Not long ago Nick Dawson, a friend and fellow blogger, paid me the compliment of saying I had inspired a post of his. Well Nick now you have inspired me…and this post is the result.
Regarding the February Health Affairs edition on Patient Engagement the and follow-on Washington D.C. briefing, Nick writes:
Personally, I was disheartened by some word choices. Implying patients need to be activated suggests patients are passive and something has to be done to them in order for them to care about their health and interactions with healthcare providers. That misses the mark.
What about physician activation? … We should be helping health systems and providers find ways to reduce the stress and fear for patients who are already engaged.
Nick is right.
The “Belle of the Health Affairs Ball” based on the social media coverage was Judith Hibbard’s interesting work linking health care costs to a person’s level of health activation. While Dr. Hibbard takes pains to differentiate “activation” from “engagement,” most people are quick to conflate the two. (Patient-centered communication bears a close resemblance to patient activation as well.) Nick’s point is that focusing just on what the patient brings to the party in terms of their “knowledge, skills and confidence” is only half the problem.
What about physician activation? Where in the Health Affairs special, or anywhere else for that matter, are discussions about the need to make sure that physicians (and other clinicians) have the knowledge, skills and confidence to effectively manage all the “already engaged” patients among us?
It Can’t Just Be About Fixing Patient Behavior
For too long, the focus among health care thought leaders has been all about fixing the patient. If only patient were more engaged, more knowledgeable, more compliant, more trusting, more prepared, ask more questions, etc.
There is a significant body of research which suggests that provider behaviors (like their communication style) are just as responsible as patients for many of the short coming in health care today.
Just as PAM research has shown that more activated patients generate lower costs…studies have shown that the physicians with strong patient-centered communication skills have lower costs as well. I guess you could say that physicians with a physician-directed, bio-medical communication style have an equivalent of a 1-2 level of activation whereas physicians with a patient-centered communication style have an equivalent activation level of 3 to 4.
Which Comes First – Activated Physicians Or Activated Patients?
I would argue that the real challenge facing providers today is to how to avoid disengaging or deactivating otherwise engaged and activated patients.
That’s because most people are already engaged in their own care, albeit not necessarily in the same way that providers want or expect. So too, patients may well believe that they have the skills and knowledge they feel they need to deal with their own health…even if it is different from those skills, etc. measured by tools like PAM.
See : Patients Are Often More Engaged In Their Health Than Providers Think
In fact there is evidence to support this. Patients with a regular source of care displayed significantly lower levels of patient activation that those without a regular source of care. According to the researchers, “one possible explanation is that respondents with a regular physician are more likely to take a passive, deferential role in their care, believing their health care needs are being met by their provider(s).” *
The degree to which there is a “meeting of the minds” on engagement and activation between patient and physician, particularly during the office visit, will determine if patients are as engaged and activated when they leave the doctor’s office as they were when they entered. It all boils down to how well the physician and patient are able to communicate.
Here’s what I mean. How engaged or activated is a person going to be if what they have to say is interrupted, ignored or otherwise dismissed by busy, stressed clinicians? Is a patient going to share information or new skills they found on the internet with their physician if they are dismissed as a Googler?
The Take Away?
Nothing against PAM or Dr. Hibbard’s work which stand on its own merits. Rather, it’s about health care being a two-way affair…with patients and clinicians both have a stake in health outcomes. The sooner health care providers, academic researchers, and health publications like Health Affairs realize this…the sooner things can improve.
That’s what I think. What’s your opinion?
Sources:
Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient-centered care. Health Affairs, 29(7).
Olson, D. P., & Windish, D. M. (2010). Communication discrepancies between physicians and hospitalized patients. Archives of Internal Medicine, 170(15), 1302-7. doi:10.1001/archinternmed.2010.239
Roumie, C. L., Greevy, R., Wallston, K. a, Elasy, T. a, Kaltenbach, L., Kotter, K., Dittus, R. S., et al. (2010). Patient centered primary care is associated with patient hypertension medication adherence. Journal of Behavioral Medicine.
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.
* Alexander, J. a, Hearld, L. R., Mittler, J. N., & Harvey, J. (2011). Patient-Physician Role Relationships and Patient Activation among Individuals with Chronic Illness. Health Services Research, 1-23.
