The Power Of Conversations Between Physicians And Patients

People always ask me how I got started with my work in physician-patient communications. Like so many people, I had a story that I felt needed to be told. Much of my inspiration over the course of the last five years of writing Mind the Gap have come from my wife and my journey as we deal with her Stage IV Lung Cancer.

But there was also a video I saw back in my blog’s early days that really gave me a sense of direction. A video featuring Maggie Breslin, at Mayo Clinic’s Transform 2009 Symposium. (Maggie is no longer with Mayo) At the time I was so taken with Maggie’s presentation that I pick up the phone and spoke with her about her “Power of Conversations” experiences. Well I rediscovered that video in a recent guest blog post on Mayo Clinic’s Center for Innovation Blog. The piece was written by by Nolan Meyer, a student at the University of Minnesota Rochester .

Here is Nolan’s post which includes the video. I hope it inspires you as much as it does me.

If you were to guess why patients consistently return to the Mayo Clinic and recommend the Mayo Clinic to friends and family, what reason would you venture? Unparalleled medical expertise? Superior technology? Prestige? Tropical weather conditions?

In contrast, the number one reason is not solely due to the excellent quality of care they receive. It is not that they receive pioneering procedures at a world-class academic medical facility, nor is it space-age medical technology. It’s not that they were prescribed miracle medications that exist nowhere else.

The reason patients return to Mayo Clinic is that providers here take the time to connect with their patients—to talk with them and ensure all their patients’ questions are answered. This connection forged between Mayo Clinic healthcare staff and their patients ensures the concerns of patients and their families are understood and fully addressed. Although the Mayo Clinic is a premiere and world-class academic medical institution, the meaningful connections made here between providers and patients are what bring people back again and again.

In a time of healthcare reform, extensive regulations, standardization, and malpractice suits, when many healthcare institutions have turned to emphasize numbers of patients seen over the overall quality of healthcare delivery, the Mayo Clinic has remained steadfast in its familiar maxim: “The needs of the patient come first.”

“I believe that if we make satisfying conversations and human connection the focus of our healthcare delivery development—if we make connecting people and having them talk to each other the single most important metric by which we judge all of our efforts—we will get everything else we want our healthcare system to be. Rich conversation is the pathway to quality, to efficiency, to affordability… when we have good conversations, we are practicing individualized medicine in its most authentic—it’s most human—form.”

Maggie Breslin, in a research-and-design effort put forth by the Center for Innovation’s Spark Design Lab, set out to find and address elements that enhance or impede quality of healthcare delivery. Maggie was granted access to observe healthcare interactions in various departments of the Mayo Clinic. During her time working on this project, Maggie observed thousands of healthcare interactions ranging from the mundane to the life-changing. Maggie observed everything from annual influenza vaccinations, to radiological studies, to discussions of unforeseen treatment complications, to emotionally wrenching diagnoses of debilitating conditions.

These thousands of observed interactions qualifies Maggie to tell us what quality healthcare delivery looks like, and according to her, it looks like a satisfying conversation. According to Maggie, quality healthcare delivery is “the most human thing you’ve ever seen in your life!” Working on this groundbreaking project, Maggie became familiar with four powerful insights regarding conversation in healthcare:

Conversation is how people determine quality and value.
Conversation has therapeutic value.
Conversation allows us to deal with ambiguity.
People seek out conversation, even when we make it hard for them.

While some of these observations may seem intuitive, they have fallen by the wayside in many modern medical institutions. The power of a simple conversation in a medical setting seems to have been deemed “nice-to-have,” but unnecessary and extraneous by many modern designers of healthcare delivery. This is an unfortunate trend, as the importance of translating advanced scientific and medical knowledge from provider to patient is more important now than ever. Maggie asserts that these satisfying conversations are not a “nice-to-have,” an extra, an unnecessary and time-consuming luxury in modern medicine. Quite the contrary: satisfying conversations are what Maggie calls “the very essence of healthcare delivery.”

Maggie relates a story in which she and her colleagues set about the hospital in search of factors which enhance or impede human connection. Her team found a startling pattern: the presence of human connection in healthcare delivery was, by and large, the result of the actions of outgoing individuals. In contrast, the absence of human connection was the result of often-unforeseen systematic hurdles. Maggie argues that in modern medicine, too many decisions are being made in the name of efficiency, standardization, legal requirements, documentation, and numbers.

