Patient-centered Care and Physician Use of Social Media

I came across a piece in USA Today this week about “Doctors who are not on Facebook, Twitter and blogs risk becoming irrelevant” by Kevin Pho, MD, author of the KevinMD blog. This article prompted the following post.

The Patient-Centered model of care is predicated among other things on physicians factoring in knowledge of the “person behind the patient” into their treatment.   That’s means understanding and, where practical, honoring the patient’s beliefs, values and preferences.   In order for a communication between a physician and person (patient) to be “patient centered,” it must be congruent with patient preferences for how they want their physician to communicate with them.

So Just How “Patient Centered” Is Social Media?

Let’s consider test result reporting to patients.   If you are among the 5% of patients who (in very recent large-scale studies) indicate they want to receive normal test results by e-mail for example, e-mail results reporting is very patient-centered. Only 1% of patients prefer receiving abnormal test results via e-mail.   Social media, e.g., e-mail, is not very patient-centered however if you among the other 95% of patients that prefer to be notified of normal and abnormal test results by telephone, snail mail, or in person visits with your doctor.   I understand that e-mail is not necessarily considered “social media” like Twitter, Facebook, or blogs, but it is the only “indicator” we have to date in the research literature.   I also acknowledge that non-physician blogs and social networking sites such as PatientsLikeMe show great promise in building self care management skills, confidence and support among people with similar chronic disease conditions.

Implications?

This is not to say that physicians should avoid social media when communicating with patients.   I am just saying that, according to the evidence, social media is not for everyone at this point.    No doubt patient preferences involving social media will evolve with the development of new applications and privacy protections…but we are nowhere near that point yet.

From my vantage point, when it comes to communicating with patients, physicians’ time would be much better spent by:

1. Learning what their patient preferences are (with regards to communications, medications, exercise, nutrition, etc.).
2. Tailoring conversations with patients during office visits to their preferences and concerns. The evidence shows that by doing, physician can more effectively engage patients, increase patient adherence, reduce cost and improve outcomes and satisfaction.

I have yet to see large scale studies that shows how social media can do that.

Where is Time for Communicating Going to Come From?

Good Question…

Dr. Richard L. Reece, author of the Medinnovationblog asked (and in part answered) this question in response to a comment I recently posted to his blog regarding poor communication between physicians and patients.

Like many physicians today, Dr. Reece believes that the lack of time is a contributing factor to poor physician-patient communication.  And like many of his peers, Dr. Reece believes that a solution will call for “more doctors and more time,” as well as “incentives and rewards for communicating with patients.”  Reece also suggests that a little technology like e-mail and Facebook wouldn’t hurt either.

I can certainly understand physicians’ concern about time.  If I had to spend 3 weeks a year on uncompensated insurance paperwork I’d feel the same way.  But the premise that “more time” (compensated or not) will necessarily lead to more or improved communication between physicians and patients appears fundamentally flawed.

Here’s why.

First, sub-optimal physician-patient communications has been the subject of research going back to 1970.  In fact, other than research methods, little seems to have changed over the last 40 years with respect to the quality of physician-patient communication.  Today as then we are still talking about the challenges of allowing patients to finish their opening statement without interruption, the lack of concurrence on the visit agenda and treatment plans, soliciting patient questions and so on.

Second, there are significantly more primary care physicians (FPs and IMs) today than there were in 1970.  The ratio of PCP to people was 55.7/100K in 1970, 85.4/100K in the Year 2000, and an estimate 125/100K in 2008. So if poor communications between physicians and patients is a function of the number of PCPs why haven’t communications improved over the last 40 years?

Third, according to a recent study in the Archives of Internal Medicine, the mean length of office visits for adult primary care increased from 18.0 to 20.8 minutes between 1997 and 2005.  Mechanic et al. came to a similar conclusion in their 2001 NEJM study. OK more time, but still no discernible improvement in communications?

To be sure, primary care physicians have more demands on their time today from patients presenting with multiple chronic conditions and complaints, to numerous care guidelines, and complex reporting requirements.

The point is more physicians and more time alone is no guarantee that physicians will do a better job communicating with patients. Rather, the answer lies in developing new skills and tools designed to help physicians and patients better communicate.

