Would Increased Reimbursement And Longer Visits Improve Physician-Patient Communications?

In a word…no.

It has been said that a physician’s patient communication skills are just as important as their clinical knowledge.   After all, it is only by “talking to and listening patients” that physicians are able to accurately diagnose and treat their conditions.   I have yet to meet a physician who did not agree with the importance of effective physician-patient communication…in principle.

In practice, a surprising number of physicians tell me that they “lack the time” and “don’t get paid” to communicate with patients.  Physicians euphemistically explain to me how current reimbursement schemes fail to incentivise physicians  to spend time talking to patients.

At face value, these objections appear to make sense.  After all we know that physicians, particularly primary care physicians, are already overextended.  We also know that the traditional fee for service model, which pays physicians on a kind of piece work basis, is not well-suited to managing “episodes of care” for a burgeoning chronic disease population.   In other words, today’s reimbursement is not properly aligned with the realities of care delivery.

The conclusion one draws from these two objections is that doctors would communicate better with patients if they simply had more time and were paid more.   But is that what would happen?

I don’t think so…and here’s why.

Many physicians, until recently, were never taught (in medical school) how to be good patient or person-centered communicators (the gold standard for physician-patient communications).   Studies show that the majority of primary care physicians today employ a physician-directed, paternalistic style when talking with patients.   This is the same style of communication practiced by physicians for the last 80 years.  This style is characterized by the physician control of the medical interview by asking the questions, focusing patient input, and providing pertinent information.  Some physicians now limit patients to asking one question per visit.  Over the course of their career, the typical physician will employ these same “conversational habits” in 120,000 to 160,000 medical interviews.

Patients, for their part are trained as well – socialized from childhood to assume the “sick role” wherein the doctor does all the talking and their job is to passively respond to questions when asked.  The average 60 year old for example will have experienced 180+ visits in which they were likely expected to assume the sick role.   Even the most engaged and empowered patient finds it difficult to avoid reverting back to this passive role.

What’s My Point?

The “communication habits” developed by and employed by physicians and patients took years to develop.   Simply increasing the length of the office visit (more time) and increasing reimbursement alone will not compensate for nor change the way physicians and patients communicate with one another.   Physicians will continue to be physician-directed and patients will continue to play the passive sick role.  Absent interventions aimed at breaking this cycle of unproductive communication by promoting more patient-centered communications, longer visits and more reimbursement will mean that physicians have more time for and get paid more for perpetuating the same physician-directed communications challenges we face now.

Patient-Centered Communication Can Lead To More Productive Visits

Physicians are concerned that patient-centered communications will increase the length of office visits.  Initially it probably will.  But imaging how much more productive office visits could be over time if patients came in focused and prepared, i.e., with a prioritized agenda, clearly articulated expectations, realistic requests for referrals, tests and medications, understanding of time limitations, and so on.  The average patient makes 3 visits to the doctor a year.  Patients with chronic conditions see the doctor up to 7 times a year.   Research shows that the adoption of specific patient-centered communication techniques in your practice could “reset” the physician-patient dynamic in ways that could increase visit productivity as well as patient outcomes and satisfaction within the course of a few consecutive visits.

That what I think…what’s your opinion?

Source:

Frankel, R. et al. Getting the Most out of the Clinical Encounter: The Four Habits Model . The Permenante Journal. 1999.

The Traditional Patient “Sick Role” Is A Major Barrier To High Quality Health Care

Each of us wears many different “hats” throughout the course of the day.  We are an employee, a wife, a father, a club member, a consumer and so on.   It comes as no surprise that our thinking, what we say, and how we say it at any particular time coincides with the hat we are wearing at that moment.   The thing about these “hats” or roles is that they come with their own set of social conventions, particularly when it comes to how we communicate.   When I was a kid for example “children were to be seen and not heard” when out in public.

So it is when we put on our patient hat – something we all do from time to time, particularly as we get older.

Unfortunately few of the roles we play come with a book of instructions.  Rather we learn them from experience or by watching others.

Think back to your first visits to the doctor – when your Mom took you to the pediatrician.  If your experiences were like mine you learned very early on that the doctor did all the talking (aka physician-directed style of communication). That’s because the doctor’s role was that of “respected expert” and my Mom’s role (and by default mine) was to play the sick role.   Much was required or expected of the person playing “sick role”…you just were there to listen and then do as told.  My Mom never was one to be passive or  quiet in most social situations but when it came to being a patient (surrogate) or a real patient in later years…she would have won an Academy Award for playing the sick role to perfection.

Believe it or not, when I have to put my patient hat on…I am no different.  In another post, I described waiting 2 hours to see a new Retinal Surgeon who was said to be very good.   The longer I waited the fewer the questions I decided to ask him…he appear too busy to spend time with little ole me answering my questions.   I couldn’t believe how easily I slipped into the sick role!  I suspect that, contrary to all the talk in the literature about how empowered everyone is…we patients basically all behave the same way when the exam room door closes.

This point was driven home for me in a recent Health Affairs article that talked about “Patient’s Fear of Being Labeled Difficult.”  The basis for the article was a series of patient focus groups conducted in the San Francisco Bay Area – the heart of Silicon Valley and all things involving digital health.   One finding stuck me – that most participants in the study talked about how they actively tried to avoid challenging their physicians during office visits.   

Deference to authority instead of genuine partnership appeared to be the participants’ mode of working.

Mind you the participants in the research were “wealthy, highly educated people from an affluent suburb in California, generally thought to be in a position of considerable social privilege and therefore more likely than others to be able to assert themselves.”  These patients were recruited from Palo Alto Medical Foundation physician practices … one of the most wired health populations in the US!

