The 10 Commandments of Patient Engagement

As a patient, care giver, researcher and a human being, here ‘s my “take” on what physicians and hospitals, and all the entities that work with them like health plans, ACOs , etc. need to do to effectively increase patient engagement in 2013 and beyond.

1. Act like you are glad to see them (patients) and have time for them… no matter how busy you really are

1. Say something relevant to suggest that you actually remember who they are – don’t get this one wrong
2. Ask how they have been since their last appointment and what brings them in to see you today
3. Probe for the patient’s ideas as to the cause of their complaints and what they would like you to do for them
4. Listen to what the patient has to say without interruption – ask clarifying questions
5. Tell the patient what you recommend doing in the way of tests, treatments and new medications…and explain why you are making those recommendations – ask if that’s ok with the patient…if it’s not ok find out why
6. Pay attention to patient-initiated cues (loss of a job or loved one, sighing…) – they probably are a call for help
7. Express empathy and support to patients
8. Find out what your patient’s health goals are and what steps they believe they can take to achieve them, e.g.,  care planning
9. Ask about or suggest ways that you and your team can support  patients’ long-term care plans

The challenge most physicians and other providers face is not one of how to engage patients.  Most of us patients (people) are already engaged to the extent we:

• went to the bother of calling your staff to make an appointment (never a pleasant experience)
• took time off work to travel to your office
• wait an average of 24 minutes to see you
• sit for 24 minutes thinking about what we want to talk with you about and how you are too busy to listen

Rather the challenge for providers is how to be engaging to patients.  Health care after all is an intensely personal and social interaction between human beings.   My apology to all the health information technology folks who suggest EMRs, web portals and smart phone health apps are the best way to engage patients (they are not).  I for one am convinced that people would be more engaged in the care (they way providers expect and prefer) if only providers were more engaging…lack of time and reimbursement notwithstanding.

I am sure I have missed something so please feel free to add to the list.

Check out more posts on Patient Engagement:

Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

 Patients Are Often More Engaged In Their Health Than Providers Think

Patent Portals. PHRs, & On-line Decision-Support Tools Alone Will Not Lead To Greater Patient Engagement

Patient Engagement  Infographic

Why It’s So Important For Physicians To Listen – The Patient’s Perspective

A recent qualitative study (structured interviews) of patients conducted at       McGill University School of Medicine underscores the importance of listening in physician-patient interactions.   In this study, patients were asked to identify the qualities of a good physician.   The following is a typical patient response:

“A good physician is somebody who will listen to what the problem is and explain to you what it is and what is being done.’’

When people were asked why listening by the physician was so important, researchers discovered three important themes that have apply to every provider today.

Theme #1 – Respondents (people/patients) believed that listening was essential if the physician was to arrive at the right (and credible) diagnosis. 

Representative Comments:

• ‘Physicians “should trust the person in front of them and hear what they’re saying. . .because I know my body better than anybody else.“

• ‘‘Listen to what they [patients] have to say; not just what other people wrote about them in the doctor’s notes.

• ‘‘[If] I feel that I haven’t had enough time with you to tell you exactly what my story is, even when you give me a prescription I’m going to say, ‘Really? Is this prescription right for me and for my illness? Or [is it] going to give me more complications?’. . .and I think sometimes that’s why you find patients will take it for 1–2 days and after that they forget about it, because they say, ‘He didn’t hear what I had to say about this pain.

Theme #2 – Listening is healing and therapeutic.

For years researchers have written about the therapeutic value of strong physician-patient communications.    Turns out patients recognize the same benefits.  For example,  a physician who listens and “validates the patient’s perspective or expresses empathy may help a patient experience improved psychological well-being—fewer negative emotions (e.g., fear, anxiety) and more positive ones (e.g., hope, optimism, and self-worth) “

Representative Comments:

• ‘‘If a doctor doesn’t respect the patient, or doesn’t listen, the patient feels more worried and unsettled and this has an impact on their health.’’

• ‘‘Sometimes, listening to a person will cure half of your problem. . . like it takes two or three months to get an appointment. In those two–three months, you make your problem worse by thinking, ‘Oh maybe it is this, or that or that or that.’

• ‘‘if you listen to the patient and give the patient respect, what you are actually doing is helping that person take responsibility for their own health – that they are also in control of the healing process and are involved somehow. So the doctor has to not take all the power away from the patient.’’

