Category Archives: doctor-patient communication

We Stop Being A “Person” And Become A “Patient” When We Do This …

… We Walk Into The Exam Room At The Doctor’s Office.

ExamRoom Door2We all play many roles in life …. spouse, employee, sibling, parent, friend, customer, and so on. Each of these roles brings with it its’ own unique set of expectations (self-imposed as well as externally imposed – can you say spouse) for how we are supposed to think and behave. One role that we all play is that of “being a patient.”

The roles and behavioral dynamics that take place in the exam room between patients and physicians gets little attention today. But they should, since the exam room is where diagnoses are made, treatment plans formulated and utilization of health care resources determined. And if outcomes are any evidence, what passes for patient communications these days, and the resulting patient behavior, is anything but patient-centered or high quality.

The Patient’s Role

Beginning with our childhood visits to the pediatrician with our mother, we have all been socialized into the “patient role.” We come seeking the doctor’s expertise. We are petitioners. Our role as patient is straightforward … answer the doctors questions … sit passively by while the doctor does their thing … and upon leaving the office, do what the doctor recommends. Doctors after all know what is in our best interest. Right?

If you do what you were told (recommended) then you care a good patient – compliant and engaged are words that clinicians often associate with good patients. If you challenge the doctor by making requests, taking up too much time, or you do not do what the doctor recommends – you are a often considered a difficult, noncompliant patient.

From the patient’s perspective, good patients get the best care … but if you are a bad patient you may not get the doctor’s full attention … or worse you could be “fired.”

The Doctor’s Role

Doctors too have a role … that of clinical expert. Many physicians will tell you that they were taught 2 things in medical school : 1) how to diagnose medical problems and 2) how to treat medical problems. To the extent that most doctors talk to you … it is for those two purposes alone. Most doctors will tell you they were never taught in medical school to get to know the patient (or person). They will also tell you they often wish patients would “shut up” after they have the information they need to arrive at a working diagnosis.

Physician Communication Styles2To do their job, physicians were taught the need to control the visit by the way they communicated with patients. Traditionally, physicians learned by watching their medical school preceptors and mentors that the way to “control the visit” was to control who the communications between they and their patients. This “physician-directed” (aka paternalistic) communication style is where the physician does most of the talking, asks most of the questions ( usually closed ended) and makes most if not all the decisions.

Here’s a comment I received recently for a decidedly Physician-Directed (Paternalistic Physician) that illustrates their role mindset: An estimated 70% of practicing physicians today employ a “Physician-Directed” style when talking with patients.

Physician-Centered QuoteOver the last 20 years, there has been a resurgence in the importance of understanding and treating the whole person … and not just their medical problems. This has lead to what is commonly referred to as Patient-Centered Care.

A patient-centered style of communications seeks to actively involve patients in the medical exam. The focus is not just on the biomedical aspects of the patient’s disease … but also how patient perceive their health issues, their ideas as to it cause as well as its treatment. It simply means that the clinician ask them for their thoughts as a way of making a better diagnosis and arriving at a better treatment plan. One they both can agree upon. A Patient-Centered style also focuses on patient psychosocial issues which are all but ignored by the Physician-Directed style.

Note : Nothing about a Patient-Centered Style suggests that physicians give patients anything they want even if they don’t need it. It means that if patients asks for something they don’t need, the clinician seeks to understand the reason for the patient request. And if unnecessary, the clinician gives the patient the courtesy and respect of explaining why they think the request is inappropriate.

Implications Of Roles and Communication Styles

Now you need to ask yourself the following questions

If 7 out of 10 physicians, including those in your provider networks, do not know how to “speak Patient-Centered”, how can you expect them to do the following:

Engage patients – How engaging is it when you doctor interrupts you, ignores or dismisses your input, or limits the number of questions you can ask …and information you receive?

Be Empathetic – If your doctors see no point in eliciting patient psychosocial issues … what makes you think you can they are doing it?

Shared Decision-Making – If you doctors just assume that patients want/expect them to make the decisions why in the world would you expect them to ask the patient what they think? They don’t solicit the patient’s input about anything else?

Missed Patient Engagement Opportunities – The average patient presents from 9 to 12 patient engagement opportunities at each visit. Most doctors miss more than 50% of these opportunities. not because they lack the time…but because their either don’t recognize them as opportunities, don’t know how to respond or simply ignore them. That comes out to almost 100 missed patient engagement opportunities per doctor per day. Remind me what the cost of an unnecessary ER visit or hospital readmission is again?

So What’s The Solution?

