Tag Archives: Accountable care organization

Shared Decision Making – Not Ready For Prime Time – Nor Evidently Is Patient-Centered Care

When it comes to delivering truly patient-centered care…how are providers supposed to know when they have “arrived”?   According to Michael Berry, MD, President of the Informed Medical Decisions Foundation, providers will know they have achieved the “pinnacle of patient-centered care” when they routinely engage their patients in shared decision-making (SDM).

Pinnicle of patient-centered communications

In theory, shared decision-making (aka collaborative decision-making) is what is supposed to happen between patients and their doctors when faced with a difficult choice.  Clinicians engaging in shared decision-making would provide patients with information pertaining to the need for the treatment, the available options, as well as the benefits and risks.  But patient-centered clinicians would also do something else. They would attempt to work with patients to arrive at a decision they could both live with.  A kind of “shared mind” that takes into consideration their clinical perspective as well as the patient’s perspective – their preferences, needs, and values (which ideally have been captured over the course of the patient-provider relationship).

The Problem Is That Most Physicians Don’t Really Engage Patients In Either Shared Decision Making  

 A 2003 study surveyed U.S. physicians (N=1,217) preferences and actual practices regarding shared decision-making.  Table 1 presents a summary of findings from this study.

Table 1

Decision Making Style

What Physicians Preferred

What Physicians Actually Do

Shared decision-making

58%

37%

Physician-dominant decision-making

28%

43%

No patient involvement

9%

13%

Patient dominant decision-making

5%

7%

While most physicians in the study may philosophically believe in and prefer shared decision-making…as this data indicates that is not what most physicians in the study reported actually doing.  In fact, 56% of physicians reported that they actually engaged in decision-making that was physician-dominated (with some patient involvement) or totally physician-dominated decision-making behavior (absent any patient involvement).

The Barriers To Shared Decision Making?

The barriers to SDM include the usual suspects:

  •  Lack of time during the visit
  • Not having access to the right decision support aids tools and training their use
  • Physician attitudes about patient’s willingness to engage in shared decision-making
  • Provider reliance upon a physician-directed (versus patient-centered) style of communicating with patients

AdoptOneBigButtonThe Take Away – Why Shared Decision Making Matters

  •  SDM is the right thing to do – the benefits associated with SDM include better outcomes, lower utilization and cost, lower malpractice risk and enhanced patient trust and satisfaction
  •  SDM is a great way to be engaging to patients – it is a way to get patients involved in their care in a meaningful way they can relate to.
  • To be eligible to participate in Medicare’s Shared Savings Program, Accountable Care Organizations must implement processes to promote patient engagement, including shared decision-making.

As readers of Mind the Gap know, I am a proponent of the adoption of patient-centered communication by providers, beginning with primary care.   Shared decision-making has rightly been identified as a leading indicator when it comes to assessing the “patient-centeredness’ of a physician practice.   So before you go around telling everyone how patient-centered your provider teams are first do a reality check.  Because if you aren’t regularly engaging your patients in shared decision making you are not there yet.

That’s my opinion…what’s your?

Sources:

Heisler, M. et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illness. 2009 Sep;5(3):165-76

Street, R. et al  The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice 17 (2011) 579–584.

Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.

The Truth About Those High Patient Satisfaction Scores For Doctor-Patient Communication

We have all seen them.  You know…those charts showing us how satisfied patients are with the way their doctors communicate.  Did your doctor listen to you?  Did you doctor explain things in a way you could understand?

Funny thing about these charts, whether they be for hospitals or doctor’s offices,  1) they never seem to change from year to year – 80% – 90% of doctors communicate well with patients and 2) patients consistently rate their doctors’ communication skills as high.

Doctor-Pt Communication GraphThe problem with satisfaction data related to doctor-patient communication is that, at face value, it simply doesn’t correlate with other published data on the subject. There is a “disconnect” between what patients say in satisfaction surveys and what happens in actual practice.

Here’s what I mean.

