for patients to ask.

Compared to 10 or 15 years ago, I think the system actually is getting better at this. We’re in a transition right now, and transitions often are difficult. It’s hard to have the conversation without clinicians getting defensive and patients getting frustrated.

I don’t want to take on the doctor’s role; I’m not smart enough for that. I’d just like to see a partnership that’s a little more 70-30 or 60-40, instead of 95-5.

The Fastest Way To Disempower, De-Activate, and Disengage Any Patient

I may not know how to tell the difference between an empowered patient, an engaged patient, or an activated patient.  But I do know that fastest way to disempower, disengage, and de-activate any patient is a trip to the doctor’s office or the hospital.  A visit to an average primary care physician (or specialist) is to an empowered/activated/engaged patient what Kryptonite is to Superman.  It will stop all but the strongest willed patients dead in their tracks.

We patients have been socialized that way.   Think about your earliest memories of “going to the doctor.”  For me, I remember my Mom taking me to the Pediatrician.  Early on I learned by watching the interaction between my Mom and the doctor that they each had a role.  The doctor’s role was that of expert – he spoke and my Mom listened.  I was there just to have one or more extremities twisted and prodded.  And oh the medicinal smell…

Things haven’t changed much in the 40 years since I was a kid sitting in Dr. Adam’s office.  Well maybe the smell isn’t as medicinal.  But the roles played by doctors and patients haven’t changed much.   Studies over the last 30 years consistently demonstrate this unfortunate reality.  If you were to believe the admonitions of the NIH, AHRQ, hospitals, pharma and every WebMD-look alike, you would think that patients these days would be more involved in their visit…asking questions, sharing information and making decisions.  But as most physicians will attest…most patients don’t have much to say in the exam room anyway.   And the longer they have to wait before being seen, the less patients are likely to bring up the few questions they wanted to ask.

This is a huge problem.  It belies conventional wisdom that the key to fixing health care begins and ends with changing patient behavior.  If only we could get patients to be more compliant, if only patients would do what I tell them, blah, blah, blah.

Physician behavior, specifically, the way they think about, relate to and talk to patients needs to change (no e-mail, text messages and social media will not solve this problem)…before long term, sustainable change in patient behavior is possible.

If you look at most theoretical models underpinning patient empowerment, patient activation, etc., you will see that none of them factor in the impact of the care delivery context, e.g., doctor’s office, hospital room, surgery suite, or pharmacy, on patient behavior.   A patient considered Stage IV (Activated) on the Patient Activation Model (PAM) or the “Action Phase” using Stages of Change would “crash and burn” if their doctor is among the majority who employ a traditional physician-dominated, biomedical communication style or “bedside manner.”

How empowered, activated, or engaged can a patient be if they don’t know when to open their mouth, are ignored , or fear taking up too much of the doctor’s time?

Yes you can and should probably change physicians…but since so many physicians “practice” the same way…even supposedly Patient Centered Medical Homes…what’s the point?

Until health plans and providers take a serious look at incentivizing physicians to become more patient or relationship centered, behavior change efforts directed at patients can only accomplish just so much.

That’s my opinion.  What’s yours?

Sources:

Cegala, D. An Exploration of Factors Promoting Patient Participation in Primary Care Medical Interviews.  Health Communication, March 2011.  1–10, 2011.

Related Posts:

6 Seconds To More Effective Physician-Patient Communications

Lack Of Time And Reimbursement  – Is That Why Physicians Don’t Do a Better Job Communicating With Patients? 

The Power Of A Physician’s Touch – A Sure Path To Better Patient Trust, Outcomes And Satisfaction

My wife has two world-class oncologists who help her manage her Stage 4 Lung Cancer.  Both are excellent clinicians.  Yet their skills differ in one very important way.  Her radiation oncologist physically touches her a lot (in a good way of course!).  There are the touches on her arm, a hand on the shoulder, hugs, and of course a thorough hands-on physician exam.  Her medical oncologist not so much.

We all recognize the therapeutic value of touch.  Dr. Abraham Verghese, a Stanford Physician and Professor, at the 2011 Med2.0 Conference, described the power of touch associated with the physical exam.  In the following scenario he describes an interaction with a chronic fatigue patient who came to him after being seen by many other physicians.

