Patients Are Often More Engaged In Their Health Than Providers Think

Patients often don’t get the respect they deserve. Take the subject of patient engagement.  Just about everywhere you turn in the health care literature these days we are told how physicians and other providers need to do a better job getting patients involved in their own health.

But is that really their role?

Patient Engagement Is Not The Job Of Health Care Providers

Why?  Because by the time a person (aka patient) presents for care in the primary care physician’s office…they are already engaged in their own care to some degree…albeit now necessarily in the way providers expect.   Here’s what I mean.

People consult with their doctor when they have a need or concern which they believe needs to be addressed.  Often times before they make an appointment to see the doctor, people will do their own home work to see if a doctor’s appoint is really necessary.   Many of us for example will talk with a friend or family member or consult our favorite health website before deciding to see a doctor.  A recent Wolters Kluwer poll on Health found that of all people who go online for health information, 50% do so before seeing their doctor.

Next we must pick up the phone and make the appointment which itself requires time and dedication given office hold times.  Then we must actually keep the appointment…telling ourselves that we are seeing the doctor for a good reason.

By the time we walk through the front door of the doctor’s office we are already engaged in our health as manifest by the cognitive involvement and expenditure of time involved with:

1)    Deciding that we need to see a physician,

2)    Making and keeping their doctor’s appointment despite the self-talk that we will get better on our own.

3)    Preparing a mental list of issues/question that we want to discuss with the doctor.

Given that people 50 years and older see their physician and average of 3-4 visits a year, they are already engaged in their own health…at least up until the time they walk into the physician’s office.

What happens in the doctor’s office plays a big role in determining whether the patient’s level of engagement grows, or is diminished if not extinguished.  Physicians that are prepared for the visit, ask patients for their input, solicit patient expectations, beliefs and previous experiences, and where possible honors them, are demonstrating traits that patients find engaging, e.g. traits which encourage patients to persevere in their get involved in their health.  Physicians who appear rushed, “not present,” not prepared, or who fail to solicit the patient’s input often have the opposite effect.

So What Is The Role Of Providers When It Comes To Patient Engagement?

Given that patients is the office are already engaged, albeit perhaps not is ways providers think of as engagement, the role of the provider is not so much one of needing to engage but rather being “.”  By engaging I mean creating an atmosphere which facilitates, cultivates, and builds upon the level of engagement which patients bring to the office.  This is accomplished when the physicians and provider staff consistent employ patient-centered communications with all their patients.

That is what I think…what’s your opinion?

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

Challenge #1 For Health Care Providers – Way Too Much Information And Way Too Little Communication With Patients

One of the biggest problems with health care today is that there is way too much information and way too little communications going on between providers and patients.

Here’s a great quote that explains what I mean:

The two words information and communication are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through.

Sydney Harris,  Journalist

I was reminded of this and the quote from “Cool Hand Luke” quote in an exchange I had with a primary care physician on LinkedIn recently.   In that exchange, which dealt with long-term physician-patient relationships, I hypothesized that intentional non-adherence may be the by-product of situations in which physicians and patients in long-term relationships simply grow to distrust each other.

The good doctor commented as follows:

“In the end, it is the patient’s decision to be compliant or not, yet many physicians continue to care for these patients because someone must. Would the patient comply better with a new doctor? I doubt it. “

I replied to the good doctor’s comment as follows:

“True…the decision to comply or not is up to patients.  But the evidence shows that compliance is not a product simply of bad patient behavior. Non-compliance is an outcome for which both physician and patient have shared responsibility.

I suggest that most people would be a lot more likely to comply if they: 1) understood and agreed with the need for the prescription and 2) believed that the benefits of taking the medication outweighed the risks and concerns. But these issues are seldom brought up by the physician or the patient, due to limited time, provider attitudes and beliefs about patient, and so on.”

Then he dropped the A-bomb – a move intended to silence anyone who would dare challenge physician authority and learnedness:

A professional who deals with this on a daily basis can explain meds, conditions, etc. very quickly and to the satisfaction of the patient.

That’s when it occurred to me…too much information and not enough communication

No doubt most providers today are proficient at quickly giving information to patients (including telling them what to do).  What most providers (and people in general) are not good at is effectively communicating, e.g.,  getting through, with patients (or each other).   Anyone who has ever been married knows the difference between information giving and communicating.