All of these decisions contribute to the construction of what Maggie calls a wall between providers and patients. The inspiring thing, though, is that both patients and providers make what Maggie calls a Herculean effort to jump over that wall and find ways to connect with one another.

The Mayo Clinic’s efforts to recognize and address impediments to meaningful patient-provider interactions are an example of how it strives to provide the best patient care possible. Maggie Breslin calls on everyone involved in healthcare delivery and its design to ask themselves one question as they do their work: what kind of conversation will result from this concept? If the answer is “a better conversation,” then have that mean something!

There’s Nothing Engaging About My First Patient Portal…It’s Actually Disengaging

In Fact It’s Downright Disengaging…

Stop the presses!   I now have access to my very own personalized patient portal courtesy of my personal physician.  The big event occurred this last Tuesday.   I have to admit I was a bit excited that my doctor was slowly merging onto the information super highway.  Heck he even sprang recently for an out-of-the box EMR system which he is forever complaining about.

But my excitement was short lived.  Very short lived in fact after reading the e-mail from E-Clinicalworks (the patient portal vendor) which I am sharing with you here.

Now I realize that my doctor works in a solo practice as part of a large IPA…not the Mayo Clinic. But this email…and presumably everything associated with this patient portal is…well…very amateurish and totally disengaging.

A couple of things immediately jumped out at me while reading this e-mail invitation to my patient portal.

The patient portal claims to offer me “the power of the web to track all aspect of my care through my doctor’s office.”That’s pretty powerful!

But I read on to discover that my physician’s concept of what I should have the “power” to do and what he thinks I should be able to do is very different. Why am I surprised…?

First there is no mention of any kind of access to my actual health information…and certainly not my “physician’s notes.”But that doesn’t mean I am willing to leave my doctor for someone who offers this capability.

Second…and perhaps most galling…is that I can’t actually communicate with my doctor via the portal.  I can email his office staff…and maybe they will respond and maybe not. In the non-digital world they would get back to me at their own leisure.

Third, I can’t actually do anything on the portal (as configured by my doctor) other than request that the surly office staff intervene with the doctor to refill my prescriptions. Asking is certainly different than doing in my book. How the heck is this supposed to make me feel engaged?

Finally the email presumes to tell me that up until today my physician apparently does not think that I have been taking an active role in my own health care.   Let me get this right…I am 100% compliant with my medications, exercise, see my doctor regularly and am in good shape…yet I am not actively involved in my own health. Come on now.

In its favor…the email was personalized – it got my first name right. It never did mention my doctor’s name or his office address.

Upon getting this email from my doctor I was immediately reminded of a quote from a recent Dave Chase Forbes article about the value of physician-patient communications in which he said this about patient portals:

“The smart healthcare providers realize simplistic patient portals, however, won’t get the job done. Simple patient portals are like a muddy puddle of water in the Sahara Desert — a big improvement but far from ideal.

Kudos to physicians everywhere that are trying… But please recognize that your patients are not simpletons and that they are already engaged in their health at least from their perspective. For portals like this to be successful – (meaning that patients actually use them more than once) – they need to offer real value (from the patient’s perspective), they need to be relevant to patients (not you or your staff) and they need to respect my intelligence.

Take Aways

Most patients are already engaged in their own health care. The biggest challenge for providers today is not so much engaging patients but rather to avoid disengaging them.

I realize that my experience offers but one example of a patient portal gone wrong.  If you have samples of patient portal experiences you would like to share e-mail me at stwilkins at gmail.com.

Is The CEO Of The Cleveland Clinic Serious When He Says “No More Passive Patients”?

If a recent blog post by the CEO of the Cleveland Clinic is representative of how health care executives (and physicians) really think about patients – aka consumers –aka people like you and me…we are all in big trouble.  In it Delos Cosgrove, MD, talks about how under health care reform there will be “No more passive patients.”

Here’s my a quote from the post by Delos Cosgrove, MD:

“For too long, healthcare has been something that was done to you. Now it’s going to be something you do for yourself in partnership with your doctor and care giving team. You’ll need to monitor your food input, get exercise, and avoid tobacco. ”

Let’s examine what’s disturbing about comments like this particularly when made by high-profile leaders like Dr. Cosgrove.