The patient was very voluble and kept talking as I began the physical.  I always begin my routine, my ritual with the patient’s hands…it seems natural to hold the hands.   I slip my figure to the radial pulse and then examine the fingers looking for cyanosis and clubbing….  As I began my routine, this talkative patient began to quiet down.   I had an eerie sense that the patient and I had slipped back into a primitive ritual…one in which I had a role and the patient had a role.

When I was done the patient said to me with some awe…I have never been examined like this before.   If this were true that was unfortunate since this patient had been examined by other physicians many times before.   Following the exam, I told the patient the same thing he had been told by other physicians, I don’t know what the problem is …but here’s what we will do.  I had earned the right to tell the patient this because of the examination.

Verghese believed that, unlike the other physicians seen by the patient, he had earned the right to diagnose the patient and expect the patient to accept and act on his findings.  Why? Because of the patient trust he had earned in part through the power of touch.

Turns out that there is scientific research to back up Verghese’s claim.  According to researchers, people are able to more accurately discern a wider range of feelings and emotion from touch than from gestures, expressions, and sometimes even words.  That’s because touch is the first language we learn.  Tiffany Field, PhD of the Touch Research Institute in Miami has found that benefits of touch seem to stem largely from its ability to reduce levels of cortisol, a stress hormone manufactured by the body.

Given the high degree of personal stress associated with a trip to the doctor, a lab test, or hospital visit, I suspect we could use a whole lot more touching…not less as is the trend.  Verghese has a name for this trend – you know where clinicians gather around the computer and not the patient.  He calls it iMedicine….and it’s not a good thing.

That’s my opinion…what’s yours?

Source:

Keltner, D. Born To Be Good: The Science of a Meaningful Life” (Norton, 2009)

Is Your Doctor Patient-Centered? Here’s A Simple Way To Find Out

I get the impression from  a recent post on KevinMD that a lot of physicians and other providers are having trouble with the term patient-centered.  I can understand this given the penchant for us health care folks for using fancy names and acronyms to discuss otherwise straight forward concepts.   The other day I came across a simple test for identifying a patient-centered provider when you actually encounter one.   It can be used by patients to evaluate their physicians.   Physicians, PAs, Nurses and other providers can also use this same tool to evaluate whether they are patient-centered nor not.

Here We Go

If you are a patient…

• Do you feel that your doctor is always trying to persuade you to follow their ideas of good health?

If you are a doctor or other provider…

• Are you always trying to persuade your patients to follow the care recommendations you have given them?

If you answered “yes” to either of these questions, then your doctor (or you if you are a provider) are not patient-centered.  More than likely your physician/provider (or you) are physician-directed or provider-directed in their patient interactions.

How Can I Say This?

Patient-centered care is also known as collaborative care – you know – where doctors and patients share information and collaborate on decision-making.    If your doctor (or you) were patient-centered, rather than tell you what you should be doing, they would routine engage you in the following types of conversations during your visit:

• Help you identify and address your primary concerns.
• Encourage you to talk about the emotional aspects of your health problems
• Help you identify and choose goals that are relevant and important to you
• Respect your right to make decisions with which they disagree

The problem with patient-centered care is that so few people, whether patient or provider, have ever really experienced it.   Seriously…when was the last time your physician asked you what you wanted to discuss during your visit, asked if you agreed with their diagnosis or treatment, or ever asked you if you were depressed?  When was the last time your doctor really listened to you rather than just going through the motions.

To this point, here’s a quote from a comment I received from a physician on my last post about the importance of being patient-centered.

I’ve come to realize how important listening is, not just to make patients feel good, but for a number of practical reasons. Most doctors, I fear, think of listening as something you do as little of as possible, just until you’ve made up your mind what the patient has and what the doc is going to do about it. Beyond that it becomes a passive exercise, essentially a waste of time.

WOW!  My Doctor Actually Listened To Me!!

As a practice administrator or hospital executive, can you image how powerful it would be if patients walked out of your facilities telling their family and friends that their doctors (including hospitalists) actually took the time to listen to them?

Listen to patients….my God what a novel concept!!

That’s my opinion…what’s yours?

Source:

Anderson, R. M., & Funnell, M. M. (2010). Patient Empowerment: Myths and Misconceptions. Patient Education & Counseling, 79(3), 277-282.