Patient-Centered Communications – Does “Lack of Time” Justify Physician Reluctance To Adopt It?

I talk with lot of physicians about the need to improve the quality of communications between physicians and patients.   Regular followers of my work will know that I am an advocate for the adoption of patient-centered communication skills by the physician and provider community.

Physicians with whom I talk seldom disagree as to the need for better physician-patient communications.   They know that physician communication skills top the list of patient complaints about their physicians, i.e., my doctor doesn’t listen,” “my doctor ignores me,” and so on.   Rather, they simply dismiss the subject out of hand as being impractical due to a “lack of time” on the part of most physicians.

I can understand their perspective.   Primary care physicians in particular are faced with sicker, more demanding patients, increased payer and regulatory requirements, and are constantly pressured to see more patients.

Yet physician waiting rooms and exam rooms are full of engaged patients (otherwise they wouldn’t be there) who have nothing to do but read outdated magazine.

What would happen if physicians actually put patients to work during wait time?

Here’s what I mean…

What if physicians integrated patient “wait time” into the office visit by:

• Talking to patients (via printed handouts, electronic media, patient portals, etc.) about their evolving new role (and that of the physician and other providers) under health reform.  Contrary to the popular press which touts the empowered patient, most of us still assume the traditional “sick role” during the office visit.  The sick role is characterized by patient passivity, limited information sharing, and minimal question-asking.

• Teaching people while waiting how (using the same media as above) to become “better patients.”   I recall an article where physicians were asked 5 things they wished their patients knew.  At the top of the physicians’ “wish list” was a desire for patient’s to be better prepared and more focused during the visit.  The point being that more prepared patients would help the physician get to the correct diagnosis and treatment plan faster

All of us, beginning in childhood, are socialized into playing the sick role when interacting with physicians.   Just as chronic disease patients needing to develop self care skills and confidence in their self care skills…patients need to be taught skills for (and develop confidence in) how to more effectively talk to and collaborate with their physicians.

•  Laying out a game plan (over a series of visits) for teaching new and established patients when and how to effectively contribute to the medical interview (exam).   Given an average wait time of 22 minutes per primary care visit, it is not reasonable to assume that patients can be taught the above in the course of 1 or 2 visits.  But patients with chronic conditions often visit their PCP 6-8 times a year.  This would afford plenty of time (2-3 hours a year) for physicians to teach (and practice) individual skills to patients (i.e., agenda setting and prioritization, question asking skills, self-care management skills, new medication considerations, etc.).   By reinforcing lessons learned by patients over the course of several visits, it is reasonable to expect that both patient and physician will become more proficient in the use of their time together.

How Exactly Will Better Physician-Patient Communication Lead To More Productive Visits?

Research has consistently shown that patient-centered communications (versus traditional physician-directed communications) can result in more productive office visits as measured by 1)  the amount/quality of information shared by patients, 2) the number of questions asked by patients, and 3)  and the level of patient retention of information shared by physicians.

These same studies show that the adoption of patient-centered communications adds little if any more time to the length of office visits.  Once patients and physicians become proficient in the use of patient-centered communications methods,  physicians may well be able to do more during the visit but in less time.  Here are some of the techniques  characteristic of patient-centered  communications associated with increased visit productivity:

•  Concise visit agenda setting and prioritization wherein both physician and patient  agreed to what can be discussed within the time allowed.  This  also eliminates  the “oh by the way” introduction of last-minute patient agenda items that can occur at the end of the visit.

•  More concise  sharing of relevant information by the patient.

• Greater physician-patient agreement as to the diagnosis and treatment.

• More collaborative decision-making

•  More information retention by patients (how to take new Rx, etc.)

• Greater patient adherence

That’s my opinion…what’s yours?

Related Post:

Do Medical Home Physician Really Communicate Any Better Than Non-PCMH Physicians?

Six Seconds To More Effective Physician-Patient Communications

Sources:

Politi, M. C., & Street, R. L. (2011). The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17(4), 579-84.

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine : JABFM, 24(3), 229-39. doi:10.3122/jabfm.2011.03.100170

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

Will Information Technology Squeeze Physicians Out Of Their Central Role In Health Care?

Not by a long shot if patients have anything to say about it.

Turns out that while most of us (90%) would like be able to make a doctor’s appointment and check lab results online….85% of us also still want the option of be able to talk to our physician face-to-face.  These are the finding from a recent 2012 study conducted by Accenture.

These finding will no doubt come as a surprise to many of those high tech newcomers to health care looking to make physician and trips to the doctor’s office a thing of the past with some new “killer health app.” You wouldn’t believe how little many of these software and app developers know about how health care works.  Then again, if you have looked at some of the EMRs, PHRs, and patient portals solutions being hyped out there maybe you could believe it.

What is significant about the finding cited above is that patients at least get it.  They understand the value of a having a relationship with a knowledgeable physician or similar health care provider.  In spite of, and for some, because of the plethora of health information outlets on the web people want to know that they always have access to your family doc when the chips are down.

What newbie software engineers and  smart phone app developers fail to understand is that health care is fundamentally about social interactions…not technical data transactions like depositing a check or making an airline reservation.

Here’s what I mean…based upon some 20+ years working in health care:

• From the get go…going back to Hippocrates…health and health care delivery has been about the relationships between people starting with the  physician-patient.relationship.

