Is The CEO Of The Cleveland Clinic Serious When He Says “No More Passive Patients”?

If a recent blog post by the CEO of the Cleveland Clinic is representative of how health care executives (and physicians) really think about patients – aka consumers –aka people like you and me…we are all in big trouble.  In it Delos Cosgrove, MD, talks about how under health care reform there will be “No more passive patients.”

Here’s my a quote from the post by Delos Cosgrove, MD:

“For too long, healthcare has been something that was done to you. Now it’s going to be something you do for yourself in partnership with your doctor and care giving team. You’ll need to monitor your food input, get exercise, and avoid tobacco. ”

Let’s examine what’s disturbing about comments like this particularly when made by high-profile leaders like Dr. Cosgrove.

First, this statement is factually inaccurate.  Here’s why.  82% of US adults visit their PCP every year at least once a year (often more) for their health.   Think about the trip to the doctor’s office from the patient’s perspective… 1) chances are they have discussed their health problem or concern with family members or friends, 2) they may well have looked up information on their condition to see if it merits a doctor’s visit, 3) they make the appointment, 4) they show up for the appointment and 5) wait in the waiting and exam room thinking about the questions they want to ask their physician.

What about any of this suggests patient passivity?

Second, this statement misrepresents the true nature of the patient passivity of which Dr. Cosgrove speaks.  You see patients (aka people) are socialized by physicians beginning in childhood visits with Mom to the pediatrician to assume a passive sick role.  We are supposed to be passive! Otherwise the doctors gets irritated and ignores or dismisses what we have to say.  While it’s true that patients (even the most empowered among us) ask very few important questions during the typical office exam…the reason isn’t that we are passive.  Rather it’s because we don’t want to be too assertive, confrontational, and argumentative or are simply afraid.

Rather that blaming patients for not being more engaged…why don’t doctors try and become more engaging (e.g., patient-centered) to patients?

Third, patient non-adherence is often not the patients fault…but rather the result of poor communications on the clinician’s part. One recent study found that 20% of medication non-adherence is the direct result of poor physician communication with patients. Poor patient communication skills top the list of complaints people have with their doctor. Poor patient communication is also the leading cause of medical errors, non-adherence and poor patient experiences.

Fourth, how exactly are patients going to learn all the skills necessary to “do everything” for themselves?  The work of Lorig et al. has shown that simply providing patients with information – the “what” of self care – is not enough to change patient health behavior.  Patients also need and want to develop the skills and self efficacy for self care management – the “how” of self care.   Right now for example clinicians spend on average <50 seconds teaching patients how to take a new medication…and we wonder why patients are non-adherent.

Given the poor patient communication skills of physicians today how exactly are patients supposed to learn how to do it all themselves?

Finally, the Dr. Cosgrove reminds us of the kind of paternalistic, physician-directed thinking and communications which has gotten the health care industry into the mess it’s in.

The following statement says it all:

“If your doctor prescribes a medication, preventive strategy, or course of treatment, you’ll want to follow it.”

What if I don’t want the medication or don’t believe it will help me? Why should I be forced to do something I don’t want to do? Will you drop me as a patient?
What happened to the IHI’s Triple Aims?  What about the need to be more patient-centered as called for in Crossing the Quality Chasm and the ACA reform legislation?

I am sorry if I seem to come down hard on Dr. Cosgrove. But my original point remains…too many health care leaders still think and talk like this.  While they may “talk the talk”…employees, patients and physicians all see how such leaders “walk the talk.“  And as Cosgorove’s comments suggest we have a long, long way to go.

I would like to extend an invitation to Dr. Cosgrove and the physicians at the Cleveland Clinic to see just how “patient-centered” their communication skills really are by participating in the Adopt One! Challenge.   You will not only be able to assess the quality of your team’s patient communication skills but also see how their skills compare to industry best practices.

All physicians are invited to participate in the Adopt One! Challenge.

That’s my opinion…what’s yours?

Patient Non-Adherence (Like Engagement) Is A Physician-Patient Communication Challenge – Not A Health Information Technology Challenge

Have you noticed all the articles in the health care press lately touting health information technologies’ ability to increase patient medication adherence?  Smart phone-based apps, Smart pill bottles and Patient Portals are all about trying to get patients to do something (take a medication) which some physician somewhere has deemed to be the right thing for the patient to do.   Some would call this process of generating adherence patient engagement.