Mind The Gap 
Firstly, as a long term patient stuck in the revolving doors of psychiatric units, I can assure you, I was absolutely passive. I recall after a long admission being unable to make a decision on which shampoo to buy. This was not because of my illness, but being stuck in a “system” where pretty much the only interaction with professionals was the daily bellow “medicayshun!” Now I think there needs to be work done to promote effective “leadership” (rather than “management”) involving patients and professionals equally. Physicians and patients can be far more effective if there is an understanding of the other’s perspective. The bringing together of professional skill and the context that people like myself can add, is on a genuinely equal basis, can lead to creativity and innovation that is so badly needed. This entails a shift in power however that remains fundamentally threatening for many practitioners. There are some indications that change is starting to happen. After many years ticking boxes in meaningless “consultation” exercises as a rewlatively cophenerent “service user”, I am now a Fellow of the Collaborative for Leadership in Applied Health Research and Care (CLAHRC) at Imperial/National Institute of Health Research working on an equal basis with a diverse group of young GPs, public health workers, etc. Already they are noting what the two “patients” among the Fellows have to say and are refocusing their research projects as a result. In the same way, I am learning the realities faced by NHS staff at the present time and more realistic in my expectations of “transformation”. This is Co Production as the original architects intended it, where we realise that we are in fact all aiming for the same thing and all our respective perspectives and experiences are of absolutely equal value. More of this kind of thing is essential.
Steve:
first, I’m flattered and honored —thanks as always for your eloquent an passionate writing.
secondly, I really love this quote:
“I would argue that the real challenge facing providers today is to how to avoid disengaging or deactivating otherwise engaged and activated patients…That’s because most people are already engaged in their own care, albeit not necessarily in the same way that providers want or expect.”
You are spot on. The industry is still in a patriarchal mode where its assumed a) providers know best and b) patients should approach them genuflect. While its certainly true doctors know more about medicine than I do, its also a fallacy to assume I don’t bring equal value to the conversation with my knowledge of my behavior, motivations, abilities, desires, emotions, needs, etc.
The risk, for providers, is in failing to see me as an equally valuable member of the care team. In fact, I’ve become a proponent of a new partnership, the “triad”, based on the existing dyad model of patient and administrator. My triad would include the patient too. Regardless of terms, I really like your point —alienating already engaged patients is a huge risk.
As a patient that was trustworthy for a very long time (through spine surgery, rehab, more rehab, injections, etc.) I have become much more engaged. After over a year of no relief, I began asking questions, seeking other opinions, etc. Instead of engaging, the doctors (most “great” by the way) became defensive and either won’t see me or are very passive in the care.
NYC Patient
In the case of my wife and her Oncologist, the physician was up front enough to express his consternation whenever we questions his decisions. When you encounter similar situations going forward (which you are probably already doing) I would simply say to the doctor…”it appears that something I said or did has upset you…as evidenced by your defensiveness or passivity. Am I misinterpreting something? Can you please tell what is wrong?”
If you don’t get the answer you want…you need to weigh the merits of switch doctors against sticking with your current doctor for the value that doctor brings.
Thanks for your comments!
Steve Willkins
Thanks, Steve.
Unfortunately apologizing for such things and conveying to them that all I want to do is gain some type of understanding doesn’t work. And I have switched doctors – there are only 2 in NYC that treat my specific issue – 1 that is at “my” hospital with most of my other doctors and the other is at a hospital I’m not too keen on and he spends far too much on marketing – a bit tacky.
As a patient that was trusting of my doctors for a very long time (through spine surgery, rehab, more rehab, injections, etc.) I have become much more engaged. After over a year of no relief, I began asking questions, seeking other opinions, etc. Instead of engaging, the doctors (most “great” by the way) became defensive and either won’t see me or are very passive in the care.
