Buy the Practice, Employ the Doctor & Pray The Doctor Has Good Patient Communications Skills

Hospitals today are aggressively buying physician practices in their local markets. Why? Hospitals want to solidify their referral base for inpatient and outpatient referrals as well as increase their negotiating power with insurance companies.

Over 50% of physician practices are now owned by hospitals according to the Medical Group Management Association. As such, many one-time private practitioners are now hospital employees.

Having done physician recruitment in a prior life, I know that before buying a practice hospitals look at a variety of things including the practice’s patient volume; number of hospital referrals, estimates of patient turnover and so on. One of the things we did not consider years ago in evaluating and buying a physician practice was the quality of the physician’s patient communication skills and supporting practices. I doubt that things have changed much since.

Hospitals today are under a lot of pressure from Medicare to address inpatient medical errors that compromise patient safety and often result in costly re-hospitalizations. As the line between doctor and hospital becomes blurred clinically and legally, hospitals need to start paying close attention to the way their doctor-employees communicates or doesn’t communicate with patients.

Consider the Problem of Medication Errors

Miscommunication between doctor and patient is thought to be a leading cause of such medication-related errors as patients not knowing:

• The names of all the prescribed medications they are taking
• Indications for using or not using the medications
• Dosage and frequency instructions

According the Institute of Medicine, approximately 500,000 drug errors or adverse drug events are reported every year in doctor’s offices and other outpatient settings.

In fact the evidence suggests that medication-related errors in ambulatory care settings may be substantially under reported. Consider a recent study of patients prescribed a blood thinner – Warfarin. Among older patients, Warfarin, and similar oral blood thinners, account for 10% of all preventable adverse drug events. In this particular study, 50% of all patients differed from their doctor in term of understanding how they we supposed to take the medication. In other words, one half of the study population was taking a Warfarin, a medication with serious side effects, incorrectly.

These finding are consistent with another 2006 study of physician-patient communications during primary care visits in which the physician prescribed a new medication. This study found that physicians:

• Did not tell the patient the name of the new medication in 26% of the cases
• Did not explain the purpose of the medication to patients in 13% of cases
• Did not tell patient about adverse side effects of the medication in 65% of cases
• Did not describe to patients how long to take the medication in 66% of cases
• Did not tell patients the number of pills to take in 45% of cases
• Did not tell patients about medication dosing and timing in 42% of cases

Doctors rely on patients to accurately tell them what prescription medications — and what dosages. In instances where the patient sees another doctor unfamiliar with their medication history, not knowing the name or dosage of a medication can cause serious problems. This is because “the other physician” may unknowingly prescribe a course of treatment that may have an adverse interaction with the patient’s primary course of treatment.

Failure to Inform Patients about Abnormal Test Results

Failure to inform a patient of an abnormal outpatient test result is another example of a serious error. The “failure to inform” rate was estimated at 7.1% in a 2009 study of 5,434 older adults in 23 primary care practices. “Failure to inform” rates for practices in the study ranged from a high of 26% to 0%. In cases like cancer where time is of the essence, any delay in treatment can have serious consequences for the patient.

Today hospitals are under pressure from regulators and payers to clean up their act with respect to inpatient quality, safety and outcomes. As hospitals employ more one time private practitioners, the list of quality, safety and outcomes issues faced by the hospital will grow to include issues like those described here. Issue previously handled by physicians in their own office.

My advice to hospitals? Know exactly what you are buying. Conduct a communications audit of the physicians in the practice before you buy. You will be glad you did.

Sources:

Schillinger, D. et al. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? Advances in Patient Safety. 2007.
Tarn, D. et al. Physician Communication When Prescribing New Medications. Patient Education and Counseling. 2008.
Casalino, A. et al. Patient-Physician Communication about Out-of-Pocket Costs. JAMA 2003.
Casalino, L. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine. 2009.
Preventing Medication Error. Institute of Medicine (IOM). 2006.,

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.