Patient Non-Adherence (Like Engagement) Is A Physician-Patient Communication Challenge – Not A Health Information Technology Challenge

Have you noticed all the articles in the health care press lately touting health information technologies’ ability to increase patient medication adherence?  Smart phone-based apps, Smart pill bottles and Patient Portals are all about trying to get patients to do something (take a medication) which some physician somewhere has deemed to be the right thing for the patient to do.   Some would call this process of generating adherence patient engagement.

Chalk these high-tech patient reminder solutions up to just another well-intentioned but misguided attempt by HIT vendors at patient engagement…one not likely to be met with much long-term success.  Sorry folks.

The fact is that these high-tech solutions, like physicians, still talk about non-adherence as if it is all the patient’s fault.  Come on …you have to admit that’s not a very engaging “message.”   You know…patients don’t fill (refill their prescriptions), patient don’t take their meds are directed, patient forget, and so on.  According to people much smarter than I am about such things, this perspective is outdated.

Many researchers now argue that patient non-adherence is more often the result of ineffective patient communication skills and not “disengaged, lazy or forgetful patients.”  One study showed that 19% of patient non-adherence was attributable to poor physician communication with patients.

It is also worth noting that there are two types of patient non-adherence – intention and unintentional…only one of which is addressed by these high-tech solutions.   In this post I want to focus on the intentionally non-adherent patients (the one not addressed by the reminders) .  After all, only bad or stupid people would intentionally go against something that clearly is their best interest…right?

Wrong.  As it turns out there are lots of legitimate reasons (from the patient’s perspective) for non-adherence.

Here are the main reasons cited in the literature:

• The patient doesn’t agree with the diagnosis necessitating the prescription
• The patient believes the diagnosis but doesn’t think the diagnosis is serious enough to merit taking a new medication prescription
• The patient doesn’t believe in taking medications
• The patient believes the risks associated with the medication outweigh the benefits
• The patient doesn’t believe the medication will work
• The patient can’t afford the medication

Think about your recent physician visits, where your clinician prescribed a new medication.  I’ll bet one or two of the above “reservations” flitted across your mind.  I’ll also bet that your provider never once asked how you felt about taking the prescribed medication.  I’ll even go out on a limb and bet that most of you never mentioned your reservations to your provider either.

Don’t believe me?  Then consider this factoid.  When prescribing a new medication, the average primary care physician spends less than 50 seconds teaching (too strong a word) patient about the medication, e.g. why they need it, how to take it, how much to take, when to take it, indications and contraindications, when to stop and what to do when you stop.  That’s not much time for the physician to say everything that needs to be said (which doesn’t happen).  Nor does it leave time for the patient to say much.

Since most patients are reluctant to interrupt or contradict their clinician, many if not most of the concerns patients have about taking the new medications are never voiced.  Rather, patients just go home and never fill the prescript.

So now help me understand how my patient portal or smart phone app can engage me by implicitly blaming me for not taking my medications.  Or motive me to take my medications  when I don’t believe that they are not necessary or that they may be worse for me than the problem they are intended to solve.

Patient adherence is much more likely to occur when the patient and clinician agree on the basics, e.g., the diagnosis and treatment.  That requires a conversation or two or three.  The goal of effective clinician-patient communication is to resolve such disagreements.  And that is why the solution to patient non-adherence lies in developing the patient-centered communication skills of clinicians…not in trying to cajole patients into using some new app or patient portal that totally ignores their concerns and beliefs.

All together now…patient adherence (and engagement) are a physician-patient communication challenge…not an HIT challenge.

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

Note:  Later this Fall, Mind the Gap will be announcing the Adopt One! Challenge TM. for physicians and their care teams.  The goal of the challenge is to encourage physicians and their care teams to adopt one new patient-centered communication skill within 2014. 

Sign-up to learn more about this one-of-a-kind “Challenge”:

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Sources:

Koenig, C. J. (2011). Patient Resistance as A in Treatment Decisions. Social Science & Medicine (1982), 72(7), 1105-14.Johnson, J, et al. (2005) Factors Associated with Medication Nonadherence in Patients With COPD. Chest. 128(5).