Hospitals, ACOs, Medical Groups and Health Plans should work with physicians in their provider networks to do the following:

  1. Commit to adopting patient-centered communication best practices – they do exist, there are 30+ years and hundreds of published studies linking patient centered communications to increased patient engagement, better outcomes, lower costs and better patient experiences.
  2. Profile and benchmark your physicians’ patient communication and engagement skills against established best practices. Audit how many patient engagement opportunities are being missed by physicians in your provider network and at what cost.
  3. Conduct patient communication and engagement skills training programs tailored to the individual needs of your physicians.

Stephen Wilkins, MPH, Principal

Mind the Gap Academy

http://www.mindthegapacademy.com

Conflict of Interest: My company works with hospitals, ACOs and Medical Groups to assess and benchmark physicians’ patient communication and engagement skills. We also offer online physician training in patient-centered communications and engagement.

Sources:

Roter, D. L., Stewart, M., Putnam, S. M., Stiles, W., & Inui, T. S. (1997). Communication Patterns of Primary Care Physicians. JAMA (277), 350-356.

Joseph-williams, N., Elwyn, G., & Edwards, A. (2013). Knowledge is not power for patients : A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Education and Counseling.

Levinson, W., Stiles, W. B., Inui, T. S., & Engle, R. (1993). Physician Frustration in Communicating with Patients. Medical Care, 31(4), 285-295.

Alexander, J. a, Hearld, L. R., Mittler, J. N., & Harvey, J. (2012). Patient-physician role relationships and patient activation among individuals with chronic illness. Health services research, 47(3 Pt 1), 1201-23.

Levinson, W. (2011). Patient-centred communication : a sophisticated procedure. BMJ Quality And Safety, 20(10), 823-826. doi:10.1136/bmjqs-2011-000323

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Death By A Thousand Cuts – Physicians’ Surprising Response To My Wife’s Lung Cancer Recurrence

This is a true story….

My wife was about to celebrate her 10th anniversary as a Stage IV Non-Small Cell Lung Cancer survivor (a pretty remarkable feat) when it happened.

It started out as a cough.  We had just returned from a family trip and assumed she had picked up a “bug” from one of the boys. It also “lite up” on her semiannual PET/CT scan down at MD Anderson as small dark masses where there weren’t supposed to be any. We all hoped the cough and the PET/Ct results was the result of a cold or allergy….it had happened before. Her medical oncologist, one of the top thoracic oncologists in the world, doubted a recurrence after 10 years.  But if it was a recurrence, he told us he would put my wife back on Tarceva, the oral chemo that had worked so well for her before.

But we were all wrong. Her lung cancer was back and appeared to have spread.  The cough escalated into a 24/7 serious hack-a-thon.  She couldn’t finish a sentence without coughing.  We avoided being around other people as the coughing got worse. My wife didn’t want “bother” people.  Nor did we want our family and friends to get the wrong impression….that my wife was dying. She had beaten the odds once and she would do it again we told ourselves.  Turns out we were the only ones that believed it.

Within the space of 2 months, my wife saw a local pulmonologist (we live in Northern California not Houston, Texas where MD Anderson is) to rule out any other causes for the cough.  She also kept two long-scheduled appointments with an endocrinologist and a cardiologist for issues unrelated to the cough or cancer.

That’s When I Noticed It – Every Physician My Wife Saw Acted As If She Would Be Dead Soon

To be sure none of my wife’s physicians ever said she was dying. But knowing something about the nuances of how physicians “communicate” with patients I could tell that’s what they were thinking.  After attending every one of her doctor’s appointments over the last 10 years you recognize the tell tale signs.   Neither the endocrinologist or cardiologist were familiar with my wife or her condition as these were our first visit to both.  But they clearly could not get past her coughing.  They politely cut short the initial appointment and told my wife to contact them after the lung cancer had been dealt with.  You have bigger problems than a thyroid nodule or a rapid heartbeat they told us.

Mind you my wife was concerned enough (let’s say she was engaged) about her thyroid nodule and heart health that she 1) made the appointment to be seen and 2) actually kept the appointment because she/we believed that she would be around long enough to have to deal with these problems sometime.

The pulmonologist, after ruling out allergies or infectious disease as the cause of my wife’s cough, threw up his hands in apparent defeat and said “your cancer’s back and there’s nothing more I can do for you. “ He referred us to a local a local thoracic surgeon in order to get her cancer re-biopsied before starting chemo.

