How One Doctor Creates A “Great Experience” For His Patients

I had a WOW experience yesterday when I accompanied my wife to interview a new doctor for her.   As some reader may know she is being seen by specialists At MD Anderson Medical Center in Houston for Stage IV lung cancer.   She has not had a local oncologist for the past 6 years…but she does now.   And we both love this guy!
 
You need to understand that I have been very underwhelmed by the local oncologists I had met up till now.   I am sure they were clinically proficient…but as a group not a one could muster a smile….or any sense of interest or curiosity in my wife’s medical condition.  I held out little hope that this new doctor would be any different.
 
After being ushered into the exam room, a Physician’s Assistant came into the room to get smart about my wife’s history and records (which she brought).   Three things surprised me about the PA.  1) She was incredibly thorough actually reading the radiology reports and reflecting with my wife on what she learned, 2) her empathy – as she read the reports she actually used terms like “bummer” when she read how my wife developed pneumonia during her treatment, and 3) she faithfully summarized the results of her review to the doctor before he came in.  In other words – the PA listened and heard what my wife shared with her!
 
Now enters the doctor.   He has a warm smile on his face while he extends a hand to my wife and me.  He says just enough for us to know that he has talked to the PA.  He asks my wife to sit on the exam table and does a physical exam (also a rare event these days).
 
He then got her down from the exam table into a chair and sat down himself facing us.  He asked my wife why she was there and what she wanted to accomplish.  After all she had world class docs back in Houston.   He asked her why she thought her docs in Texas had stopped her oral chemo for 3 months.   He asked why they suggested she start some of her care locally instead of continuing to go down to Texas.  If the point isn’t obvious…the doctor seemed to value her opinion of what was going on with her care.
 
He empathized about it is like to be treated in a world class academic medical center….often long on experience but sometimes short on bedside manner.    He volunteered that given my wife’s situation he saw his role as collaborator with her primary cancer care team in Houston.   He would take care of her needs locally and advocate on her behalf when needed with the “experts” at MD Anderson.   And I was worried that this guy’s nose would be out of joint given her continued relationship with her docs in Houston.    The visit ended with a hug between my wife and her new doctor.   Something my wife told the doctor she was used to from one of her Houston docs.
 

What we like about my wife’s new doctor is his “mindfulness.”  
 Specifically we liked the doctor’s attentiveness, curiosity, flexibility, and presence – all qualities of mindfulness according to note researcher Ronald Epstein, PhD.

 
We have already established the doctor’s attentiveness to the details of my wife condition.   His curiosity was evident by his questioning of my wife’s opinions on how her case was being managed.   In addition, the doctor enjoyed working with lung cancer patients.  The doctor flexibility was evident from his willingness to play “second fiddle” to my wife’s doctors in Houston.   Finally this doctor was “present” at all times during her visit.   He listened, picked up on “cues” from my wife and I, anticipated my wife’s needs and never looked at his watch.
 
So the next time you visit your doctor…or you visit with a patient, you might think about “mindfulness.”
 
It doesn’t take any more time I suspect…but can make all the difference to patients and their caregivers.  Heck I was so impressed that I wrote a blog posting about it!
 
Sources:
 
Epstein RM. Making communication research matter : What do patients notice , what do patients want , and what do patients need ?  Journal of General Internal Medicine. 2006;60:272-278.

Accountable Care, Medical Homes and Employers – Do Physicians “Get” the Concept of Providing Value?

Ok…here’s a brain teaser.  What medical condition is the most costly to employers?  I’ll give you a hint.  It is also a medical condition that is likely to go unrecognized and undiagnosed by primary care physicians.
 
If you guessed depression you are correct.  If you mentioned obesity you get a gold start since that comes in right behind depression for both criteria…at least in terms of cost and the undiagnosed part.
 
Four out of every ten people at work or sitting in the doctor’s waiting room suffer from moderate to severe depression.  Prevalence rates for depression are highest among women and older patients with chronic conditions.  Yet despite its high prevalence and costly nature, depression is significantly under-diagnosed (<50%) and under-treated by physicians.
 

 
For employers, the cost of depression cost far exceeds the direct costs associated with its diagnosis and treatment    As the graphic above indicates, the cost of lost productivity for on the job depressed workers (Presenteeism) and lost time for depressed workers that are absent from the job (Absenteeism) far exceed the cost of cost of treatment (medical and medication cost).
 
