Tag Archives: depression

The 10 Commandments of Patient Engagement

As a patient, care giver, researcher and a human being, here ‘s my “take” on what physicians and hospitals, and all the entities that work with them like health plans, ACOs , etc. need to do to effectively increase patient engagement in 2013 and beyond.

Tweet to Hospitals

  1. Act like you are glad to see them (patients) and have time for them… no matter how busy you really are
  2. Say something relevant to suggest that you actually remember who they are – don’t get this one wrong
  3. Ask how they have been since their last appointment and what brings them in to see you today
  4. Probe for the patient’s ideas as to the cause of their complaints and what they would like you to do for them
  5. Listen to what the patient has to say without interruption – ask clarifying questions
  6. Tell the patient what you recommend doing in the way of tests, treatments and new medications…and explain why you are making those recommendations – ask if that’s ok with the patient…if it’s not ok find out why
  7. Pay attention to patient-initiated cues (loss of a job or loved one, sighing…) – they probably are a call for help
  8. Express empathy and support to patients
  9. Find out what your patient’s health goals are and what steps they believe they can take to achieve them, e.g.,  care planning
  10. Ask about or suggest ways that you and your team can support  patients’ long-term care plans

AdoptOneBigButtonThe challenge most physicians and other providers face is not one of how to engage patients.  Most of us patients (people) are already engaged to the extent we:

  • went to the bother of calling your staff to make an appointment (never a pleasant experience)
  • took time off work to travel to your office
  • wait an average of 24 minutes to see you
  • sit for 24 minutes thinking about what we want to talk with you about and how you are too busy to listen

Rather the challenge for providers is how to be engaging to patients.  Health care after all is an intensely personal and social interaction between human beings.   My apology to all the health information technology folks who suggest EMRs, web portals and smart phone health apps are the best way to engage patients (they are not).  I for one am convinced that people would be more engaged in the care (they way providers expect and prefer) if only providers were more engaging…lack of time and reimbursement notwithstanding.

I am sure I have missed something so please feel free to add to the list.

Check out more posts on Patient Engagement:

Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

 Patients Are Often More Engaged In Their Health Than Providers Think

Patent Portals. PHRs, & On-line Decision-Support Tools Alone Will Not Lead To Greater Patient Engagement

Patient Engagement  Infographic

Accountable Care, Medical Homes and Employers – Do Physicians “Get” the Concept of Providing Value?

[tweetmeme source=”Healthmessaging” only_single=false]Ok…here’s a brain teaser.  What medical condition is the most costly to employers?  I’ll give you a hint.  It is also a medical condition that is likely to go unrecognized and undiagnosed by primary care physicians.
If you guessed depression you are correct.  If you mentioned obesity you get a gold start since that comes in right behind depression for both criteria…at least in terms of cost and the undiagnosed part.
Four out of every ten people at work or sitting in the doctor’s waiting room suffer from moderate to severe depression.  Prevalence rates for depression are highest among women and older patients with chronic conditions.  Yet despite its high prevalence and costly nature, depression is significantly under-diagnosed (<50%) and under-treated by physicians.

For employers, the cost of depression cost far exceeds the direct costs associated with its diagnosis and treatment    As the graphic above indicates, the cost of lost productivity for on the job depressed workers (Presenteeism) and lost time for depressed workers that are absent from the job (Absenteeism) far exceed the cost of cost of treatment (medical and medication cost).
Since I first addressed depression in an earlier post, I have identified what I believe to be the central reason why depression continues to go undiagnosed and untreated in primary care.   The reason is that physicians are uncomfortable talking to patients about it, e.g., psychosocial issues.   Even when patients provide “cues” suggesting evidence of depression in the opening statement, i.e., I have been sleeping well, I haven’t been myself lately, etc., evidence suggests that physicians are likely to simply not recognize or ignore the cues.   Physicians themselves admit that their training predisposes them to be more comfortable dealing with biomedical versus psychosocial issues.
Now think Accountable Care Organizations and Medical Homes.  Both of these concepts, one a payment reform model and the other a delivery model, are predicated upon the notion that the medical services offered have real value to the payer, e.g., employer or health plan.  But what kind of value are primary care physicians providing when they fail to diagnose and treat the biggest problem facing the people that ultimately pay for their service?
Tying this all back to physician-patient communications, physicians need to begin employing more patient-centered communication techniques in their dealing with patients.  In particular, physicians need to do a better job listening to what their patients are trying to tell you, even if it is outside your comfort zone.   At the very least you can refer the patient to a counselor for help.  In so doing you will be clearly helping the patient and adding real value to the people who ultimately pay for your valuable service.
That’s what I think.  What are your thoughts?
Sherman, B., et al. Patient-Centered Medical Home and Employer Metrics. Patient- Centered Primary Care Collaborative

What Do Doctors Know About The People In Their Waiting Room? – The Scourge of Unemployment

[tweetmeme source=”Healthmessaging” only_single=false]Anyone has ever been down-sized or otherwise lost a job knows the feelings.   Personal loss (social, financial and routine),  self doubt, and in some cases fear of what the future will bring.   Unemployment and its cousin under employment are not subjects that a lot of people are comfortable bringing up in polite conversation…even with their doctor.