Chalk these high-tech patient reminder solutions up to just another well-intentioned but misguided attempt by HIT vendors at patient engagement…one not likely to be met with much long-term success.  Sorry folks.

The fact is that these high-tech solutions, like physicians, still talk about non-adherence as if it is all the patient’s fault.  Come on …you have to admit that’s not a very engaging “message.”   You know…patients don’t fill (refill their prescriptions), patient don’t take their meds are directed, patient forget, and so on.  According to people much smarter than I am about such things, this perspective is outdated.

Many researchers now argue that patient non-adherence is more often the result of ineffective patient communication skills and not “disengaged, lazy or forgetful patients.”  One study showed that 19% of patient non-adherence was attributable to poor physician communication with patients.

It is also worth noting that there are two types of patient non-adherence – intention and unintentional…only one of which is addressed by these high-tech solutions.   In this post I want to focus on the intentionally non-adherent patients (the one not addressed by the reminders) .  After all, only bad or stupid people would intentionally go against something that clearly is their best interest…right?

Wrong.  As it turns out there are lots of legitimate reasons (from the patient’s perspective) for non-adherence.

Here are the main reasons cited in the literature:

• The patient doesn’t agree with the diagnosis necessitating the prescription
• The patient believes the diagnosis but doesn’t think the diagnosis is serious enough to merit taking a new medication prescription
• The patient doesn’t believe in taking medications
• The patient believes the risks associated with the medication outweigh the benefits
• The patient doesn’t believe the medication will work
• The patient can’t afford the medication

Think about your recent physician visits, where your clinician prescribed a new medication.  I’ll bet one or two of the above “reservations” flitted across your mind.  I’ll also bet that your provider never once asked how you felt about taking the prescribed medication.  I’ll even go out on a limb and bet that most of you never mentioned your reservations to your provider either.

Don’t believe me?  Then consider this factoid.  When prescribing a new medication, the average primary care physician spends less than 50 seconds teaching (too strong a word) patient about the medication, e.g. why they need it, how to take it, how much to take, when to take it, indications and contraindications, when to stop and what to do when you stop.  That’s not much time for the physician to say everything that needs to be said (which doesn’t happen).  Nor does it leave time for the patient to say much.

Since most patients are reluctant to interrupt or contradict their clinician, many if not most of the concerns patients have about taking the new medications are never voiced.  Rather, patients just go home and never fill the prescript.

So now help me understand how my patient portal or smart phone app can engage me by implicitly blaming me for not taking my medications.  Or motive me to take my medications  when I don’t believe that they are not necessary or that they may be worse for me than the problem they are intended to solve.

Patient adherence is much more likely to occur when the patient and clinician agree on the basics, e.g., the diagnosis and treatment.  That requires a conversation or two or three.  The goal of effective clinician-patient communication is to resolve such disagreements.  And that is why the solution to patient non-adherence lies in developing the patient-centered communication skills of clinicians…not in trying to cajole patients into using some new app or patient portal that totally ignores their concerns and beliefs.

All together now…patient adherence (and engagement) are a physician-patient communication challenge…not an HIT challenge.

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

Note:  Later this Fall, Mind the Gap will be announcing the Adopt One! Challenge TM. for physicians and their care teams.  The goal of the challenge is to encourage physicians and their care teams to adopt one new patient-centered communication skill within 2014. 

Sign-up to learn more about this one-of-a-kind “Challenge”:

Name(required)

Email(required)

Submit

Δ

Sources:

Koenig, C. J. (2011). Patient Resistance as A in Treatment Decisions. Social Science & Medicine (1982), 72(7), 1105-14.Johnson, J, et al. (2005) Factors Associated with Medication Nonadherence in Patients With COPD. Chest. 128(5).

Wilson, I. et al. (2007). Physician – Patient Communication About Prescription Medication Nonadherence: A 50-State Study of America’s Seniors. Journal of General Internal Medicine. 22(1), 6-12

Johnson, J, et al. (2005) Factors Associated with Medication Nonadherence in Patients With COPD. Chest. 128(5).

Zolnierek, H. et al. (2009) Physician Communication and Patient Adherence to Treatment: A Meta-Analysis. Medical Care. 47(8), 826-834.