First, this statement is factually inaccurate.  Here’s why.  82% of US adults visit their PCP every year at least once a year (often more) for their health.   Think about the trip to the doctor’s office from the patient’s perspective… 1) chances are they have discussed their health problem or concern with family members or friends, 2) they may well have looked up information on their condition to see if it merits a doctor’s visit, 3) they make the appointment, 4) they show up for the appointment and 5) wait in the waiting and exam room thinking about the questions they want to ask their physician.

What about any of this suggests patient passivity?

Second, this statement misrepresents the true nature of the patient passivity of which Dr. Cosgrove speaks.  You see patients (aka people) are socialized by physicians beginning in childhood visits with Mom to the pediatrician to assume a passive sick role.  We are supposed to be passive! Otherwise the doctors gets irritated and ignores or dismisses what we have to say.  While it’s true that patients (even the most empowered among us) ask very few important questions during the typical office exam…the reason isn’t that we are passive.  Rather it’s because we don’t want to be too assertive, confrontational, and argumentative or are simply afraid.

Rather that blaming patients for not being more engaged…why don’t doctors try and become more engaging (e.g., patient-centered) to patients?

Third, patient non-adherence is often not the patients fault…but rather the result of poor communications on the clinician’s part. One recent study found that 20% of medication non-adherence is the direct result of poor physician communication with patients. Poor patient communication skills top the list of complaints people have with their doctor. Poor patient communication is also the leading cause of medical errors, non-adherence and poor patient experiences.

Fourth, how exactly are patients going to learn all the skills necessary to “do everything” for themselves?  The work of Lorig et al. has shown that simply providing patients with information – the “what” of self care – is not enough to change patient health behavior.  Patients also need and want to develop the skills and self efficacy for self care management – the “how” of self care.   Right now for example clinicians spend on average <50 seconds teaching patients how to take a new medication…and we wonder why patients are non-adherent.

Given the poor patient communication skills of physicians today how exactly are patients supposed to learn how to do it all themselves?

Finally, the Dr. Cosgrove reminds us of the kind of paternalistic, physician-directed thinking and communications which has gotten the health care industry into the mess it’s in.

The following statement says it all:

“If your doctor prescribes a medication, preventive strategy, or course of treatment, you’ll want to follow it.”

What if I don’t want the medication or don’t believe it will help me? Why should I be forced to do something I don’t want to do? Will you drop me as a patient?
What happened to the IHI’s Triple Aims?  What about the need to be more patient-centered as called for in Crossing the Quality Chasm and the ACA reform legislation?

I am sorry if I seem to come down hard on Dr. Cosgrove. But my original point remains…too many health care leaders still think and talk like this.  While they may “talk the talk”…employees, patients and physicians all see how such leaders “walk the talk.“  And as Cosgorove’s comments suggest we have a long, long way to go.

I would like to extend an invitation to Dr. Cosgrove and the physicians at the Cleveland Clinic to see just how “patient-centered” their communication skills really are by participating in the Adopt One! Challenge.   You will not only be able to assess the quality of your team’s patient communication skills but also see how their skills compare to industry best practices.

All physicians are invited to participate in the Adopt One! Challenge.

That’s my opinion…what’s yours?

Patient-Centered Medical Homes Need To Become More “Patient-Centered”

A recent study in Medical Care about Horizon BCBS’s Medical Home pilot reminded me of the expression a “house does not make a home.”   Or in this case how building a medical house to the spec (as laid out 3rd parties like NCQA and JACHO)  is not the same as building a medical home that is truly patient-centered .   As it turns out, researchers involved in the Horizon study claimed not to have found any significant differences between PCMH practices and non-PCMH practices.

Don’t get me wrong, my hat is off to the thousands upon thousands of primary care practices from New Jersey to Hawaii that have put in long hours going the extra mile to become recognized as Patient Centered Medical Homes.  Due to the efforts of these first generation PCMH pioneers, and their health plan partners, millions of people now have unprecedented access to primary care physicians providing:

• Physician-led team care
• Electronic records (EMR/Registry)
• Embedded care coordinators
• PHRs and web portals

Yes, many of the PCMH pilots, now into their 4^th or 5^th year, are showing promising results with reported reductions in ER visits, hospitalizations and 30-day hospital readmissions.  These pilots are also reporting improvements in HEDIS-related quality indicators.

