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

Want Your ACO To Succeed? …Then You Better Focus On Improving How Your Doctors & Patients Communicate

The basic premise of the Accountable Care Organizations is simple enough.  By incentivizing providers (physicians and hospitals) to assume financial responsibility for coordinating the health care of a defined patient population, it is possible to increase the quality of care while decreasing the cost of care delivery.

For ACOs to succeed, experts tell us that 3 things are required: 1) health information technology is needed to track and manage patient populations, 2) redesigned care delivery processes are needed to support patient care coordination, and 3) the right set of provider financial incentives must be in place.

But The “Experts” Have Overlooked Perhaps The Most Important Requirement

The improvements in quality and cost effectiveness in large part are predicated upon providers being able to engage patients with the goal of changing their health behavior.  

The problem is that most physicians lack the patient-centered communication skills needed to engage patients in their own health care not to mention persuade patients to change their health behavior. 

An Example – Physician and Patient “Meeting of the Minds” 

I think we can all agree that “telling patients what to do” is not an effective patient engagement or behavior management strategy.  After all, if patients don’t agree with or understand the rationale for a recommendation from their doctor, they are not likely to comply with it.

Rather, a meeting of the minds by physicians and patients is needed…and that requires physicians  understanding the patient’s perspective.  The evidence bears this out.  Higher ratings of trust, satisfaction, and intention to adhere occur when patients see themselves as similar to their physicians in personal beliefs, values, and communication.[1]

The problem is that physicians and patients often disagree on even the most fundamental issues…and herein lies the problem:

• Doctors & patients disagree on the principal reasons for office visits 53% of the time.[2]
• There is “substantial discordance” between the problems patients describe to physicians and the symptoms that physicians document in the EMR.[3]
• For diabetic patients who cited pain or depression as their top health concern their physicians rated these conditions “as likely to affect the patient’s health outcomes” in only 9% and 32% of cases respectively. (Remember, 95% of the treatment for diabetes is patient self care). [4]
• 41% of patients disagree with their physician as to whether their presenting symptoms represented a psychological versus a medical problem. [5]
• Physician perceptions of “how pleased, cheerful, relieved, worried, angry, and disappointed” they thought the patients were during office visits differed significantly from patient rating of how they actually felt. [6]
• Physicians tend to underestimate the patient’s desire for health information in 65% of visits.[6]

So What’s The Take Away?

Many physicians today are ill prepared to assume the role or financial responsibility of care coordination (or care management) given their lack of patient-centered communication skills.  Notice I didn’t mention lack of time since effective use of patient-centered communication skills over time can actually save providers time.

Unless and until medical groups, hospitals, health plans, CMS, and ACOs address this critical shortcoming through providing physicians with the  training, tools and resources needed to develop and refine patient-centered communication skills, ACOs will not deliver on their promise of more effective and efficient medical care.

That’s my opinion. What’s yours?

Sources:

[1] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of Family Medicine. 6:198-205.

[2] Greer, J. and H. R. (2006). Predictors of Physician-Patient Agreement on Symptom Etiology in Primary Care. Psychosomatic Medicine, 282, 277-282.

[3] Stein, T. et al. (1999) Inaccuracies in physicians’ perceptions of their patients. Medical Care.  Nov;37(11):1164-8.

[4] Keulers, B. J., Scheltinga, M. R. M., Houterman, S., Van Der Wilt, G. J., & Spauwen, P. H. M. (2008). Surgeons underestimate their patients’ desire for preoperative information. World Journal of Surgery, 32(6), 964-70.

[4] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of  Family Medicine, 6:198-205.

[5] Freidin, R., et al. (1980). Patient Physician Concordance in Problem Identification. Annals of Internal Medicine, (93), 490-493.

[6]Stein, T. et al., Inaccuracies in Physicians’ Perceptions of Their Patients.  Medical Care. 1999 Nov;37(11):1164-8.

[7] Pakhomov, S. et al. (2008). Agreement between Patient-reported Symptoms and their Documentation in the Medical Record. American Journal Of Managed Care, 14(8), 530-539.

Wonder What Your Doctors And Patients Talk About…Or Don’t Talk About…Behind Closed Exam Room Doors?