Sarkar, U., et al. (2011). Patient-Physicians’ Information Exchange in Outpatient Cardiac Care: Time for a Heart to Heart? Patient Education and Counseling, 85(2), 173-9.

Three Reasons Why Doctors Need To Spend More Time Talking and Listening To Their Patients

Since most physicians probably will not be able to get beyond the first couple of lines of this post without yelling at the monitor…I will get to the 3 reasons…and if you stick with me …I’ll present my case for why they are so important.

1. Your visits will be more productive…and shorter
2. You will be a better diagnostician and a much better doctor
3. Your patients will sing your praises to all their friends and family

Reason #1- Your visits will be more productive…and shorter.

Physician experts argue that the best way to improve productivity and time management during the office visit is by improving the way physicians talk with their patients.  Most of you are probably screaming this is not possible because patients:

• Show up with 3-4 complaints/visit
• Just want a “quick fix “or prescription
• Are unfocused and make rambling opening statements
• Appear totally disinterested and unengaged
•  Won’t do what I tell them

Let’s stipulate that all these arguments are true.

Now suspend your judgment for a moment and consider this.

Where is it that patients are taught how they are supposed to behave when in the presence of their doctor?   Have you ever talked to them about such things?  Do you imagine their previous doctors advised them about such things?  Is there a school people are supposed to go to learn how to talk productively with your doctor?

The fact is that patients aren’t taught these things….ever.  They learn these behaviors through the school of hard knocks.  We have all been socialized from childhood to assume the “passive, subservient “sick role” in the presence of our doctors.  That’s not anyone’s fault…it is just the reality of the way health care have evolved.

Now imagine there was a school for patients where they learned things like how the medical interview is structured, what patients can do to prepare for their visit, why time is limited, how to make the best use of the time available, and so on. Then imagine you reinforcing these “learning” at each of your patient visits through repetition, encouragement, and changes in your communication behavior.  In relatively short order patients would begin to “reciprocate“your behavior with the behavior you desire…and viola you have set the stage for shorter, more productive (and organized visits).

Reason #2- You will be a better diagnostician and a much better doctor

Sir William Osler, a founding father of modern medicine, once said “Listen to the patient – they will tell you what’s wrong.”  Numerous other luminaries have said that a doctor’s patient communication skills (talking and listening) are as important as their clinical skills and knowledge.  Talking and listening is how physicians arrive at the correct diagnosis and treatment.  Strong patient communication skills are needed to engage and activate patients.   Talking and listening is therapeutic and to patients.

Some patients will get better with a commonsense explanation of their difficulties; others for some unknown reason remain unchanged. Some patients will respond to friendliness on the part of their physician; others require a more formal attitude. Some can establish rapport with their physician even though they appreciate his intellectual shortcomings.       M. Balint 1957

As physicians come to rely upon EMRs, there is a risk that the computer will come between the patient and physician.  This will result in even less “talking and listening” between patients and physicians, more   disengaged patients, and even poorer outcomes.

Reason #3 – Your patients will sing your praises to all their friends and family  

Let’s face it…with few exceptions…most physicians’ patient communication skills need improvement.   Poor physician communications skills top the list of complaints patients have about their doctor, i.e., physicians that don’t listen, physicians that ignore what they have to say, physicians that don’t provide enough information, and so on.    Many of us have never been exposed to a physician with superlative patient communication skills.   We don’t know what we are missing.

Given how “average” most physician communication skills are…. imagine how easy it would be for a physician with good communication skills (patient-centered) to compete with other physicians in your group or local market.  Soon such physicians will also be rewarded for their ability to create exceptional patient experiences simply by virtue of their ability to talk and listen to patients.

Is what I talk about here counter intuitive…yes.  Does it requires some out of the box thinking…definitely.   Do I have a solution for helping patients and physicians accomplish what I talk about here.   Absolutely.   Contact me to learn more.

That’s my opinion…what’s yours?

 Sources:

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?  Center for Study of Health System Change. Issue Brief. April 2010.

Balint, M. The doctor, his patient and the illness, Inter-national Universities Press, New York, 1957.

Rosenow, E., Patients’ Understanding of and Compliance With Medications:  The Sixth Vital Sign. Mayo Clinic Proceedings. August 2005.

Cene, C., et al. The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication. Journal of General Internal Medicine. July 3, 2009. 24(9):1057–64.

Patient-Centered Communications – Does “Lack of Time” Justify Physician Reluctance To Adopt It?