The thoracic surgeon, like the other doctors, couldn’t deal with my wife’s coughing and shortness of breath which was pretty bad by now.  Rather than come up with a definitive plan of action regarding the biopsy, the surgeon hemmed and hawed about the different approaches to doing the lung biopsy – one more invasive than the other.  The surgeon gave me the distinct impression that the biopsy in the long run wouldn’t matter given the apparent seriousness of my wife’s condition.  He promised to discuss the biopsy options with my wife’s oncologist the next day and call us with the “game plan.”  The doctor never called us back.

By this time it was 5:00 pm on a Friday afternoon.  We felt we had already wasted too much time between the pulmonologist and the thoracic surgeon and my wife started her oral chemo at 5:01 pm.  We immediately felt better because at least we were finally doing something positive to address my wife’s problem.  Anything is preferable to watching sympathetic physicians, nurses, office staff, radiology techs, etc.  shake their heads saying to themselves “poor woman” doesn’t have long to live.

Post Script

Within 10 days of starting her oral chemo, my wife’s cough and shortness of breath completely disappeared.  After 2 months of being on Tarceva the first follow up the first PET/CT scan revealed what the radiologists called a significant response to the treatment.

Not bad for someone whom so many clinicians had written off!

The Take Away

Physicians need to be aware of the fact that they both bring pre-existing attitudes and biases to the office visit…and check them at the door.  These attitudes and beliefs color the decisions clinicians make.  The extent to which clinicians inform patients of all their diagnosis and treatment options, engage patients in shared decision making, or decisions as to how aggressively treat the patient’s condition are all influenced by physician’s beliefs and attitudes.

Lung cancer that presents as a bad cough is like a red flag to a bull. It invokes a whole set of assumptions about 1) how the person got the disease (you must have been a smoker) and 2) the person’s odds of survival – slim to none.

You have to wonder how many people’s lives are cut short or whose care is not what it should be simply because their doctor jumped to the wrong conclusions.

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

First Principle of Patient Engagement & Patient Portals– Be “Relevant” From The Patient’s Perspective

One of the biggest challenges facing health care providers today when it comes to engaging patients is RELEVANCE…or more specifically the lack of it.   I say “engaging” because any one presenting in the doctor’s office, visiting a patient portal or using a smart phone health app is already engaged in their health.   By engaged I mean they are already cognitively involved in their health to a certain extent with an end Relevantpoint or goal in mind, i.e., learn something, do something or decide about something.   Face it, who do you know that goes to the doctor’s office just for fun.  There is always a reason…and behind that reason is cognition, e.g., intellectual engagement.

Fact – 82% of U.S.  adults see their personal physician at least once a year (avg. is 3 visits/year) and yet experts tell us that most of us are still  unengaged in our health.  What’s with that?

Relevance Is Important In The Doctor’s Office

Now imagine a 55 years old person going into their doctor’s office because of a persistent headache and back pain.  Before deciding to see the doctor they probably talked with their family or friends about their concerns. Maybe they went online to research their concerns before making a doctor’s appointment.  Now imagine that same person in the exam room and all the doctor wants to talk about is the patient’s risk for colon cancer and the need for an overdue colonoscopy.  Bam. Instant patient disengagement.

AdoptOneBigButtonTo be sure, the clinician in this scenario is legitimately trying to “engage” the patient by getting them to comply with a recommended, evidence-based screening.  But there is a disconnect in this scenario between what the person (patient) wants to talk about during their office visit…and what the clinician wants’ to discuss.  The disconnect? A lack of relevance.  What the clinician wants to talk about is not nearly as relevant to the patient as it is to the clinician and that’s a problem.

Here’s another example of a common physician-patient disconnect.  Using the same scenario, imagine that the person/patient concerns regarding their headache and back pain have to do with how these symptoms are affecting their vision (ability to drive), their gait, their ability to sleep at night and their appetite.  For the person/patient, their quality of life is suffering as a consequence of their complaints.

Now consider that physicians – at least those with a physician- or disease- oriented style of communicating with patients (which make up 2/3s of primary care physician) – will focus during the medical exam on the biomedical causes of the patient’s complaints rather than the quality of life issues of concern to the person/patient.  Also realize that most patients are now very good or willing to interrupt or correct their physicians.  Bam. Bam. Instant patient disengagement.

Once again, while what the clinician focuses on may be the cause of the patient’s problems, it’s not relevant to the patient that wants to know how the doctor will fix their loss of vision, gait, sleeping and appetite.