Effective Physician-Patient Communication Skills Saves Time

In a previous post I spoke about how physicians fear that the patient-centered model of communications will add to the length of their visits.  As I pointed out, just the opposite happens to be true.  Communication techniques such as the following have been shown to add at most 6 seconds to the average length of the physician visit:

• agenda setting
• use of open-ended questions to help identify clinical and emotional context
• active listening which can lead to new opportunities to support and encourage patients
• solicitation of patient thoughts and expectations can provide clues into treatment options
• establish agreement of patient goals

In addition to being “time neutral,” these communication skills have other benefits for busy physician practices.  In the United Kingdom, studies have shown that patients in a strong physician-patient relationship are more understanding and accommodating when they believe their doctor to be under time pressure during their visit.   Numerous studies have also linked to benefits including improved patient trust, patient adherence, patient outcomes, and patient satisfaction.  One has to wonder if these behaviors might eventually lead to additional time savings in the form of reduced visits and hospitalizations, the need for less counseling, and so on.

Sources:

Chen L., et al. Primary Care Visit Duration and Quality. Archives of Internal Medicine. 2009; 169(20):1866-1872.

Dugdale D., et al. Time and the Patient-Physician Relationship. Journal of General Internal Medicine. 1999;14:S34-S40.

The Cost of Poor Physician-Patient Communication

The Missed or Incomplete Diagnosis – Depression

Depression is one of those conditions that patients, particularly men and certain ethnic groups, are reluctant to bring up on their own.  Unfortunately  most physicians also seem reluctant to bring up the subject of depression with their patients.

Depression is a big problem these days.   Four out of every ten patients in  primary care waiting room suffer from moderate to severe depression.  Prevalence rates for depression are highest among women and older patients with chronic conditions.

It costs twice as much to treat a patient with depression ($4,780) as it does to treat a patient without depression ($2,794).  That’s because patients suffering from depression generate more physician visits, medical tests, RX medications and hospitalizations.

Despite its high prevalence and costly nature (medically and socially), depression is significantly under-diagnosed (<50%) and under-treated with medications (50% not prescribed) and/or counseling (90% never referred).

Role of Communication in the Detection and Treatment of Depression

Reasons why most primary care physicians spend little time talking about depression with patients include;  lack of time, competing priorities, perception that the patient will be resistance/non-adherent to therapy, a lack of confidence in treatment efficacy, and uncertainty how best to treat depression.  Whatever the reason, very few physicians 1) routinely ask patients (even high risk ones) if they are depressed, i.e., feel down, loss of interest, etc.  and 2) spend much time educating patients about the condition or treatment options.

On a personal note, during the last six years of my wife’s lung cancer treatment she was never once asked about her emotional or mental health status by her treating or primary physician.

If the subject of depression does come up, it is mostly likely raised by the patient.   Even then patients probably bring it up only when they are in real pain.   Most patients would probably just as soon avoid the subject.   Up to 40% of U.S. adults, particularly older folks, still believe that depression is a personal character flaw and not a biomedical condition.   Many of these people are resistant to a diagnosis of depression from their doctor.   Some believe that anti-depressants are ineffective and addictive, while others simply don’t like taking pills of any kind or cannot afford the medication.

So How can Doctors do a Better Job Talking with Patients about Depression?

• Screen all patients for depression not just Medicare patients at their mandated initial preventive exam

• Assess patient attitudes and belief about depression and its causes

• Ask the patient if they are depressed

• Help patients understand that depression is not a personal problem but a real biomedical condition that can be effectively treated

• Provide anticipatory depression guidance for older patients and patients with chronic conditions

• Prescribe treatments and therapies that are in alignment with the patient’s desires and expectations.

• Ask patients if they can afford prescribed medication

• Teach patients how to take medications and what do before stopping their medications

Sources:

Depression Among High Utilizers of Medical Care.  Pearson et al.  Journal of General Internal Medicine. 1999: 14:461-468.

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives.  Henke et al.  Implementation Science 2008, 3:40.

Attitudes to depression and its treatment in primary care.  Weich et al.  Psychological Medicine, 2007, 37, 1239–1248.