Mind The Gap

Physicians With High Productivity And Satisfaction Scores Employ Strong Patient-Centered Communication Skills

Stephen Wilkins — Mon, 06 May 2013 19:15:09 +0000

People are forever telling me that I am wasting my time talking to providers about the need to improve their patient communication skills. Naysayers typically cite one of the following reasons for why things will never change:

Reason 1 – Every physician thinks they already have good patient communication skills.

Reason 2 – Physicians don’t have time to talk to patients

Reason 3 – Physicians don’t get paid to talk to patients

Reason 1 is relatively easy to debunk. After all, if all physicians were really such good communicators:

poor communications skills wouldn’t consistently top the list of patient complaints about physicians
patient non-adherence wouldn’t be so high since physician and patients would always agree on what is wrong and what needs to be done
patients would not be walking out of their doctor’s office not understanding what they were told
patients would not experience so many communication-related medical errors

Reason 3 requires a little straightforward logic:

Since physicians are paid to diagnose and treat patients presenting problems…and the accuracy of their diagnosis and treatment depends upon their physicians’ ability to elicit and listen to the patient’s story…then indeed physicians are already being paid to talk to patients.

Reason 3 (physicians don’t have time) has always been hard to address. That is until now.

Most us tend to think about physician time on a zero sum basis. Take the office visit for example. Providers will argue that they either spend more time trying to be patient-centered (associated with great patient experiences) or they can use less time to diagnose and treat patients the way they have always done – but no way can they do both at the same time.

A recent published study conducted by HealthPartners in Minneapolis suggests that physician time is not a zero sum game – that providers can in fact be productive while at the same time creating a satisfying patient experience.

Individual productivity and patient experience scores were calculated and plotted for 22 HealthPartners physicians using a scatter diagram like that shown in Figure 1 (for demonstration purposes only). What the study found was that a relatively equal number of physicians fell into each of 4 quadrants – strong productivity/strong satisfaction, strong productivity/weak satisfaction, weak productivity/strong satisfaction and weak productivity/weak satisfaction.

Figure 1

The researchers then looked to explain the difference between physicians in each of the quadrants. They ended up identifying a set of “behaviors and characteristics” to help explain why some physicians had strong productivity/strong satisfaction scores while others did not.

Physicians in the strong productivity/strong satisfaction quadrant exhibited the following behaviors and characteristics:

Focused on teaching and explanations
Conveys warmth from the start
Well-planned flow of visit with focus on patient’s agenda
Controlled script with clear parts
Extremely personable—connects with every patient
Always looking for buy-in from the patient that s/he fully understands
Recap the history: “I read your chart …”
Confident but not arrogant
Finishes dictation and coding each day
Clinic staff enters orders and prepares after-visit summary

Physicians in the weak productivity/weak satisfaction quadrant exhibited the following behaviors and characteristics:

Lack of “being there” emotionally
Lack of smiling
Abrupt actions
Behavior changes when not interested in the “case”
Patients kept waiting and wondering
No handshake
Sense of interrogating to get a diagnosis
No attempt to match the patient’s energy

What struck me about these lists was that were dominated by the presence (strong productivity/strong satisfaction) or absence (weak productivity/weak satisfaction) of communication-related “behaviors and characteristics.”

Perhaps not so surprisingly, the behaviors and characteristics of physicians in the strong productivity/strong satisfaction are consistent with those traits commonly associated with a patient-centered style of communications. This evidence belies the conventional belief among physicians that they will be less productive (rather than more productive) by adopting a patient-centered style of communications with their patients.

Based upon the evidence, HealthPartners has since gone on to provide its physicians with useful guidelines for how to improve their productivity and patient experience scores.

Take Aways Physicians and practice managers need to seriously reexamine:

their assumptions about the value of and barriers to improving their patient communication skills
the evidence in support of the adoption patient-centered communications skills and styles

Physicians and managers should consider assessing the quality and effectiveness of their existing patient communication skills. The last time most physicians focused on their patient communication skills was back in medical school.

Implement interventions and guidelines designed to improve the patient-centered communication skills of physicians and their care teams.

That’s what I think…what’s your opinion?

Sources:

Boffeli, T., et al. Patient Experience and Physician Productivity: Debunking the Mythical Divide at HealthPartners Clinics. The Permanente Journal/ Fall 2012/ Volume 16 No. 4.