This same scenario is played out every day in physician offices across the country.  Disagreement over the visit agenda isn’t the only reason for communication disconnects or gaps.  Lack of physician-patient agreement is also common when it comes to:

• What’s wrong
• Diagnostic tests needed
• Accuracy of the diagnosis
• Severity of the diagnosis
• Cause of diagnosis
• Appropriateness of the recommended treatment
• Expected efficacy of the recommended treatment
• Need for a specialist referral

Relevance Is Just As Important To Patient Portals

Finally, imagine that the Electronic Medical Records and Open Notes detailing the above scenarios are available to the person/patient via a patient portal.   Imagine also that the HIT folks used the patient’s diagnosis and doctor’s notes to “trigger” personalized, tailored health information for the patient.   That means that the patient is sent messages about this risk of colon cancer, information about diet and colon health and a coupon for a colonoscopy.

Now ask yourself…how in God’s name is the information provided via the patient portal in this scenario relevant or engaging from the person/patient perspective?  Explain to me how the information in the EMR and Open Notes is relevant to the patient if its ignored?  It’s not…and people/patients need only look at their patient portal once to figure that out.

The Take Away?

HIT’s current attempts at patient engagement remind me of the parable of “putting old wine (same old information) in to new wine skins (patient portals). The wine’s going to go bad and few will drink it. The solution is to add relevant, “patient-centered” wine into the new wine skins.

Patient engagement is not an HIT challenge…it is a physician-patient communication challenge. As such, the role of the clinician is to engage patients…but rather to be engaging or at the very least avoid disengaging patients.

That’s my opinion. What’s yours?

Here’s Why You Should Ask Your Doctor To Show You Any “Alerts” In Your Electronic Medical Record

Electronic medical records (EMRs) make a lot of sense.  Ideally they capture, store, and report on all the pertinent information that’s floating around out there concerning your health.   One of the supposed advantages of EMRs is their ability to sort through vast quantities of health data to “alert” physicians to important gaps in your care.

Alerts are triggered when something in your EMR is flagged (think red flag) indicating that something that is supposed to happen to you has not yet happened….and vice versa    For example, EMRs can alert physicians when you are overdue for a screening test.  They can also alert physicians to lab and radiology test results that need to be followed up on.

It Is A Great Way To Engage Patients

Since everyone is so concerned about getting patients more engaged in their health care…why not start by turning the computer screen around and showing patients the “alerts” in their EMR.   I am sure that will get most patients’ attention.

Here’s why this is necessary

A study in a recent issue of the Journal of General Internal Medicine found that care gaps persisted among primary care physicians using EMRs and alerts.   Researchers found that:

  • Physicians failed to follow-up abnormal lab test results in a timely fashion (<30 days) in 7% to 62% of patients
  • Physicians failed to follow-up abnormal radiology test results in a timely fashion in 1% to 36% of patients.

Remember these where practices in which the EMR system was capable of generating electronic alerts telling the treating physicians that action was needed.  These follow-up rates are not all that different from similar studies of physician practices without EMRs.

The lack of timely follow-up by physicians reported in these studies resulted in otherwise preventable hospitalizations and delays in initiating time-sensitive cancer diagnosis and treatment.

In my wife’s case, her Non Small Cell Lung Cancer was identified in a hospital employee health screening when it was Stage 1… yet she was not told of the finding for some 5 years later at which time she was Stage 4.  This despite a “paper copy” of the radiologist report (chest X-ray) being sent to her PCP, OB-GYN and Employee Health Medical Director.

Why The Lack Of Timely Follow-Up?  

Researchers have found that primary care physicians in integrated delivery systems receive an average of 57 alerts per day.  Among the reason given for the lack of timely follow-up, despite the alerts, were the following:

  •  Physicians were found to be less likely to acknowledge alerts when they are behind schedule.
  • Physicians focused their attention on alerts concerning patients with greater “clinical burdens” (e.g., providers were more likely to acknowledge alerts about elderly or highly co morbid patients).
  • Physician lack of knowledge – physician knowledge of EMR alert-management features in one study ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two.  Put another way, many physicians don’t know how to use all the features of their EMR system.
  • Physicians ignored or turned the alert function off

The Take Away?

If you are a patient in a practice that uses an EMR, politely tell your physician that you would like to see any alerts that pertain to you.  If there aren’t any – fine.  If there are, simply ask your doctor what’s the plan for addressing the outstanding issue.  He or she may well have a good reason for ignoring the alert which I am sure they would be happy to explain to you.

If you are a patient in a “pencil and paper” practice, ask your physician what his/her policy is regarding test result notification, including timeliness.  Ask what their policies and procedures are to make sure that no one – particularly you – falls through the cracks.  Never leave your doctor’s office without a copy of all your test results!

