Patient Engagement – Here’s The Key To Success In Case You Are Interested


Primary care physicians are the point of first contact that people like you and I have with a hospital or health systems.   We are 13 times more likely to visit a primary care physician in any given year than we are to need a hospital stay.

Primary care physicians are very important.   Yes they are they the first line of care for many people.   The primary care physician’s office is also the  “make or break” point for “engaging the patient.”  

What people experience have experienced in primary care physicians’ offices  in the past tends to “shapes and frames” their expectations of future health care experiences.    Patient complaints about doctors that don’t listen, long waits, etc. are as much a reflection  of our collective life-long experience as they are the reality of any one physician.   So it is with the tendency of patients  to stay disengaged from their health care.   That’s what we as patients are taught from childhood.

This post is the 3rd in a series of posts on Patient Engagement.  Be sure to also check out:  Patient Engagement Versus Physician Engagement – Which Comes First? and Patient Engagement From The Patient’s Perspective.

What’s the Point?

The point is that the medical exam – the most frequent point of contact between patients and the health care – was never designed to engage patients.  This is the same “medical exam process” taught in medical schools to this day.

The medical exam is a highly structured affair.  It doesn’t just happen.   It consists of 6 steps or processes that physicians move the exam through with the single goal of diagnosis and treating the medical problem

The most important “take away” from this graphic is that patients – people – are invited to freely speak only during the 2nd step – the patient’s opening statement.  This is where people tell the doctor the reason for their visit.   Even then…patients are often interrupted before finishing their story.

From this point of the medical exam on, the patient’s role – aka the sick role – is to answer yes or no to their physician’s questions.

How can physicians, hospitals or health systems ever hope to truly engage patients in their own health  care when the heart of the heart of the health care system – the medical interview – is so un-engaging?

The Key to Patient Engagement – High Quality Patient-Centered Communication

Patient-centered communications by definition is tailored to the patient – their beliefs, fears, concerns and past experiences.   It invites patient input and participation.   It engages us in important conversations with our physician that would not otherwise occur.   When practiced over time, patient-centered communications will enable physicians to accomplish more…in shorter visits…while creating exceptional patient experiences.

Hospitals, health plans, and ACOs looking to engage patients should begin by looking to ways to help their physicians adopt more patient-centered communication skills.   Simply providing them with EMR systems and care coordinators is not enough.   Going forward, those physician groups and hospitals most successful at engaging patients will be the ones that are the most patient-centered where it counts – physician-patient communications during the medical exam.

That’s my opinion…what’s yours?

Sources:

Haidet, P., & Paterniti, D. A. (2003). Building a history rather than “taking” one: a perspective on information sharing during the medical interview. Archives of Internal Medicine, 163(10), 1134-40.

Cegala, D. J., McClure, L., Marinelli, T. M., & Post, D. M. (2000). The effects of communication skills training on patients’ participation during medical interviews. Patient Education and Counseling, 41(2), 209-22.

21 responses to “Patient Engagement – Here’s The Key To Success In Case You Are Interested

  1. I’ve read somewhere that medical students are now being trained in patient-physician communication skills. Until that filters through, patients are going to have to advocate for themselves. They have to be clear about their needs and state their views competently. Either that, or they’ll be waiting a long time for those students to graduate.

    • Tom,
      You are right that some medical schools are now teaching med med students how to be more “patient-centered” in their communications. Evidence also shows however that the under the pressures of actual practice (vs med school), physicians begin to default to the a quicker but less effective physician-directed communication style.

      Thanks for your comments!

      Steve Wilkins

  2. Hello Steve and thanks so much for covering this critical gateway to good health care – the medical exam. In a very laser-like fashion, you’ve hit upon one of the most challenging parts of this encounter. No wonder that doctor-patient communication, as outlined on your simple yet profoundly important infographic, can become so muddled. An older woman in one of my heart health talks recently raised her hand during the Q&A portion of the presentation and asked: “My doctor says I have a heart valve problem. What does that mean?” I was thunderstruck that this articulate, well-dressed intelligent woman could have left her last doctor’s appointment with apparently no concept of what her diagnosis meant!

    Dr. Richard Frankel, a Regenstrief Institute research scientist at the Indiana University School of Medicine, offers this observation on this classic doctor/patient miscommunication problem:

    “We don’t assume when a pilot and an air traffic controller converse that they have understood each other until there is an affirmation of understanding. That acknowledgement is lacking in most patient-physician encounters.”

    I’m wondering if the CLOSING part of your infographic is where this “affirmation of understanding” goes missing during the medical exam?

    • Carolyn,

      Thanks for you kind thoughts. It is surprising to me how pverlooked the medical interview is relative to patient engagement and communications.

      Re: “affirmation of understanding,” that is actually a process that should occur throughout the course of the medical interview, i.e., the patient makes a statement and the physician acknowledges with an “Uh huh” or a question to let the patient know that he/she heard the patient. That goes for patients as well.

      Regards,

      Steve

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  4. Lots of attention is focused on this topic of late. Tools for the Patient Centered Medical Home, patient goals, motivational interviewing, are all efforts to get at engaging patients. A recommendation: bring your top 2 questions, concerns, or goals to the doctor visit. It will help the doctor meet your needs. Patients have the power to change the system. Start with your next visit.
    Ellen Barnett, MD

  5. Excellent stuff Stephen! Think this You Tube clip by TEDxMaastricht – Bas Bloem – “From God to Guide” also re-enforces this message.

