Category Archives: Physician Attitudes

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?