Category Archives: Patient Satisfaction

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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What Some Patients Really Think About Their Doctors? How To Make Lemonade Out Of Lemons.

[tweetmeme source=”Healthmessaging” only_single=false]I highly recommend you take a look at “10 dumb things you do at the doc’s office.”  Be sure to scan the article…but what you really need to look at is the “comments”…all 700+ of them.

While by no means a representative sample of how we think about physicians, there is a clear pattern to the comments.  A lot of people feel disrespected by their doctors…and they are pretty angry.

Here’s what patients (including a lot of former patients) had to say.  I attempted to summaries the comments by category and included the top five categories of comments below.

#1 – Being on time is a two way street – patients are expected to be on time for their appointments – why aren’t physicians expected to be on time.   Doctor’s think and act as if their time is more valuable than the patient’s time.

#2 – Listen to what I have to say.  “Doctors should realize that many patients have more life experience and have done more research about a condition and drug and may possibly know more than them. God forbid!”  “If you do not like listening to your patients and getting proper information from them, you are in the wrong business.”

#3 – “Don’t just hear one or two of my complaints.   You try telling the doctor all the problems you have and the doctor stops you mid-way, telling you that he or she will take care of two and to come back again for other issues!”  “What about someone like me who is on disability for a multitude of health problems?  What then?”

#4 – “Treat the patient like a sentient human being instead of a lump of potatoes and you will get intelligent patients.”

#5 – Let the patient ask a few questions ok?   I’d ask more questions if I wasn’t treated like I was a crazy hypochondriac or an idiot every time I did.

Too be sure there were a handful of supportive patient comments…even a few physicians tried to explain themselves…but these folks were quickly shouted down by the mob.

What Does It All Mean For Physicians?  What Can/Should Physicians Do?

Based upon my 20+ years of experience working in health care marketing here’s is what I recommend:

  • Realize that patient satisfaction surveys often do not tell the whole story.  That’s because people who are really dissatisfied will not waste the time telling you.   Rather they will go on to tell 10 other people how bad you are.
  • Evaluate these patient comments in the context of your own practice.  You alone know if any of these comments consistently apply to your practice.   I doubt very much that these patient comments were coming from patients in physician-patient relationships characterized by strong, trusting physician-patient communications.
  • Most of these comments seem to come out of anger at having been disrespected in some way.  I you have patients like this, simply acknowledge that you know this has been a problem in the past, that you are sorry, and will try and do better.  Then really try to improve.
  • Talk to your patients about their experiences in your practice.  Just ask patients how you are doing…and then follow-up with meaningful change.   Don’t ask if you really don’t care.
  • Turn lemons into lemonade.  The fact is that many patients find themselves in sub-optimal physician-patient relationships.   Given the dismal experience everyone is having, why not strive to stand out from the pack by providing an exceptional experience.   It should be relatively easy.

I’ll close with my favorite patient comment:

Doing exactly what your doctor told you to do.  It’s the number 3 killer according to The New England Journal of Medicine and JAMA.”

That’s what I think.  What are your thoughts?