Soon you can stop wondering…

For the most us, our first patient experience was a trip to the Pediatrician’s office with our mother. As we age things don’t change much…the doctor’s office remains the center of most people’s “health care experience” except that now we are taking our parents to see the doctor.

The physician-patient relationship is and will continue to be the key stone holding together the rest of U.S. health care system. Why? Because the primary care physician’s office is where the vast majority of health care decisions are made and where most health care is delivered. We are still 13 times more likely to visit our doctor’s office than we are to require an overnight stay in the hospital.

What happens behind the closed doors of the exam room between doctor and patient drives everything else in health care – patient health status, patient adherence, referrals, ER visits, hospital admissions and re-admissions, patient satisfaction and so on. Other than our own personal experience and some vague top line satisfaction survey data, we health care professionals (non-physicians) really know very little about how doctors in our organizations talk with and relate to patients one another once the exam room door closes.

We Know Even Less About The Impact Of Different Styles of Physician-Patient On Our Organizations

For example, what impact does a paternalistic, physician-directed communication style have on patient activation and engagement in hospital-owned physician practices? Or how successful will a physician with poor patient- centered communication skills be when it comes to managing the health of a patient population in an ACO?  Can physicians with poor communication skills hope to retain members attributed to the ACO?  How much money will your organization forfeit next year in incentives and penalties due to poor physician-patient communications resulting in preventable re-admissions and sub-optimal patient experiences?

Exciting New Research Will Soon Provide You Invaluable New Insights Into How Physicians And Patients In Your Market Communication With One Another…And The Implications For Your Organization

It is not often that one gets the chance to become involved in landmark research.  I guess this in my luck day.  Working together with a corporate partner Verilogue in the upcoming months I will be analyzing the patient communication skills of 2,500 HIPPA-compliant physician-patient interviews collected from across the U.S.  The goal of the research will be to deconstruct what primary care doctors and their patients say (and don’t say) to one another and how they say.  We will then benchmark the patient communication skills of physicians in the study against agreed upon industry best practices – aka patient-centered communications.  Ideally the results can be used by hospitals, physician groups, ACOs and health plans to improve the patient-centered communication skills of primary care physicians across the country.

Stay Tuned

As more details of this excite new research become available you will find them here at Mind the Gap first. I look forward to helping advance the field of physician-patient communications. More importantly, I look forward to doing what I can to disseminate and make actionable the finding on behalf of those who will benefits the most – patients.

What things would you like to learn from this research?  Please let me know.

What Kinds Of “Patient Experiences” Are Occurring In Your Doctors’ Offices?

Hint: They Aren’t As Good As Your HCAHPS Scores Suggest

Now that over 50% of physicians are employed by hospitals, this is a question that should be on the minds of progressive hospital executive teams.  With good reason. Patient-reported outcomes, including satisfaction and loyalty, are going to play an increasing role in determining how much hospitals and physicians are paid. This means that astute hospital marketers will be able to build a strong business case for investing in programs aimed at creating superlative ambulatory and inpatient experiences for patients.

But Our Physicians Already Have High Patient Satisfaction Scores

Health care executives should take little comfort in the global patient satisfaction and loyalty ratings found uniformly in HCAHPS  and every patient satisfaction survey.

Generally speaking,  “one can assume that the quality of care is, actually, worse than surveys of patient satisfaction (suggest)”according to Avedis Donabedian, MD, the father of today’s quality movement.   Donabedian goes on to say that “patients are, in fact, overly patient; they put up with unnecessary discomforts and grant their doctors the benefit of every doubt, until deficiencies in care are too manifest to be overlooked. “

Just look at the quality of physician-patient communication, a key ingredient of the “patient experience” in the physician’s office.

1. In only 26% of the visits are patients allowed to complete their opening statement (agenda) without interruption (by the doctor); in 37% the physicians interrupted; and in 37% physician never asked about the patient’s visit agenda.
2. Studies suggest that patients do not express their health concerns, expectations or opinions in up to 75 percent of physician visits principally because their doctor never asked.
3. Primary care physicians typically spend less than 60 seconds informing patients how to take new medications…or why.
4. Primary care physicians and patient disagree about the diagnosis, treatment, and cause/severity of their condition over 50% of the time.
5. Over 50% of patients walk out of their doctor’s office not understanding what they were told, including why or how to take their medications.