• The most important diagnostic tool a physician has at their disposal is not a smart phone…but their ability to talk with and observe  patients verbal and non-verbal behavior.

•  “Talk” is not only how physicians diagnose problems and recommend the appropriate treatments…talk is also how patients are able to engage in the health care.  Perhaps the most overlooked aspect of talk (and touch) during the medical exam is the therapeutic benefits patients derive from being able to express heart-felt fears and concerns to someone who hopefully cares.

The unfulfilled promises of so much of health information technology today (like Electronic Medical Records, Personal Health Records, and Patient Portals), with some notable exceptions like Kaiser, Group Health and the VA, can be traced directly back to developers not understanding that their job is to enable physician-patient relationships not get in their way or try and replace them.

Check out this related post – Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

I don’t consider myself a Luddite when it comes to health information technology…nor would I put most physicians in this category.  The health industry is going through massive change, and unfortunately in such time, there is also a lot of false starts and waste that comes from ill conceived HIT solutions.  I suspect that tech vendors that take the time to learn the business that is health care, and commit themselves to improving the physician-patient relationship…will do just fine.

 The Take Away…

The physician-patient relationship remains paramount for us patients.  Yes there are problems…yes physicians and patient need to learn to do a better job communicating with one another.  But when everything is said and done…when the chips are down…we don’t want to be forced to diagnose and treat ourselves.  We want to be able to see and talk with our doctor when we want.  And honoring the patient’s perspective after all is what patient-centered care is all about right?

And oh by the way…we still want the convenience of being able to go online to schedule an appointment and check out lab tests.

That’s my opinion…what’s yours?

Sources:

Squeezing out the doctor -The role of physicians at the center of health care is under pressure.  The Economist. June 2012.

Could mobile apps replace doctors?  KevinMD.com

 

ACO Success Will Depend Upon The Patient-Centered Communication Skills Of Providers

Accountable Care Organizations (ACOs) and “bundled payments” are set to play a central role in the Affordable Care Act.  Under accountable care, physicians and hospitals would be paid out of a “single payment” from CMS or health insurers for all the care needed to treat a clinically defined “episode of care” like a heart attack.   The premise is that bundle payments will incentivize physicians and hospitals to deliver more efficient, high quality care.

Much has been written about the health information technology infrastructure needed to support ACOs.  Experts also underscore the need for providers (physicians and hospitals) to get patients with conditions like heart failure more engaged in prevention and self-care.  After all, as much as 90% of the “care” for chronic conditions like heart failure is provided by the patient and their care givers at home.  But effectively engaging patients has been a difficult nut to crack for health care providers.

What Can ACO Providers Do To Increase Patient Engagement?

Here’s the short answer – improve the quality of communications between physicians and patients.  After all, physician-patient communications is how most patients are diagnosed and treated.

The degree to which patients and physicians agree on key aspects of the diagnosis and treatment is said to be an indicator of communication effectiveness.  Disagreements such as the nature or severity of a medical condition or the need for a new medication represent a breakdown in physician-patient communications.  Such breakdowns are common and are closely associated with patient behavioral issues such as non-compliance, excessive health care use, and decreased satisfaction.

High levels of physician-patient agreement are linked with more desirable patient outcomes and behavior.  Physicians that use a patient-centered style of communication tend to report much higher levels of agreement with their patients on critical diagnosis and treatment issues.

The Current State of Physician-Patient Communications

A 2011 study of patients diagnosed with a heart condition, and being seen in a public hospital cardiology clinic, illustrates the scope of the communication problems facing not just ACOs…but all health care providers today.

In the study, 55% of patients diagnosed with heart failure did not recognize (nor agree with their doctor) that they had heart failure.  Even more disconcerting was the finding that “only 15% of those with hypertension agreed with their doctor’s diagnosis.”

Physician-Patient Disagreement And A Lack of Patient-Centered Communication Are Greatest Amongst Population Groups That Are The Sickest And Most In Need

African-Americans experience heart failure at a rate this is 20 times higher than their white counterparts.  Physicians that treat blacks are less likely, according to researchers, to use a patient-centered communication style.

Numerous studies have revealed that when treating black patients, as opposed to white patients, physicians tend to “provide less health information, are more physician-directed (versus patient-centered), spend less time building a rapport with patients, and are more verbally dominant.“  In other words, the patients that are in greatest need for patient-centered communications, and the benefits it provides, are presently the least likely to receive it.  The lack of high quality patient-centered communication is not limited to minority groups.  An estimated 60% of practicing physicians use a physician-directed communication style.

 The Take Away?

Needless to say, the quality of physician-patient communications in the U.S. does not bode well for the success of ACOs.  Health plans, physician groups and hospitals looking to realize the financial benefits of bundled payments and accountable care should give serious consideration to investing in benchmarking tools and communications interventions that will measurably improve the quality of physician-patient communication both in the office and hospital.

That’s my opinion…what’s yours?

Sources:

Cené, C. et al. The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication. Journal of General Internal Medicine. 2009. 24(9):1057–64

Sarkar, U. et al. Patient-physicians’ information exchange in outpatient cardiac care: time for a heart to heart? Patient Education and Counseling. 2011. Nov;85(2):173-9.

Johnson, R. et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 2004. 94(12), 2084-90.