Wilson, I. et al. (2007). Physician – Patient Communication About Prescription Medication Nonadherence: A 50-State Study of America’s Seniors. Journal of General Internal Medicine. 22(1), 6-12

Johnson, J, et al. (2005) Factors Associated with Medication Nonadherence in Patients With COPD. Chest. 128(5).

Zolnierek, H. et al. (2009) Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care. 47(8), 826-834.

Sarkar, U., et al. (2011). Patient-Physicians’ Information Exchange in Outpatient Cardiac Care: Time for a Heart to Heart? Patient Education and Counseling, 85(2), 173-9.

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

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 get paid to talk to patients

Reason 3 – Physicians don’t have time 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 2 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:

1. their assumptions about the value of and barriers to improving their patient communication skills
2. 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.

ACO Success Will Depend Upon The Patient-Centered Communication Skills Of Providers

Accountable Care Organizations (ACOs) and “bundled payments” are set to play a central role in the Affordable Care Act.  Under accountable care, physicians and hospitals would be paid out of a “single payment” from CMS or health insurers for all the care needed to treat a clinically defined “episode of care” like a heart attack.   The premise is that bundle payments will incentivize physicians and hospitals to deliver more efficient, high quality care.

Much has been written about the health information technology infrastructure needed to support ACOs.  Experts also underscore the need for providers (physicians and hospitals) to get patients with conditions like heart failure more engaged in prevention and self-care.  After all, as much as 90% of the “care” for chronic conditions like heart failure is provided by the patient and their care givers at home.  But effectively engaging patients has been a difficult nut to crack for health care providers.

What Can ACO Providers Do To Increase Patient Engagement?

Here’s the short answer – improve the quality of communications between physicians and patients.  After all, physician-patient communications is how most patients are diagnosed and treated.

The degree to which patients and physicians agree on key aspects of the diagnosis and treatment is said to be an indicator of communication effectiveness.  Disagreements such as the nature or severity of a medical condition or the need for a new medication represent a breakdown in physician-patient communications.  Such breakdowns are common and are closely associated with patient behavioral issues such as non-compliance, excessive health care use, and decreased satisfaction.

High levels of physician-patient agreement are linked with more desirable patient outcomes and behavior.  Physicians that use a patient-centered style of communication tend to report much higher levels of agreement with their patients on critical diagnosis and treatment issues.

The Current State of Physician-Patient Communications

A 2011 study of patients diagnosed with a heart condition, and being seen in a public hospital cardiology clinic, illustrates the scope of the communication problems facing not just ACOs…but all health care providers today.

In the study, 55% of patients diagnosed with heart failure did not recognize (nor agree with their doctor) that they had heart failure.  Even more disconcerting was the finding that “only 15% of those with hypertension agreed with their doctor’s diagnosis.”

Physician-Patient Disagreement And A Lack of Patient-Centered Communication Are Greatest Amongst Population Groups That Are The Sickest And Most In Need

African-Americans experience heart failure at a rate this is 20 times higher than their white counterparts.  Physicians that treat blacks are less likely, according to researchers, to use a patient-centered communication style.

Numerous studies have revealed that when treating black patients, as opposed to white patients, physicians tend to “provide less health information, are more physician-directed (versus patient-centered), spend less time building a rapport with patients, and are more verbally dominant.“  In other words, the patients that are in greatest need for patient-centered communications, and the benefits it provides, are presently the least likely to receive it.  The lack of high quality patient-centered communication is not limited to minority groups.  An estimated 60% of practicing physicians use a physician-directed communication style.

 The Take Away?

Needless to say, the quality of physician-patient communications in the U.S. does not bode well for the success of ACOs.  Health plans, physician groups and hospitals looking to realize the financial benefits of bundled payments and accountable care should give serious consideration to investing in benchmarking tools and communications interventions that will measurably improve the quality of physician-patient communication both in the office and hospital.

That’s my opinion…what’s yours?

Sources:

Cené, C. et al. The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication. Journal of General Internal Medicine. 2009. 24(9):1057–64

Sarkar, U. et al. Patient-physicians’ information exchange in outpatient cardiac care: time for a heart to heart? Patient Education and Counseling. 2011. Nov;85(2):173-9.

Johnson, R. et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 2004. 94(12), 2084-90.

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

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.