For related patient (and physician thoughts) on this subject, check the following story and COMMENTS on CNN

Theme #3 – Listening can foster and strengthen the doctor–patient relationship if it is authentic

Representative Comments:

• ‘‘I want the doctor. . . to have empathy and to listen and to look into my eyes and to make me feel that for that short moment…you are hearing me, you are there for me, and you give me that sense that I matter

• ‘‘It still makes me angry when I think about how I was. . .how I sort of felt ridiculed for my looking into alternative options.’’

• I think they [physicians] should listen out of respect. Sometimes I think that caring and compassion can be patronizing, if it is insincere. You can still be arrogant and project this caring and compassionate facade.

Take Aways

Over all I was struck by the following as I read this study…particularly the respondent comments.

• People/patients in the study clearly recognized the link between effective listening (by providers) and quality of care.    Too often providers are quick to discount the accuracy or validity of patient perceptions of quality whether in the hospital or doctor’s office.  The comments reflected in this study suggest otherwise.

• Listen skills are essential to patient engagement and positive patient experiences.   To be engaging, providers must be “relevant” from the patient’s perspective.   To be relevant, providers must solicit and listen to what patients want to tell them.

• If listening is therapeutic and has the power to heal…does this mean that physicians who 1) do not solicit or 2)  ignore or gloss over patient input are not practicing at the “standard of care?”  Given that poor physician-patient communications is a leading cause of malpractice suits it would seem so.

• Health care providers (physicians and hospitals) would do well routinely do a “deep dive” into their patient satisfaction research to get a true and realistic handle on the quality of their provider’s listening and other communication skills.   I am not sure that the standard HCAPS and CHAPS survey instruments  probe physician-patient communications far enough.

That’s what I think.  What’s your opinion?

Source:

R. L. Street et al.   How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling, 2009. 74(3), 295-301.

J.  Jagosh et al.  Patient Education and Counseling.  85 (2011) 369–374

The Critical Role of Patient Trust In Their Doctor – Infographic

Often the simplest solutions to problems are the best.   So it would seem when it comes to the impact that increasing patient trust in physicians could have on  many of the  intractable challenges that face the health care industry everyday like non-adherence, lack of involvement, poor health status, dissatisfaction and so on.

I explore the link between patient trust and outcomes in the following infographic I curated and designed.   What surprised me is how a patient’s level of  trust in their doctor, like so much of what I talk about in this blog,  boils downs to the patient’s perception of the physician’s ability to communicate.

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.

If Evidence Really Mattered, Physicians Would Be More Empathetic With Patients

Is anyone else tired of hearing about how important empathy is in the physician-patient relationship?  Every other day it seems a new study is talking about the therapeutic value of empathy.  Enough already!

It’s not that I don’t believe that empathy is important, I do.  I also believe the data that links physician empathy with improved patient outcomes, increased satisfaction, and better patient experiences.

A recent study released in Academic Medicine reported that “patients of physicians with high empathy scores were significantly more likely to have good control over their blood sugar as well as cholesterol, while the inverse was true for patients of physicians with low scores.”

Finding findings from this study by Hojat et al are consistent with a 2009 study by Rakel et al which found that among patients with the common cold those with physicians displaying high empathy had a significantly shorter duration of illness and trend toward lesser severity of illness and higher levels of immune response, compared to those patient whose physician displayed less empathy.

Going back further, in a 2001 review of 25 randomly controlled studies that looked at the influence of the practitioner-patient interac­tions outcomes , Di Blasi et al concluded that:

One relatively consistent finding is that physicians who adopt a warm, friendly, and reassuring manner are more effective than those who keep consul­tations formal and do not offer reassurance.

The problem with empathy research is that no one, including doctors, seems to be any paying attention as attested to the fact that nothing has changed.  Research documenting the therapeutic value of empathy goes back at least 20 years.  Despite the evidence, it seems that physicians are no more empathetic today than when people first started researching empathy.

Today we are told the health care is supposed to be evidence –based.   I wish that was the case when it came to empathy and the physician-patient relationship.  If it were we would have a lot more empathetic physicians, healthier patients, and much more satisfying patient experiences.

What do you think?

Sources:

Hojat, M. et al. Physicians’ Empathy and Clinical Outcomes for Diabetic Patients. Academic Medicine March 2011 – Volume 86 – Issue 3 – pp 359-364.

Rakel, D. et al. Practitioner Empathy and the Duration of the Common Cold.  Family Medicine, 2009;41(7):494-501.

Di Blasi, Z. et al. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357(9258):757-62.