For their part, patients today are hard pressed to rate the effectiveness of their relationship with their doctor.  The evidence shows that poor physician-patient communications is the norm rather than the exception.   As such, most patients do not appreciate all the ways in which their doctor could in fact do a better job communicating with them.

Why Is Any Of This Important?

Simple.  Hospital and physician reimbursement is increasingly determined by things that are closely linked with the a physician’s patient communication skills:

• improved patient outcomes
• fewer hospital re-admits
•  fewer medical errors

So if hospital chiefs of staff or health plan medical directors are looking for a way to improve these types of metrics consider improving the way your physicians and patients talk to each other.   In the long run patients and physicians will thank you for doing so.

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

Sources:

Dyche, L., & Swiderski, D. (2002). The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns. Family Medicine, 267-270.

Lang, F., Floyd, M. R., & Beine, K. L. (2000). Clues to patients’ explanations and concerns about their illnesses. A call for active listening. Archives of family medicine, 9(3), 222-7.

Howard Waitzkin, MD, P. (1984). Doctor-patient communication – Clinical Implications of Social Scientific Research.  JAMA, 252(5), 2441-2446.

Heisler, M. (2008). Actively Engaging Patients in Treatment Decision Making and Monitoring as a Strategy to Improve Hypertension Outcomes in Diabetes Mellitus. Circulation.

When It Comes To Patient Engagement…It’s The Little Things That Count

I did a dumb thing a couple of weeks ago.   I fell off a ladder on to a cement floor and broke some ribs.

I went to the local ER, was x-rayed, and went home.   There’s nothing they do for broken ribs these days it seems.   The treating Physician’s Assistant told me she had notified my primary care doctor of my fall and resulting injuries.   Mind you this is the same primary care physician who was aware of my 3 recent retinal detachments, major surgeries (Vitrectomies), and prolonged recovery from these events.

It’s been a month since I feel off the ladder….and in all that time I haven’t heard a peep from my personal physician.  That bothers me.

It’s not like I had a problem that needed follow-up…but it would have been nice – perhaps even prudent – for his office to call and see how I was doing.   Why?  The fact that he didn’t call just reminds me that my physician really doesn’t think or care very much about me – as a patient or a person.   Either that or he has yet to read the ER report of my injury from 4 week ago.

In truth everyone I have spoken to about this has had a similar experience.  This is unfortunate for patients and the medical profession.   As patient’s we are continually reminded that physicians don’t have time for us or our problems.  We chide ourselves for not looking for a new doctor in the hope that things might be better.   For their part,  medical professionals meanwhile are clueless why their patients are not as engaged in their health or adherent as they should be.

Want to Engage Your Patients?  Act Like You Care

We all know primary care physicians are very busy and not properly reimbursed for all the work they do.  We also know you all had mothers that “taught you better.”  We all had those same mothers.  Mine used to tell us kids that you “catch more flies with honey than you do with vinegar.”

If you really want to blow the socks off even the most jaded of patients….call them up and ask them how they are doing.  Start with a phone call – it’s more personal than an e-mail.  Just tell the patient that you “know there not ever enough time during office visits to show you care…so when you had a free minute you wanted to remedy that.”

Start with your chronic and frail patients – one call is all you need.  Do this one simple  albeit time consumer thing and your outcomes ill improve, patient adherence will improve, patient satisfaction and loyalty will improve…and you will feel better about yourself.  Think of it as a long-term investment.

You need more proof?  Calculate the ROI of buying and installing an EMR system and hiring a care coordinator and then compare it to the cost of making a single phone call to your sickest patients.   When you compare the saving from the EMR and the cost of your time to make the phone calls….you will be amazed that you didn’t do it sooner!

This ain’t rocket science!  Go out now and make your Mamma proud!

That’s my opinion…what’s yours?

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

Sources:

Stein, T., Nagy, V.T., Jacobs, L. (1998). Caring for Patients One Conversation at a Time : Permanente Journal, 2(4), 62-68.