I think that it is extremely difficult to create an atmosphere of mutual trust between doctor and patient, we had not mutually comparable risks – in terms of my health. When the doctor might be wrong in the diagnosis or the choice of treatment method, so it almost he never argued while after my explicit evidence that he was wrong after 4 weeks by X-Ray image of hip – the consequences of mistakes keep allways the patients, often for the rest of life. In addition, in certain investigative medical testing methods such as biopsy or colonoscopy – there are not only painful, but can generally have dangerous for injury – many times with consequences and patient risk too upset by doctor – someone with a lifetime of patients urinary incontinence, can someone in the company with continuous diarrhea and it is not yet certain that it was not possible to evaluate the patient other with a non-destructive way to his health. Has anyone tried to tell as patients to your doctors – for example for neurologist – “Sir, I’m afraid you’re mistaken diagnosis ´of spinal irritation of the nerve in backbone endings – but there are actually probably beginning incipient necrosis of the femoral head, and now instead of 4 injections weekly with analegetics to the end of the spinal, you should have to more correctly: …. you should send me to a magnetic resonance in time and to begin to heal damage to the hip joint with non-surgical method but with set of infusions and with fully stop of patient locomotion for next 4 further week!!! Yes, I tried it say and although I had by literally the truth, at another department teaching hospitals refused to treat me as a “foreign patient… and despite when they gave me their agreement with my primary hypthoses about my right diagnose.” My official neurologist so long wondered whether find wrong -or true – but after 4 week lately the new X-ray image shown of absolute devastation now – it was seen sliding surfaces of the hip joint – and then it was the only one medical solution to THR surgery! …No apology for me, no satisfaction for me, no better view for risk prevences for futher next orthopadic patients and differential testing variant diagnoses with the same pains…
We have ALL – clinicians and patients alike – been conditioned by the same longstanding, outdated, model of clinician centered care. So, although “Patient Centered Care has been on the table since 1969, old habits are proving difficult to break on both sides of the bed. Even with the best of intentions to be “Patient Centered, many clinicians continue to “diagnose” the problem on behalf of the patient (they are so conditioned to be the problem solvers in the relationship) and just as many patients continue to expect the clinicians to fix what’s wrong.
It remains a “them and us” divide with lots of finger pointing. It is as true to say that the system remains patriarchal as to say that patients still often respond as would children to a strict or controlling parent. It is a transition as painful and awkward as the one we all know – of transitioning from the parent/child relationship to the adult/adult relationship that begins during adolescence (and sometimes lasts as long as this transition in healthcare! )
I admire your focus on that point of contact between the health care system and the person. On one side is a miriad of health care workers who meet, touch or prescribe and the other side is a person. Finding out how to make that contact as meaningful and helpful is hugely important. Providers do try to move patients in a direction they don’t naturally want to go. Do people want health care? Absolutely not, it’s irritating, expensive and reminds them eventually they will die. If you ever try to get a smoker to quit smoking you can get a feel for the natural tension in the doctor-patient interaction. Is that activation or lack of activation?
I am so happy to see more and more of these important discussions take place. I am a psychologist who for the last twenty five years has been working with physicians to improve their interactions with patients and colleagues. For the past four years I have been on a consulting project whereby I teach and co-precept at a primary care clinic with attendings and residents. My role their is to “activate” the young doctors and inculcate a culture of patient-centered care for the attendings to infuse into their interactions with both patients and residents. I am in the patient consultations and evaluate the new docs on their communication skills, cultural sensitivity, intervention/management of chronic illnesses, and psychosocial matters that may also be a focus of health and treatment.
As a result of the work we are doing, we are seeing the young doctors appreciate the focus we are providing and inculcating it into their interactions with patients and their families. And we are seeing changes in patient behavior as a result. Patients are getting better at losing weight, tackling addictions, following their doctors Tx recommendations and, most importantly, interacting more meaningfully with their doctor. We didn’t have to do anything but change the physicians’ behavior in order to do this. So, yes, activating the doctors is what is needed. The patients, I find in most cases, will mirror the energy and level of engagement their physician brings to their interaction with them. Thanks again for this important conversation and allowing me to be a part of it.
BRAVO Michael!! BRAVO!!! I am a psychologist and a person who has had 17 years as a patient following a major multi trauma accident. I now speak world wide to health care professionals about the importance of the clinician/patient relationship and the role of interpersonal and communication understandings and skills in maximizing the benefits of that relationship. Plus I show how, from a systems perspective, there is no sense focusing alone on the C/P relationship without looking after relationships throughout the healthcare environment using those same essential interpersonal and communication understandings and skills.
As you know, being inspired at a conference doesn’t always translate into sustainable changes in behaviour. Sounds like what you do is exactly what is needed!