And how would the good doctor know that his patients understood the information he gave them…not to mention their being satisfied with it?   Surely he’s not banking his revenue going forward under P4P on his patient satisfaction surveys alone.

If anything, the weight of evidence suggests that his patients probably do not understand the information he quick doles out and probably are not particularly  satisfied with it.   Like many of us, his patients probably do not want to confront the good doctor choosing instead to ignore his recommendations or seek advice elsewhere, e.g., no-adherence.

But as with any good relationship, effective spouse-centered (I mean patient-centered) communications is key.   To truly engage the other party, you have to know where they are coming from, what’s important to them and never, never ask them to do more than they are willing and able to do.  I had to say that since my wife “proof reads” my blog posts…lol).

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

Can Long-Term Physician-Patient Relationships Be Bad For Your Health?

I wonder how many problems like non-compliance, usually attributed to “poor patient behavior,” actually stem from long-term physician-patient relationships in which both parties have just given up.

You know what I mean…physicians who have treated certain patients long enough that they believe they are just plain never going to do what they are told…and patients with expectations for care and service from their physician that never seem to be met.

Like any long-term relationship, people become used to one another and develop coping mechanisms to avoid an outright breakdown.  People in long-term become complacent with one another’s “quirks.”   We are all too willing to settle for the things as they are and not push the boundaries of the relationship hoping to improve it.

But there is a long-term cost to the patient and physician when we ”settle” and try to just get by as the graphic below suggests.

At face value, most physicians and patients don’t do a great job when it comes to communicating with one another.  Take patient expectations .

Most people have certain basic  expectation for what we want to happen when we consult our physician.   At a minimum we expect to have the time and opportunity to tell the doctor why we are there.   After all, if we are concerned enough to make an appointment we want to be heard.  Maybe we also have an expectation for a specific service – say a test, a referral or a new medication.

Quite often however, patient’s expectations, reasonable or not, often go unmet.  According to researchers, physicians failed to ask for patient’s full reason for their visit in 77% of visits.   Maybe the physician has little time to allow the patient to ramble on or maybe the physician has already arrived at a diagnosis already.

The reality is that the patient’s expectations were unmet perhaps resulting in disappointment and perhaps frustration.  Unfortunately, as Avedis Donabedian, MD, once said, “patients are overly patient with their physicians” and are willing to put up with a lot without saying anything (or reporting it on patient satisfaction surveys).

Not every patient request for a test, referral or medication is appropriate.  Physicians have an obligation to deny inappropriate patient expectations.  But again, depending upon how well the physician explained their reasoning for the denial, some patients will be disappointed and perhaps even angry.   Another study found that 56% of patients expressed an expectation for a specific service – a test, referral or medication… with 50% not getting what they asked for.

Now imagine playing this scenario playing out between patient and physician 2 or 3 times a year over a number of years.   I have to believe that in situations like this patients continually lower their expectations of their physicians…and along with it their trust, willingness to share information, and a willingness to comply what the physician recommends.  Physicians for their part probably reciprocate these feeling in some way.

The point is that settling and being complacent can be bad for the patient’s health and very unsatisfying for the physician.   Too bad we don’t measure patient and physician complacency…it could probably explain a lot.

That’s my opinion…what’s yours?

Sources:

Dyche, L. et al.  The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns.  Journal of General Internal Medicine. 2005; 20:267–270

Peck, B. et al.  Do unmet expectations for specific tests, referrals, and new medications reduce patients’ satisfaction? Journal of General Internal Medicine, 2004; 19(11), 1080-7.

The Annual Physical: What Do You Think?

The following is a guest post by Anne Polta, an outstanding writer and author of the blog HealthBeat.  Please check out her work.  

 
Do annual visits to the doctor make sense? Are people healthier when they receive yearly checkups, or is the yearly visit something we do mostly because we think we’re supposed to?

There’s a fair amount of debate in the medical world about the value of that time-honored custom, the annual checkup. Many experts question whether it’s really necessary to subject healthy, asymptomatic adults to a battery of one-size-fits-all tests that might or might not be helpful.

As long ago as 1989, the U.S. Preventive Services Task Force, an independent panel of experts that weighs the evidence and issues recommendations on the use of screening and preventive health care services, found insufficient proof to endorse the benefits of the standard yearly checkup for otherwise healthy adults.