    I used to be a patient, but pleased to say I have become a person again.

  6. Forgot to include You Tube address for – Bas Bloem – “From God to Guide” http://www.youtube.com/watch?v=LnDWt10Maf8&feature=player_embedded

  7. Thanks, Stephen and thanks also to Pete for a link to the great video. Though I agree that the opening statement is a good, and perhaps necessary place to start the engagement process, I also agree with you and others about the need to continue to support patient participation and collaboration throughout the visit.

    Michael

  8. Interesting discussion. I think that we are largely focused on the behavior on the physician side. One thing that may be helpful is to shape the behavior on the patient’s side. It is a legitimate concern for a physician and his or her staff to need to get the most relevant information as quickly as they can from the patient for a number of reasons. I have developed the habit of always preceding my visit to the physician’s office with a written summary of why I am visiting. This prevents me from getting distracted during the visit or forgetting what my priorities are for that visit. I have a copy, the doctor and nurse have a copy.

    We know paperwork is a pain, but if a kiosk or simple but adequate form could be included for patients to complete with more than just “why are you here today” then the engagement level might go up significantly just by virtue of the fact that all are literally working off the same page. This is a strategy that might work at all levels of technology. The primary limitation might be the patient’s ability to express their needs in writing.

  9. I understand the physician point of view, but I also believe that the initial contact,”Port of Entry” is where it all begins. The first person they meeting will set the tone and shape the customers opinion of the care they will recveive prior to them ever meeting the physician.

    • Jack,

      There is no denying the impact of that the front office staff can have on one’s experience. Having said that, I would bet that an highly productive and satisfying conversation with the physician would trump a poor front office experience. If one has to start somewhere, I would start with the “touch point” that has the greatest potential for improving health outcomes.

      Thanks for your comment!

      Steve Wilkins

  10. One thing that should not be overlooked is that patients are intimidated by their doctors. They know doctors are much more educated than they are and that they have likely seen cases much worse than theirs, making them feel more restricted to opening up fully about the extent of their pain, worries, or worries about their treatment for fear of negative judgement from the doctor. One of the easiest things a doctor can do is express concern over minor problems with a patient -perspective a minor scratch perhaps- even though it’s not significant it will challenge this intrinsic perspective in the patient about sharing “insignificant” things that might actually be quite significant and in the realm of patient oriented communication.

    • Eric,

      My wife and I travel regularly to MD Anderson in Houston for her care. Here Medical Oncologist travels with a retinue of “fellows.” He alone has a very imposing and intimidating persona. When combined with his minions…yikes…!

      Thanks for making your point so well.

      Steve Wilkins

  11. Terrific 3-part series. The phrase I use is that “communication is the most important medical instrument of the future.” Consider that ~3/4 of all healthcare spend is around chronic conditions. If you think about how is *really* in control of decisions that drive outcomes, it is the individual (aka “patient”). They drive whether they fill a Rx, take med, exercise, what they eat, etc. In the new reimbursement world, providers will fail if they don’t master delivering care beyond the clinic. You might be interested in the piece I wrote “Patients are more than a vessel for billing codes.” See http://techcrunch.com/2012/03/29/patients-are-more-than-a-vessel-for-billing-codes/

    • Dave,

      Thanks for you kind words. I am glad you enjoyed the series on patient engagement. I am finishing up a white paper on the subject right now. I totally agree with you “take” on the importance of strong physician-patient communication as a critical tool for the future. To steal a quote from George Bernard Shaw ..”the problems with communication is the illusion that it has taken place.”

      Thanks for the link to your article..I will check it out.

      Steve Wilkins

  12. Msc. S. Metselaar

    I have to say, i never realised this.. but you’re totally right. Although i belief that putting the patient in the centre, is not the way to go. Like everything else, processes are moving dynamic. If you put the patient in the centre, you’ll take the dynamics out of it. I rather see that a patient is moving along in the proces… not all the time in the middle, but at the place where the moment takes him and this also counts for the GP.

  13. Steve – I think you’ve done an excellent job pointing out valuable insights to JUST ONE SLICE of the patient engagement landscape. It seems that you are presuming that all patient engagement does, or should, occur through the physician, and in the doctor’s office. This is absolutely not true! Patient engagement can, and should, take many different forms, and different times, by different individuals, for different reasons, etc. We must all start THINKING OUTSIDE THE (physician-office) BOX about patient engagement!

    Long before a patient is even a patient (i.e. being cared-for by some healthcare provider), he/she is simply a person. THAT is where “patient (to be) engagement” should begin! And it should continue before the patient-to-be even makes an appointment or sees a doctor, nurse, case worker, or anyone else for that matter. What sorts of information might the provider community make available (or pro-actively push out) to individuals who want to avoid becoming patients, i.e. to take control of their own health maintenance, pro-actively, rather than rely solely on re-active health recovery?

    I could go on…but I won’t. I really just wanted to make the point about how many other alternatives we should all be thinking about…besides the physician in his/her office. Who else, when else, how else, with what else, and where else can we engage patients (or patients-to-be)? Answering those questions goes hand-in-hand with why else to do so.

    That’s MY opinion! 😉

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