Tagged: doctor-patient communication, lack of time, medical errors, medication adherence, non-adherence, paternalistic communication style, patient compliance, Patient-centered Communications, physician-patient communication. doctor-patient communication, physician-patient communications, productivity

Thoughts On Patient Engagement, Patient-Centeredness and Communication-Centered Medical Records

Stephen Wilkins — Wed, 24 Apr 2013 15:23:31 +0000

Sometimes I come across a post that I absolutely must share… such is the case with this re-print of a post by Rob Lamberts, MD, a primary care physician practicing “somewhere in the southeastern United States.” He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared.

“Patient engagement.”

What is “Patient Engagement?” It sounds like a season of “The Bachelor” where a doctor dates hot patients. It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks. There was even an entire day at the recent HIMSS conference dedicated to “Patient engagement.” I think the next season of “The Bachelor” should feature a wonk at HIMSS looking for a wonkettes to love.

Here’s how the Internets define “Patient engagement”:

The Get Well Network (with a smiley face) calls it: “A national health priority and a core strategy for performance improvement.”
Leonard Kish refers to it as “The Blockbuster Drug of the Century” (it narrowly beat out Viagra) – HT to Dave Chase.
Steve Wilkins refers to it as “The Holy Grail of Health Care” (it also narrowly beat out Viagra) – HT to Kevin MD.
On the HIMSS Patient Engagement Day, the following topics were discussed:
- How to make Patients Your Partners in Satisfying Meaningful Use Stage 2 Objectives; Case Studies in Patient Engagement, session #64;
- Review Business Cases for Implementing a Patient-Centered Communication Strategy and Building Patient 2.0, session #84;: and
- Engaging People in Health Through Consumer-Facing Devices and Tools, session #102.

So then, “patient engagement” is:

a strategy
a drug
a grail (although I already have a grail)
a “meaningful use” objective
something that requires a business case
something that requires “consumer-facing devices and tools” (I already have one of those too).

I hope that clears things up.

So why am I being so snarky about this? Why make fun of a term used by many people I trust and respect? I was recently discussing my ideas on a communication-centered medical record with a colleague. At the end of my pontification, my friend agreed, saying: “you are right; communication is an important part of health care.” I surprised him by disagreeing. Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.

But our fine system doesn’t embrace this definition. We indict ourselves when we talk about “patient engagement” as if it’s a goal, as it reveals the current state of disengagement . Patients are not the center of care. Patients are a source of data so doctors can get “meaningful use” checks. Patients are the proof that our organizations are accountable. Patients live in our “patient-centered” medical homes.

Replacing patients as the object of our attention (and affection) is our dear friend, the medical record. We faun over medical records. Companies earn epic profits from medical records. We hold huge conferences to celebrate medical records. We charge patients money to get to see their own medical records. We even build special booths (portals) where patients are allowed to peer in through a peep hole and see parts of their medical records.

This is why I’ve had such a hard time finding a record system for my new practice. I want my IT to center on patients, but medical record systems are self-absorbed. They are an end in themselves. They are all about making records, not engaging patients. They are for the storage of ideas, not the transfer of them. Asking medical records to engage patients is like asking a dictionary to tell a story.

The problem is, documentation has taken over health care. Just as the practice of a religion can overshadow its purpose: the search for God, documentation chokes out the heart of health care: the communication of ideas . It did this because we are paid to document, not communicate. Communication takes time and it is not reimbursed. Communication prevents unnecessary care, which is a revenue stream. Communication eliminates waste, and waste is food that feeds the system, the bricks that build the wings to hospitals, the revenue source that pads IT budgets.

So what’s a doctor to do? I’m not sure. I am still looking for a solution that will meet the central goals of my practice:

Communication – health care is a hassle, with communication relegated to the exam room. I want care to be easily accessible for my patients,using IT in one of its strongest areas: tools for easy communication.
Collaboration – the patient should be engaged, but in a two-way relationship. This means they not only should have access to their records, they should contribute to those records.
Organization – I want a calendar documenting visits, symptoms, problems, medications, past and future events in each patient’s record. I also want a task-management system I share with patients to make sure care gets done.
Education – I want to practice high-quality medicine, care that is informed by good information and the best evidence. Why not do a yearly stress test? There’s evidence for that. Why not use antibiotics for sinus infections? There’s evidence there. Why use an ACE inhibitor to control the blood pressure? I need to be able to support my recommendations with data, not just “because the doctor said so.”

The point of all of this is the moving of medicine from an industry where money is milked from disease to a communications network where diseases are prevented. ”Patient engagement” that is done to the patient for the sake of the doctor or hospital is a sham. Engagement is about interaction, listening, and learning in relationship to another person. Engagement is not a strategy, it is care.

If only I could find the tools to make this happen.