But.. But.. Everyone Is Supposed To Be Empowered and Activated?  

Baloney.  The patients in the study were socialized into the same sick role as the rest of us.  Deference and passivity, at least while in the exam room with the physician, are dead giveaway signs of sick role behavior.   Too be sure these people did go online after they left the doctor’s office to do what they should have done with their doctor – ask important questions.   Did you know that during the average primary care office visit patients ask very few “important” questions?

The Finding Should Be Concerning To All Of Us

Talking (and listening) is how physicians diagnose and treat patients.  If patients are deferential (due to fear , concern about taking up too much time, etc.) to  their physician to the point that they don’t share valuable information, don’t ask challenging questions and don’t engage in collaborative decision-making  then something is very wrong.   The net result is sub-optimal outcomes, medical errors, preventable ER visits and hospital readmits and poor patient experiences.

The Take Away

The first step is for providers to recognize the scope of the problem and the need to fix it.  The second step is for providers to examine their own attitudes and skills with respect to helping patients break out of the sick role into a more collaborative role.  Third, providers and their hospital partners need to acquire the tools, training, and resources needed to help patients as well as themselves design and adapt to their new hats, roles, and social conventions.

That’s What I Think…What’s Your Opinion?

Source:

Frosch, D. et al.   Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making. Health Affairs.  No. 5 (2012): 1030–1038

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.

Improving The Way Doctors And Patients Communicate – A Silver Bullet For Fixing What’s Wrong With Health Care?

Sometimes a picture is worth a thousand words…

Engaging Patients In Care Planning – What Providers Say And How They Say It Matters

The following is s post by Carolyn Thomas, a fellow 2012 Stanford Medicine X e-patient scholar, which she wrote for her award-winning blog  Heart Sisters.

Imagine that your daughter is preparing for a junior ski race. It’s five minutes before the start of the race. You want to give her some meaningful advice. Which one of these two messages are you going to use?

1. “Honey, remember to do XYZ – it will help you avoid losing!”
2. “Honey, remember to do XYZ – it will make you faster and you will have more fun!”

Austrian physician Dr. Franz Wiesbauer, writing to his fellow doctors in a Medcrunch article called Why Your Health Message Does Not Work, has asked this question many times in an informal little experiment. His results?

“Everyone chose answer #2. Why? Because it’s more encouraging. It’s an approach message – and approach goals (like happiness or success) rock!

“Our problem as physicians is that we are constantly sending out avoidance messages to our patients, and these have been proven to be much less effective.”

The avoidance messages that doctors may give to their patients include:

• “Stop smoking so you won’t develop lung cancer or heart disease!”
• “Lose weight so you won’t get diabetes!”
• “Take your daily blood pressure meds so you won’t have a stroke!”

Most well-meaning doctors, Dr. Wiesbauer believes, do try to deliver this kind of sound health advice to their patients, but, based on results, it seems that we patients are just not listening:

“We tell them again, still to no avail. Frustration sets in and we ask ourselves why they come to us in the first place when they won’t do what we tell them to!”

“It’s not that these patients are stupid by any means. Many of them are really smart and successful. Many have university degrees, drive expensive cars, live in beautiful houses. So most of them know the art of setting goals and achieving them.

“So what’s the problem we are facing here? We think it’s because the whole health-communication paradigm is broken. Why? Because health itself is a misnomer.”

Researchers in the field of goal-setting theory tell us that the most effective goals are indeed ones that move you toward a particular objective, rather than away from something you’re trying to avoid.

Dr. Wiesbauer adds that if you ask patients what “health” is, many will come up with responses like “not being sick” or “not being in the hospital” -  as if health is merely the absence of disease.

He also explains to other doctors the difference between proposing an avoidance goal and an approach goal.  Psychologists have found that avoidance goals (“Do this so you won’t get sick”) are far less effective than approach goals (“Do this so you’ll feel great!)

For example, I could head to the gym today to help prevent another heart attack (which is an avoidance goal) or I could head to the gym today to stay strong and fit (an approach goal).

Or I could say NO to second helpings at the Empress Hotel’s famous Death by Chocolate buffet because I don’t want to gain weight (avoidance) or I could say NO because I really want to wake up tomorrow morning feeling good about myself (approach).

Psychology professors Dr. Andrew Elliot and Dr. Ken Sheldon have pioneered research* about these approach and avoidance goals. Their research suggests that framing a goal with an approach message is almost always more successful than framing it as an avoidance message.

They add that when we pursue avoidance goals (“I’m doing this to avoid something bad happening!”), we are far more likely to experience:

• less satisfaction with progress and more negative feelings about progress with personal goals
• decreased self-esteem, personal control and vitality
• less satisfaction with life
• less competence in relation to goal pursuits

And interestingly, avoidance goals are also more likely to be associated with procrastination.

As Dr. Wiesbauer says, the average patient’s definition of health as the absence of disease counteracts the medical profession’s preventive health measures.

Reframing a health goal from avoidance to approach is where the concept of wellbeing enters the stage. So Dr. Wiesbauer warns his fellow physicians:

“We have to communicate to our patients the concept of wellbeing or wellness (we think that the word ‘fitness’ has too much of a sporty touch).

“Our personal wellbeing is a continuum between death, disease, health, wellbeing and perfect wellbeing. It is not a dichotomy.  Doctors and their patients have to realize that we are not either healthy or diseased. We all have our sets of risk factors and protective factors. We are all on a continuum and we have to strive for optimal wellbeing.”

If you like this post you will love my White Paper on Patient Engagement send me your email and I get you a copy.

* Elliot, A. J. & Sheldon, K. M. (1997).  Avoidance achievement motivation: A personal goals analysis. Journal of Personality and Social Psychology, 73, 171-185.