Given today’s tough economic environment, chances are that 15% to 20% of the people sitting in most doctors’ waiting rooms are out of work.  Do you know who they are?

You should.

Losing a job is a highly stressful event.  For most employed adults, work is a central part of one’s life and identity and a major source of income.  While job loss affects people differently, research suggests that loss of a job affects how many people feel – emotionally and physically.  Job loss, as well as job insecurity, has been linked to increased mental distress (depression) and physiologic responses such as a weakening of the immune system, increase inflammatory response which is associated with cardiovascular disease as well as an increase in blood pressure.  Depression is also correlated with more physician visits, medical tests, RX medications, hospitalizations and decreased adherence among patients.

As I pointed out in an earlier post:

It costs twice as much to treat a patient with depression ($4,780) as it does to treat a patient without depression ($2,794).

The solution?

Ask your patients what’s going on in their life, including current or potential job loss and problems at home.  Understanding the context of the patient’s life will allow you to provide true patient centered care to patients that desperately need and want your help.

Addendum:  For more information check out the following NYT article:

When Unemployed Means Unhealthy Too


Cohen, F., et al. Immune Function Declines With Unemployment and Recovers After Stressor Termination. Psychosomatic Medicine 69:225–234 (2007).

Depression Among High Utilizers of Medical Care.  Pearson et al.  Journal of General Internal Medicine. 1999: 14:461-468.

The Cost of Poor Physician-Patient Communication

[tweetmeme source=”Healthmessaging” only_single=false]The Missed or Incomplete Diagnosis – Depression

Depression is one of those conditions that patients, particularly men and certain ethnic groups, are reluctant to bring up on their own.  Unfortunately  most physicians also seem reluctant to bring up the subject of depression with their patients.

Depression is a big problem these days.   Four out of every ten patients in  primary care waiting room suffer from moderate to severe depression.  Prevalence rates for depression are highest among women and older patients with chronic conditions.

It costs twice as much to treat a patient with depression ($4,780) as it does to treat a patient without depression ($2,794).  That’s because patients suffering from depression generate more physician visits, medical tests, RX medications and hospitalizations.

Despite its high prevalence and costly nature (medically and socially), depression is significantly under-diagnosed (<50%) and under-treated with medications (50% not prescribed) and/or counseling (90% never referred).

Role of Communication in the Detection and Treatment of Depression

Reasons why most primary care physicians spend little time talking about depression with patients include;  lack of time, competing priorities, perception that the patient will be resistance/non-adherent to therapy, a lack of confidence in treatment efficacy, and uncertainty how best to treat depression.  Whatever the reason, very few physicians 1) routinely ask patients (even high risk ones) if they are depressed, i.e., feel down, loss of interest, etc.  and 2) spend much time educating patients about the condition or treatment options.

On a personal note, during the last six years of my wife’s lung cancer treatment she was never once asked about her emotional or mental health status by her treating or primary physician.

If the subject of depression does come up, it is mostly likely raised by the patient.   Even then patients probably bring it up only when they are in real pain.   Most patients would probably just as soon avoid the subject.   Up to 40% of U.S. adults, particularly older folks, still believe that depression is a personal character flaw and not a biomedical condition.   Many of these people are resistant to a diagnosis of depression from their doctor.   Some believe that anti-depressants are ineffective and addictive, while others simply don’t like taking pills of any kind or cannot afford the medication.

So How can Doctors do a Better Job Talking with Patients about Depression?

  • Screen all patients for depression not just Medicare patients at their mandated initial preventive exam
  • Assess patient attitudes and belief about depression and its causes
  • Ask the patient if they are depressed
  • Help patients understand that depression is not a personal problem but a real biomedical condition that can be effectively treated
  • Provide anticipatory depression guidance for older patients and patients with chronic conditions
  • Prescribe treatments and therapies that are in alignment with the patient’s desires and expectations.
  • Ask patients if they can afford prescribed medication
  • Teach patients how to take medications and what do before stopping their medications


Depression Among High Utilizers of Medical Care.  Pearson et al.  Journal of General Internal Medicine. 1999: 14:461-468.

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives.  Henke et al.  Implementation Science 2008, 3:40.

Attitudes to depression and its treatment in primary care.  Weich et al.  Psychological Medicine, 2007, 37, 1239–1248.