Tagged: Accountable Care Organizations, cost of poor physician-patient communication, doctor-patient relationship, EMR, lack of time, patient centered medical home, patient engagement, PCMH, physician-patient communication. doctor-patient communication

Shared Decision Making – Not Ready For Prime Time – Nor Evidently Is Patient-Centered Care

Stephen Wilkins — Mon, 08 Apr 2013 18:00:13 +0000

When it comes to delivering truly patient-centered care…how are providers supposed to know when they have “arrived”? According to Michael Berry, MD, President of the Informed Medical Decisions Foundation, providers will know they have achieved the “pinnacle of patient-centered care” when they routinely engage their patients in shared decision-making (SDM).

In theory, shared decision-making (aka collaborative decision-making) is what is supposed to happen between patients and their doctors when faced with a difficult choice. Clinicians engaging in shared decision-making would provide patients with information pertaining to the need for the treatment, the available options, as well as the benefits and risks. But patient-centered clinicians would also do something else. They would attempt to work with patients to arrive at a decision they could both live with. A kind of “shared mind” that takes into consideration their clinical perspective as well as the patient’s perspective – their preferences, needs, and values (which ideally have been captured over the course of the patient-provider relationship).

The Problem Is That Most Physicians Don’t Really Engage Patients In Either Shared Decision Making

A 2003 study surveyed U.S. physicians (N=1,217) preferences and actual practices regarding shared decision-making. Table 1 presents a summary of findings from this study.

Table 1

Decision Making Style	What Physicians Preferred	What Physicians Actually Do
Shared decision-making	58%	37%
Physician-dominant decision-making	28%	43%
No patient involvement	9%	13%
Patient dominant decision-making	5%	7%

While most physicians in the study may philosophically believe in and prefer shared decision-making…as this data indicates that is not what most physicians in the study reported actually doing. In fact, 56% of physicians reported that they actually engaged in decision-making that was physician-dominated (with some patient involvement) or totally physician-dominated decision-making behavior (absent any patient involvement).

The Barriers To Shared Decision Making?

The barriers to SDM include the usual suspects:

Lack of time during the visit
Not having access to the right decision support aids tools and training their use
Physician attitudes about patient’s willingness to engage in shared decision-making
Provider reliance upon a physician-directed (versus patient-centered) style of communicating with patients

The Take Away – Why Shared Decision Making Matters

SDM is the right thing to do – the benefits associated with SDM include better outcomes, lower utilization and cost, lower malpractice risk and enhanced patient trust and satisfaction

SDM is a great way to be engaging to patients – it is a way to get patients involved in their care in a meaningful way they can relate to.

To be eligible to participate in Medicare’s Shared Savings Program, Accountable Care Organizations must implement processes to promote patient engagement, including shared decision-making.

As readers of Mind the Gap know, I am a proponent of the adoption of patient-centered communication by providers, beginning with primary care. Shared decision-making has rightly been identified as a leading indicator when it comes to assessing the “patient-centeredness’ of a physician practice. So before you go around telling everyone how patient-centered your provider teams are first do a reality check. Because if you aren’t regularly engaging your patients in shared decision making you are not there yet.

That’s my opinion…what’s your?

Sources:

Heisler, M. et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illness. 2009 Sep;5(3):165-76

Street, R. et al The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice 17 (2011) 579–584.

Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.

Tagged: Accountable care organization, Accountable Care Organizations, ACOs, collaborative decision making, doctor-patient communication, patient attitudes and beliefs, patient engagement, patient-centered care, Patient-centered Communications, PCMH, physician attitudes, physician directed decision making, physician-patient communications, Primary care, SDM, shared decision making, trust

Belated Happy Doctor’s Day – Thanks For All You Do! We Don’t Thank You Often Enough…

Stephen Wilkins — Tue, 02 Apr 2013 17:19:58 +0000

March 30th Was National Doctor’s Day! A Belated Thank You To Doctors Everywhere

Check out the interesting stats about today’s doctors in this great infographic from Soliant Health – A Health Staffing Firm.

Tagged: Doctors, physicians

We Doctors Are Required To Do What’s In The Patient’s Best Interest…But We Are Not Required To “Like” Every Patient We Treat

Stephen Wilkins — Tue, 26 Mar 2013 18:18:17 +0000

Don S. Dizon , MD, FACP

This post was originally published on ASCOconnection.org, the American Society of Clinical Oncology’s professional networking site

“Great,” I thought, as I stood at my desk, looking at my patient list early in the morning. She was coming in today. “She” was a patient of mine in her forties, with newly diagnosed triple-negative breast cancer, without nodal involvement. Our first meeting had been several months ago, and it had not been a good one.