The task force has not suggested that people can skip seeing a doctor unless they’re sick.   Rather, guidelines by the USPSTF, researchers and other physician groups increasingly have tilted in favor of individualized assessment and counseling based on the patient’s age, gender, risk factors, health history and preferences.  In other words, EKGs don’t need to be administered to every middle-aged person who comes in for a physical, nor does everyone need to have annual chest X-rays or a comprehensive blood panel unless there’s a reason for doing so.

This isn’t always an easy message to convey, especially to an American public who’s accustomed to being told to get screened for everything.

The whole issue, in fact, is more nuanced than it appears.   When a group of researchers undertook a review a few years ago of the evidence on the pros vs. cons of the routine physical, the results were mixed.   In their findings, published in 2007 in the Annals of Internal Medicine, the researchers reported consistently clear benefits for regular cholesterol screening, gynecological exams, Pap smears and fecal occult blood testing.   Regular physical exams also appeared to be reassuring for patients.   But the benefits were less clear on other measures, such as whether regular checkups resulted in better clinical outcomes, fewer hospitalizations or lower health care costs.

Why, then, do we continue to have regular checkups, and why do most doctors continue to believe they’re an important part of health care?   The real benefit, it seems, lies in the intangible things: the opportunity for doctor and patient to get to know each other and to develop a relationship when the patient is well rather than sick or in the middle of a crisis.

Dr. Steven Reznick, who has a concierge practice in Boca Raton, Fla., tackled this very issue last week in a guest essay at Kevin, MD. “Is it cost-effective? Does it prevent disease? It doesn’t matter,” he wrote. “  It is an essential part of the development and continuation of the doctor-patient relationship.”

It’s also a way to benchmark the patient’s health from one year to the next and address important issues such as previous illnesses, family history and lifestyle, Dr. Reznick writes.

Where Does The Patient’s Responsibility For Their Health Begin? Do We Know?

When you or I visit an accountant, a lawyer or car mechanic, we know what our role is and have a pretty clear understanding of what the ” expert” is supposed to do. But when it comes to a trip to the doctor these days the roles and responsibilities of patients and physicians have become blurred and unpredictable…and the patient seems to generally be on the losing end.

Take my Mom’s case. My Mom who was 89 years old and evidently had severe osteoarthritis. She never knew that even though she was been seen every couple of months by her Internist for years and years. It’s too bad…because my Mom died last week from complications due to a compressed fracture of her spine. Turns out her spine was very fragile according to her consulting Neurosurgeon but no one ever told her.

The first question that entered my mind when I heard of her condition was why didn’t her primary care physician “pick up” on the severity of her condition before she fell and fractured her spine?

From my perspective, my Mom’s primary care physician should have told/warned her as to the severity of her condition. As it was, she was never prescribed any medications or dietary supplements nor was she advised of the benefits of staying active.

My wife says my Mom should have been aware of the fact that older women routinely experience bone loss. After all, there are ads everywhere warning of the perils of osteoporosis and the benefits of staying active.

So how are patients supposed to know what they are supposed to know?

Is it common practice for physicians to assume their patients have a certain level of health knowledge? If so, is there a difference between expecting patients to understand the perils of smoking versus the perils of bone loss? I was not aware that compression fractures of the spine were so common among women with osteoarthritis. I bet most non-physicians aren’t aware of this fact either.

Where is the dividing line between what patients are supposed to know versus what physicians have an obligation to tell them?

I am all for have people take more responsibility for their health. I understand that physicians can not possibly handle the competing demands they face and that patients have to do more. The problem is that it seems that someone should tell the patient!! If physicians expect patients to take on more responsiblity for their health then why not explain that to patients? But simply telling patients they have to do more is not enough…patients need to be taught what they need to know and what they need to do.

This problem seems to be particularly acute for the elderly. Having grown up before the age of patient empowerment, they generally do what they are told by their physician. If something is important, they believe that their physician will tell them. Unfortunately the rules have changed and I fear that patients are the last to figure it out…often when it’s too late.

Going forward I hope doctors and patients start having frank, honest discussions about expectations and responsibilities. Yes it may take a minute or two…but in the long run it should save lots of time, pain…and yes even prevent accidental falls and untimely deaths.

That’s what I think. Please share your thoughts and experiences…don’t be afraid to disagree.