But while team care, care coordination and EMRs may increase practice efficiency, there is nothing inherently patient-centered about these “things.”

That’s because patient-centered care is a philosophy of care delivery…not simply a punch list of HIT and staffing requirements.  Crossing the Quality Chasm defines patient-centered care as “respectful of and responsive (where practicable) to individual patient preferences, needs, and values”; or as Berwick is quoted as saying, “nothing about me (the patient) without me.” Patient-centered care occurs between people – not things – and manifests itself in the way the clinician and patient talk with and relate to one another, e.g. patient-centered communications.

With all the attention placed on building out the HIT and staffing infrastructure,  this first generation of PCMH pilots, with some notable exceptions, has lost sight of the most what makes a medical house and patient-centered medical home – notably the relationship between the patient and the clinician, beginning with the quality of clinicians’ patient-centered communication skills.

Yes, many accredited PCMH’s have patient advisory boards and conduct patient satisfaction surveys.   But as researchers like Street and Epstein have suggested,  relying just on patients’ impressions and ratings of “patient-centeredness” may provide false reassurance given that many patients have never experienced anything but suboptimal care and physicians that employ a paternalistic, decidedly un-patient-centered style of talking to patients.  (Until recently, I myself had never encountered a real patient-centered physician).

As I discussed in an earlier post, the majority of physicians today employ a paternalistic, physician-directed style of communicating with patients.   As such, there is no evidence to suggest that the patient communication skills of physicians practicing in accredited PCMHs are any more patient-centered that their counter parts in traditional practices.

Based upon the literature, what is absent in this first generation of PCMH pilots is any serious, systematic attention given to assessing and/or improving the quality of the patient-centered communication skills of physicians and their care teams.   This oversight is worth noting since the benefits expected by policy makers and underwriters of PCMHs and ACOs under health care reform have been linked in the research to the strong patient-centered communications and not HIT, team care and care coordinators.

Why Is This Important If PCMH Pilots Are Reporting Positive Outcomes?  

The early saving being reported by many PCMH pilots may well represent the “low hanging fruit.” This is not an unreasonable supposition given that most physician practices have never had EMRs, care coordinators, or team care prior to the PCMH pilots.  As is so often the case, within a short few years, this low hanging fruit will disappear.

But there is another way. Thirty years of research has demonstrated the benefits of patient-centered communications when it comes to increased productivity, greater patient engagement; better outcomes, lower health care use/cost and superior patient experiences.

Going forward, PCMHs, ACOs and their sponsors will need to look past HIT and team care to the quality of their patient-centered communication skills if they are to assume the role envisioned for them under health care reform.

That’s my opinion…what’s yours?

Note:  Later this Summer, 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:

Epstein RM, Fiscella K, Lesser CS, Stange KC.  Why the nation needs
a policy push on patient-centered health care. Health Affairs. 2010;29(8):1489-1495.

Ming Tai-Seale, et al.  Recognition as a Patient-Centered Medical Home: Fundamental or Incidental? Annals of Family Medicine. 2013;11:S14-S18.

Street, R., et al.  The Values and Value of Patient-Centered
Care.  Annals of Family Medicine.  2011;9:100-103.

The Truth About Those High Patient Satisfaction Scores For Doctor-Patient Communication

We have all seen them.  You know…those charts showing us how satisfied patients are with the way their doctors communicate.  Did your doctor listen to you?  Did you doctor explain things in a way you could understand?

Funny thing about these charts, whether they be for hospitals or doctor’s offices,  1) they never seem to change from year to year – 80% – 90% of doctors communicate well with patients and 2) patients consistently rate their doctors’ communication skills as high.

The problem with satisfaction data related to doctor-patient communication is that, at face value, it simply doesn’t correlate with other published data on the subject. There is a “disconnect” between what patients say in satisfaction surveys and what happens in actual practice.

Here’s what I mean.