I had asked about her history, how she presented; she had been fairly surprised I did not have that information. “You mean, you don’t know?” she had asked. “I would’ve expected you to at least have read my chart or talked to my surgeon,” she said. Then, with a sigh, she had recounted how she got to this point—finding a mass, the normal mammogram, the ultrasound-guided biopsy, receiving her diagnosis. Then surgery, more results, culminating in a referral to me. Every question I asked was met with a furrowed brow, as if I were interrupting her.

“It must be really shocking to be here. No one our age expects something like this to happen,” I said.

She had gotten angry at this. “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.”

We launched in to a discussion about her diagnosis, stage, and natural history of the disease. She questioned everything we discussed: “Are you sure your statistics are right? From what I read, it’s more like this . . .” I remember getting defensive, as if each question back to me was a personal attack on my competence as a physician, as an oncologist. I remember feeling flushed as we talked, trying to get my point across as clearly as possible, yet feeling that she did not (and was never) going to “believe” me.

We then discussed chemotherapy—both standard treatments and those available on clinical trials. She had even more questions:

“Why should I get doxorubicin? I heard I’ll be throwing up all day. Are you sure I need it?”

“How is a clinical trial better for me? There’s still a 50% chance I can get doxorubicin, so why is this even an option?”

We covered alternative approaches—ones that did not involve doxorubicin and were available off a clinical trial. I then rendered a recommendation taking into account her tumor, her priorities and beliefs, and what the evidence told me. We talked some more and I fielded additional questions; then I asked her if there was anything else she wanted to discuss.

“Not for you.” She said. I looked to the floor and left the room.

As time passed, I resented having to see her and take care of her because despite what I perceived as my best efforts, I felt we had no real doctor-patient relationship. Each subsequent meeting was tense because I felt more and more certain that (a) she didn’t trust me and (b) she did not like me. I had expected her to find a new doctor—within my practice or somewhere else—but she did not. Indeed, I remember being surprised (and anxious) each time she showed up.

On that day she showed up on my list, I confessed something to my partners: “I don’t like this woman,” I said. They looked at me, shocked. “You should not say that,” one had said. “It’s not her fault she has cancer, and people cope in very different ways.”

Although much time has passed, this patient stays with me because it was perhaps one of my most difficult patient relationships—not because she had questions, but because, as sometimes happens, I felt we did not “connect,” despite my trying really hard to make her like me, and to see that I was a good and decent doctor.

As I developed this blog, I decided to show it to a very dear friend, Dr. Barbara Rabinowitz, whose advice and guidance have been important to me on a number of occasions, particularly when we served on the board of a national organization together. I had wondered what she thought of my experience.

Dr. Rabinowitz:

I do believe we hold high and sometimes unrealistic expectations of ourselves. In spite of your usual ease and rapport with patients, the experience you describe above is far from unknown. According to Haas et al., studies have shown that about 15% of the time physicians experience working with “difficult patients.”

In my experience, health care providers often feel trapped by the resultant negative feelings of these non-satisfying relationships. Though not in this case, difficulties may arise in the physician-patient relationship stimulated by pressures from the health care system itself (time allotted for visits, etc.), from undiscussed differences in expectations between the patient and physician, and the patient’s own previously held (and perhaps undiagnosed) conditions (e.g., personality disorders, etc.). Not uncommonly in cancer care, the free-floating anger at having been diagnosed with cancer may also be aimed at one or more members of the cancer care team.

I believe there is an even greater pressure to “like every patient” in cancer care than in general practice, as in this case, as exemplified by the reactions of your colleagues to your frustrated admission.

Ultimately, I clarified something with my partners: “I did not say anything about having cancer being ‘her fault’—I said I did not like her.”

With that, I realized that even with our white coats on, we possess our feelings, likes, dislikes, and personalities. Medicine requires us to do what is in the best interests of our patients, to “do no harm.” It does not compel us, however, to “like” everyone we treat. As a result, I experienced something interesting—almost liberating. I found that subsequent discussions and encounters with this patient became easier and that I was able to listen to her questions and answer them without getting defensive.

I realized that when I stopped trying to make her like me, I was able to take care of her. The pressure of wanting to be “liked” faded. It dawned on me that I was working so hard to make her like me (and vice versa), that it was affecting my ability to care for her. Once I admitted to myself that it was okay to not like a patient, I was able to do what she wanted me to do—to be her doctor.

At the end of the day, doctors are not a deity—omnipresent and omniscient. We are people—we are fallible, prone to our prejudices and our preferences, insecurities, and biases. I have learned that to become a good doctor, one must be honest with one’s self and exert introspection in order to become self aware; to admit that maybe the difficult patient is perceived as difficult not because of who or what she says, but rather the pressures we put on ourselves to “like” everyone we treat.