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

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.

Patient Engagement Infographic

Check out other recent posts on the topic of Patient Engagement:

Patient Engagement Is Very Important – It’s Just That No One Agrees On What It Is…Or How To Do It – Infographic

Patient Engagement From The Patient’s Perspective

Patient Engagement Versus Physician Engagement – Which Comes First?

Patient Engagement – Here’s The Key To Success

Patient Portals – What Do Patients Really Think About Them?

There seems to be an inverse relationship between the amount of spin one hears about “the next big thing”…and reality.    First it was EMRs and virtual e-visits, then social media, and now patient portals seem poised to be next big thing.   The drumbeat of vendors and pundits is unmistakable….physician that don’t adapt will be toast.   It can all sound pretty convincing until you ask to see the evidence.  What do patients think?

Take the physician patient portal.   If you read between the lines, patient portals are frequently being positioned as the new “front door” to physician practices.   By signing on to a secure website patients will have real time access to the electronic health record and will be able to communicate with their physicians by e-mail.   Additional patient features include being able to schedule an appointment with their doctor, reading their test results and refilling prescriptions.  But despite these features, according to John Moore at Chilmark Research, “nationwide use of patient portals remains at a paltry 6%.”

Ok… so now we know what vendors and pundits think about patient portals. What about patients – what do they think?

They would love it right?  I mean who at this very moment isn’t at home trying to e-mail their doctor.  Yeah right.

If a qualitative study of primary care patients in Journal of Internal Medicine is any indication, those most interested in using a patient portal were patients who were:

• Dissatisfied with their physician
• Dissatisfied with their physicians communications ability
• Dissatisfied with their ability to get medical information from their physician

Those patients least likely interested in using a patient portal offered by their physician are patients who are:

• Satisfied with their physician
• Satisfied with their physician’s communication abilities
• Difficulty in using the portal

Of significant note, patients who reported good relationships with their doctors were afraid that the patient portal would potentially undermine that strength of that relationship.    In other words, patients were afraid that e-visits would replace face to face visits.  Researchers were surprised that not one patient in the study identified encrypted e-mail communication with their doctor as an advantage of patient portals.

While the findings from this study are not generalizable, the study does highlight a potentially significant unintended consequence of encouraging patients to use a new patient portal.   Patients may interpret the move as a signal from their physician that they will have less face-to-face time with their doctor…which in their mind is not a good thing.

To be sure, there are notable exceptions to the cautionary tale described here.  MYGroupHealth , the patient portal developed by patients and providers at Group Health Cooperative in Seattle, is perhaps the best example.

Take Aways

1. Patient Portals are not going to go away.  Having a patient portal is expected to be a requirement in the final  Stage 2 Meaningful Use (MU) Requirements (June 2012) and is listed as a condition for advanced Patient Centered Medical Home (PCMH) accreditation by NCQA
2. Ask patients what they think about a patient portal – what services should it offer, would they use it, how should it be promoted and so on.  After all, it is supposed to be patient-centered.
3. The real value of the patient portal lies in physicians providing  patient-centered, clinical support to patients rather than promoting products and services.
4. Integrate the patient portal into the primary care physician’s work flow and practice.  If you collect patient data on the portal then make use the physician actually uses the information during the patient visit.

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

Sources:

Zickmund SL, Hess R, Bryce CL, et al. Interest in the use of computerized patient portals: role of the provider-patient relationship. Journal of General Internal Medicine. 2008;23.

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.