Recent studies of hospitalized patients have shown that:

• 68% to 85.3% of patients could not name the physician in charge of their care.
• 43% to 58% of patients did not know the reason for their hospital admission.
• 67% of patients received a new medication while hospitalized… yet 25% of these patients were unaware that they were given a new medication.
• 90% of patients given a new medication reported never being told of adverse effects of the new medication.
• 38% of patients were not aware of planned tests for the day.

The amazing thing was that majority of these patients (up to 58% in one study) said that their doctors always explained things in ways they could understand!

The same types of “disconnects” show up in satisfaction surveys done in doctor’s offices.   Studies of primary care physicians show that:

• Patients are interrupted by their physicians within the first 18 seconds of their opening statement during office visits

• Physicians and patients agree on the reason for the office visit only 50% to 70% of the time

• Physician underestimate the patient’s desire for health information in 65% of the time

• 50% of patients walk out of their doctor’s office not understanding what their doctor told them to do

• Patient are not asked if they have any questions in up to 50% of office visits

Again, I am sure these same patients praised their physicians’ communication skills on one or another satisfaction survey.

So What Explains The “Disconnect” Between How Physicians Actually Talk To Patients…And Patient Satisfaction?

Today’s high patient satisfaction scores are an artifact of the way we (when we become patients) have been “socialized” when it comes to a trip to the doctor’s office. Here’s what I mean.

1) Beginning with childhood, we have all been socialized to assume the “sick role” when seeing the doctor.  From our initial visits to the pediatrician with our Mom we quickly learned that the doctor is in charge and that our Mom’s role (and ours) is to sit passive by while the doctor does most of the talking.  Notwithstanding all the “talk” about how empowered patients are today, most of us still assume the “sick role” when seeing our doctor.

2) Accustomed as most of us today are to the sick role, and accepting the fact that physicians are very busy, we are not surprised when doctors don’t seem to listen to us or interrupt us. We are not surprised that they don’t have time for all our questions or frown on us bringing in lists of things we have researched on the internet. This for most patients is what we are used to…it is what we are satisfied with given that most of us have don’t another or better point of comparison, i.e., a highly patient-centered physician.

3) Consistent with the sick role, we as patients “tend to be overly patient.” We “grant our doctors the benefit of every doubt.” Most of us begrudgingly put up with poor service, inconvenience, and unnecessary discomforts, until we can’t overlook it anymore. Even then we are reluctant to take our busy, overburdened doctor to task for these shortcomings by giving them a low score on a satisfaction survey.

The Take Away?

Hospital, medical group, IPA and ACO executives need to:

• Be cautious about putting too much credence in patient ratings of physician communication skills. “One can assume that the quality of care is actually worse than surveys of patient satisfaction would seem to show” to quote Avedis Donabedian, MD, an old professor of mine.

• Recognize that high quality, patient-centered communications (the gold standard for physician-patient communications) is essential to patient engagement, optimal patient outcomes and great patient experiences. If physician communication were as great as patients satisfaction surveys suggest, we wouldn’t be having the problems we are with low levels of patient engagement and non-adherence.

• Benchmark the patient centered communication skills of the primary care physicians on their staff (employed and otherwise) and compare the findings against established best practices.

• Take the additional reimbursement you will get from CMS for your patient high satisfaction scores and invest it back into improving the patient-centered communication skills of their physicians and patients. That is, if you don’t have to pay a penalty to CMS for high re-admission rates – which by the way is another by-product of poor physician-patient communication.

Remember that there is perhaps no better, more cost-effective way to differentiate your physicians (and your brand) these days than to have physicians on staff who really know how to listen and relate to patients.

That’s my opinion…what’s your?

Sources:

Makaryus, A. et al. Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Mayo Clinic Proceedings. 2005;80(8):991-994

Boland, B. et al. Patient-Physician Agreement on Reasons for Ambulatory General Medical Examinations. Mayo Clinic Proceedings, 1998;73(1), 109-117.

O’Leary, K. et al. Hospitalized Patients’ Understanding of Their Plan of Care. Mayo Clinic Proceedings 2010;85(1):47-52.

Olson, D. et al. Communication Discrepancies Between Physicians and Hospitalized Patients. Archives of Internal Medicine. 2010;170(15):1302-1307