If you are a physician with an EMR system…learn how to use the darn thing. Your patients will appreciate you for it and I dare say you prevent what happened to my wife and me.

That’s what I think.  What’s Your Opinion?

Sources:

Hysong, S.  et al.  Provider management strategies of abnormal test result alerts: a cognitive task analysis.  Journal American Medical Informatics  Association. 2010;17:71–77.

Singh, H. et al.  Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting.  Archives of Internal Medicine. 2009;169(17):1578-1586

Sittig, D. et al. Improving Test Result Follow-up through Electronic Health Records Requires More than Just an Alert.  Journal of General Internal Medicine. 2012 Oct;27(10):1235-7.

Buy the Practice, Employ the Doctor & Pray The Doctor Has Good Patient Communications Skills

Hospitals today are aggressively buying physician practices in their local markets. Why? Hospitals want to solidify their referral base for inpatient and outpatient referrals as well as increase their negotiating power with insurance companies.

Over 50% of physician practices are now owned by hospitals according to the Medical Group Management Association. As such, many one-time private practitioners are now hospital employees.

Having done physician recruitment in a prior life, I know that before buying a practice hospitals look at a variety of things including the practice’s patient volume; number of hospital referrals, estimates of patient turnover and so on. One of the things we did not consider years ago in evaluating and buying a physician practice was the quality of the physician’s patient communication skills and supporting practices. I doubt that things have changed much since.

Hospitals today are under a lot of pressure from Medicare to address inpatient medical errors that compromise patient safety and often result in costly re-hospitalizations. As the line between doctor and hospital becomes blurred clinically and legally, hospitals need to start paying close attention to the way their doctor-employees communicates or doesn’t communicate with patients.

Consider the Problem of Medication Errors

Miscommunication between doctor and patient is thought to be a leading cause of such medication-related errors as patients not knowing:

  • The names of all the prescribed medications they are taking
  • Indications for using or not using the medications
  • Dosage and frequency instructions

According the Institute of Medicine, approximately 500,000 drug errors or adverse drug events are reported every year in doctor’s offices and other outpatient settings.

In fact the evidence suggests that medication-related errors in ambulatory care settings may be substantially under reported. Consider a recent study of patients prescribed a blood thinner – Warfarin. Among older patients, Warfarin, and similar oral blood thinners, account for 10% of all preventable adverse drug events. In this particular study, 50% of all patients differed from their doctor in term of understanding how they we supposed to take the medication. In other words, one half of the study population was taking a Warfarin, a medication with serious side effects, incorrectly.

These finding are consistent with another 2006 study of physician-patient communications during primary care visits in which the physician prescribed a new medication. This study found that physicians:

  • Did not tell the patient the name of the new medication in 26% of the cases
  • Did not explain the purpose of the medication to patients in 13% of cases
  • Did not tell patient about adverse side effects of the medication in 65% of cases
  • Did not describe to patients how long to take the medication in 66% of cases
  • Did not tell patients the number of pills to take in 45% of cases
  • Did not tell patients about medication dosing and timing in 42% of cases

Doctors rely on patients to accurately tell them what prescription medications — and what dosages. In instances where the patient sees another doctor unfamiliar with their medication history, not knowing the name or dosage of a medication can cause serious problems. This is because “the other physician” may unknowingly prescribe a course of treatment that may have an adverse interaction with the patient’s primary course of treatment.

Failure to Inform Patients about Abnormal Test Results

Failure to inform a patient of an abnormal outpatient test result is another example of a serious error. The “failure to inform” rate was estimated at 7.1% in a 2009 study of 5,434 older adults in 23 primary care practices. “Failure to inform” rates for practices in the study ranged from a high of 26% to 0%. In cases like cancer where time is of the essence, any delay in treatment can have serious consequences for the patient.

Today hospitals are under pressure from regulators and payers to clean up their act with respect to inpatient quality, safety and outcomes. As hospitals employ more one time private practitioners, the list of quality, safety and outcomes issues faced by the hospital will grow to include issues like those described here. Issue previously handled by physicians in their own office.

My advice to hospitals? Know exactly what you are buying. Conduct a communications audit of the physicians in the practice before you buy. You will be glad you did.

Sources:

Schillinger, D. et al. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? Advances in Patient Safety. 2007.
Tarn, D. et al. Physician Communication When Prescribing New Medications. Patient Education and Counseling. 2008.
Casalino, A. et al. Patient-Physician Communication about Out-of-Pocket Costs. JAMA 2003.
Casalino, L. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine. 2009.
Preventing Medication Error. Institute of Medicine (IOM). 2006.,