Since I first addressed depression in an earlier post, I have identified what I believe to be the central reason why depression continues to go undiagnosed and untreated in primary care.   The reason is that physicians are uncomfortable talking to patients about it, e.g., psychosocial issues.   Even when patients provide “cues” suggesting evidence of depression in the opening statement, i.e., I have been sleeping well, I haven’t been myself lately, etc., evidence suggests that physicians are likely to simply not recognize or ignore the cues.   Physicians themselves admit that their training predisposes them to be more comfortable dealing with biomedical versus psychosocial issues.
 
Now think Accountable Care Organizations and Medical Homes.  Both of these concepts, one a payment reform model and the other a delivery model, are predicated upon the notion that the medical services offered have real value to the payer, e.g., employer or health plan.  But what kind of value are primary care physicians providing when they fail to diagnose and treat the biggest problem facing the people that ultimately pay for their service?
 
Tying this all back to physician-patient communications, physicians need to begin employing more patient-centered communication techniques in their dealing with patients.  In particular, physicians need to do a better job listening to what their patients are trying to tell you, even if it is outside your comfort zone.   At the very least you can refer the patient to a counselor for help.  In so doing you will be clearly helping the patient and adding real value to the people who ultimately pay for your valuable service.
 
That’s what I think.  What are your thoughts?
 
Source:
 
Sherman, B., et al. Patient-Centered Medical Home and Employer Metrics. Patient- Centered Primary Care Collaborative

Effective Physician-Patient Communications Takes Too Much Time – Says Who?

I recently participated in a Twitter Chat about physician-patient communications. A common refrain from some of the providers in the group was that “there isn’t enough time” during the typical office visit for physicians to worry about communicating effectively. What’s up with that?
 
The goal of patient centered communications is to engage the patient in their own health care. While most physicians endorse the concept of patient centered communications, many seem reluctant to employ such techniques in their own practice.  Why?  I suspect that many fear that too much patient involvement will increase the length of the visit.
 
Take the patient’s opening statement aka “patient agenda” in patient centered lingo.  This is where the doctor asks the patient why they are there.  The resulting patient narrative is an opportunity for the physician to obtain valuable information to help assess the patient.  Patient centered advocates recommend that physicians use open-ended questions like “what brings you in today” to solicit the patient’s concerns and agenda.  Active listening by the physician and paying attention to the patient’s emotional cues are also hallmarks of patient centered communications.
 
The reality is that regardless of how they are asked, patients are often not able to complete their opening statement.  That’s because many physicians (75% in one study of primary care physicians) interrupt their patients within the first 18-23 once they start talking.  According to Jerome Groopman, MD, author of the book How Doctors Think, this is because doctors often have a hypothesis in mind regarding a diagnosis even before the patient says a word.  When patients do speak, there is always the risk that physicians “take off” on the first concern mentioned on the assumption that it is the most important reason for the patient being there.
 
Here’s a personal example.  Three times over the last several years my wife developed severe abdominal pain, nausea, vomiting and dehydration. Each time I took her into the emergency room as the problem always seemed to occur at night.  The physician would come in and ask my wife what the problem was.  No sooner did her opening words “I am a lung cancer survivor” get out of her mouth and the physician was off to the races apparently assuming that her being in the ER was due to her cancer.  Chest X-rays were ordered…the whole works.  Yet each time all she apparently needed was to get rehydrated (an IV) and given something to stop the nausea and vomiting.  After 6 hours we would go home and she would be fine the next day.

 
My point is that a lot of time and resources can be misdirected when the patient is not allowed to say what they think is wrong.  Not only is there a risk of wasting time, but physicians also risk losing the respect and trust of patients who feel they are not being listened to.  Had my wife been allowed to fully explain what she thought she needed, based upon previous experience, she would have been quickly treated and out of the ER.

 
The Take Away – The use of patient-centered communications techniques like agenda setting and active listening can go a long way in: 1) obtaining useful diagnostic information, 2) giving patients a sense that they are being listened and that what they have to say is important and 3) building rapport between the physician and patient.
 
The Bottom Line – According to researchers, the use of open-ended questions and active listening during the patient’s opening statement added 6 seconds to the average visit length.  In exchange, according to researchers, patients are more satisfied, adherent and report better outcomes.   Not a bad investment for 6 seconds!  What do you think?

Sources:

Beckman HB, Frankel, RM.   The effect of physician behavior on the collection of data. Annals of  Internal Medicine. 1984 Nov;101(5):692-6.

Marvel, K, Epstein, R, Flowers, K, Beckman H.  Soliciting the Patient’s Agenda, Have We Improved?  JAMA. 1999;281:283-287.

Groopman J. How Doctors Think. Houghton Mifflin. 2007.