Recent studies of hospitalized patients have shown that:

  • 68% to 85.3% of patients could not name the physician in charge of their care.
  • 43% to 58% of patients did not know the reason for their hospital admission.
  • 67% of patients received a new medication while hospitalized… yet 25% of these patients were unaware that they were given a new medication.
  • 90% of patients given a new medication reported never being told of adverse effects of the new medication.
  • 38% of patients were not aware of planned tests for the day.

The amazing thing was that majority of these patients (up to 58% in one study) said that their doctors always explained things in ways they could understand!

The same types of “disconnects” show up in satisfaction surveys done in doctor’s offices.   Studies of primary care physicians show that:

  • Patients are interrupted by their physicians within the first 18 seconds of their opening statement during office visits
  • Physicians and patients agree on the reason for the office visit only 50% to 70% of the time
  • Physician underestimate the patient’s desire for health information in 65% of the time
  • 50% of patients walk out of their doctor’s office not understanding what their doctor told them to do
  • Patient are not asked if they have any questions in up to 50% of office visits

Again, I am sure these same patients praised their physicians’ communication skills on one or another satisfaction survey.

So What Explains The “Disconnect” Between How Physicians Actually Talk To Patients…And Patient Satisfaction?

Today’s high patient satisfaction scores are an artifact of the way we (when we become patients) have been “socialized” when it comes to a trip to the doctor’s office. Here’s what I mean.

1) Beginning with childhood, we have all been socialized to assume the “sick role” when seeing the doctor.  From our initial visits to the pediatrician with our Mom we quickly learned that the doctor is in charge and that our Mom’s role (and ours) is to sit passive by while the doctor does most of the talking.  Notwithstanding all the “talk” about how empowered patients are today, most of us still assume the “sick role” when seeing our doctor.

2) Accustomed as most of us today are to the sick role, and accepting the fact that physicians are very busy, we are not surprised when doctors don’t seem to listen to us or interrupt us. We are not surprised that they don’t have time for all our questions or frown on us bringing in lists of things we have researched on the internet. This for most patients is what we are used to…it is what we are satisfied with given that most of us have don’t another or better point of comparison, i.e., a highly patient-centered physician.

3) Consistent with the sick role, we as patients “tend to be overly patient.” We “grant our doctors the benefit of every doubt.” Most of us begrudgingly put up with poor service, inconvenience, and unnecessary discomforts, until we can’t overlook it anymore. Even then we are reluctant to take our busy, overburdened doctor to task for these shortcomings by giving them a low score on a satisfaction survey.

The Take Away?

Hospital, medical group, IPA and ACO executives need to:

  • Be cautious about putting too much credence in patient ratings of physician communication skills. “One can assume that the quality of care is actually worse than surveys of patient satisfaction would seem to show” to quote Avedis Donabedian, MD, an old professor of mine.
  • Recognize that high quality, patient-centered communications (the gold standard for physician-patient communications) is essential to patient engagement, optimal patient outcomes and great patient experiences. If physician communication were as great as patients satisfaction surveys suggest, we wouldn’t be having the problems we are with low levels of patient engagement and non-adherence.
  • Benchmark the patient centered communication skills of the primary care physicians on their staff (employed and otherwise) and compare the findings against established best practices.
  • Take the additional reimbursement you will get from CMS for your patient high satisfaction scores and invest it back into improving the patient-centered communication skills of their physicians and patients. That is, if you don’t have to pay a penalty to CMS for high re-admission rates – which by the way is another by-product of poor physician-patient communication.

Remember that there is perhaps no better, more cost-effective way to differentiate your physicians (and your brand) these days than to have physicians on staff who really know how to listen and relate to patients.

That’s my opinion…what’s your?

Sources:

Makaryus, A. et al. Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Mayo Clinic Proceedings. 2005;80(8):991-994

Boland, B. et al. Patient-Physician Agreement on Reasons for Ambulatory General Medical Examinations. Mayo Clinic Proceedings, 1998;73(1), 109-117.

O’Leary, K. et al. Hospitalized Patients’ Understanding of Their Plan of Care. Mayo Clinic Proceedings 2010;85(1):47-52.

Olson, D. et al. Communication Discrepancies Between Physicians and Hospitalized Patients. Archives of Internal Medicine. 2010;170(15):1302-1307