I talk with lot of physicians about the need to improve the quality of communications between physicians and patients.   Regular followers of my work will know that I am an advocate for the adoption of patient-centered communication skills by the physician and provider community.

Physicians with whom I talk seldom disagree as to the need for better physician-patient communications.   They know that physician communication skills top the list of patient complaints about their physicians, i.e., my doctor doesn’t listen,” “my doctor ignores me,” and so on.   Rather, they simply dismiss the subject out of hand as being impractical due to a “lack of time” on the part of most physicians.

I can understand their perspective.   Primary care physicians in particular are faced with sicker, more demanding patients, increased payer and regulatory requirements, and are constantly pressured to see more patients.

Yet physician waiting rooms and exam rooms are full of engaged patients (otherwise they wouldn’t be there) who have nothing to do but read outdated magazine.

What would happen if physicians actually put patients to work during wait time?

Here’s what I mean…

What if physicians integrated patient “wait time” into the office visit by:

• Talking to patients (via printed handouts, electronic media, patient portals, etc.) about their evolving new role (and that of the physician and other providers) under health reform.  Contrary to the popular press which touts the empowered patient, most of us still assume the traditional “sick role” during the office visit.  The sick role is characterized by patient passivity, limited information sharing, and minimal question-asking.

• Teaching people while waiting how (using the same media as above) to become “better patients.”   I recall an article where physicians were asked 5 things they wished their patients knew.  At the top of the physicians’ “wish list” was a desire for patient’s to be better prepared and more focused during the visit.  The point being that more prepared patients would help the physician get to the correct diagnosis and treatment plan faster

All of us, beginning in childhood, are socialized into playing the sick role when interacting with physicians.   Just as chronic disease patients needing to develop self care skills and confidence in their self care skills…patients need to be taught skills for (and develop confidence in) how to more effectively talk to and collaborate with their physicians.

•  Laying out a game plan (over a series of visits) for teaching new and established patients when and how to effectively contribute to the medical interview (exam).   Given an average wait time of 22 minutes per primary care visit, it is not reasonable to assume that patients can be taught the above in the course of 1 or 2 visits.  But patients with chronic conditions often visit their PCP 6-8 times a year.  This would afford plenty of time (2-3 hours a year) for physicians to teach (and practice) individual skills to patients (i.e., agenda setting and prioritization, question asking skills, self-care management skills, new medication considerations, etc.).   By reinforcing lessons learned by patients over the course of several visits, it is reasonable to expect that both patient and physician will become more proficient in the use of their time together.

How Exactly Will Better Physician-Patient Communication Lead To More Productive Visits?

Research has consistently shown that patient-centered communications (versus traditional physician-directed communications) can result in more productive office visits as measured by 1)  the amount/quality of information shared by patients, 2) the number of questions asked by patients, and 3)  and the level of patient retention of information shared by physicians.

These same studies show that the adoption of patient-centered communications adds little if any more time to the length of office visits.  Once patients and physicians become proficient in the use of patient-centered communications methods,  physicians may well be able to do more during the visit but in less time.  Here are some of the techniques  characteristic of patient-centered  communications associated with increased visit productivity:

•  Concise visit agenda setting and prioritization wherein both physician and patient  agreed to what can be discussed within the time allowed.  This  also eliminates  the “oh by the way” introduction of last-minute patient agenda items that can occur at the end of the visit.

•  More concise  sharing of relevant information by the patient.

• Greater physician-patient agreement as to the diagnosis and treatment.

• More collaborative decision-making

•  More information retention by patients (how to take new Rx, etc.)

• Greater patient adherence

That’s my opinion…what’s yours?

Related Post:

Do Medical Home Physician Really Communicate Any Better Than Non-PCMH Physicians?

Six Seconds To More Effective Physician-Patient Communications

Sources:

Politi, M. C., & Street, R. L. (2011). The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17(4), 579-84.

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine : JABFM, 24(3), 229-39. doi:10.3122/jabfm.2011.03.100170

Marvel, K, Epstein, R, Flowers, K, Beckman H.  Soliciting the Patient’s Agenda, Have We Improved?  JAMA. 1999;281:283-287.

Will Information Technology Squeeze Physicians Out Of Their Central Role In Health Care?

Not by a long shot if patients have anything to say about it.

Turns out that while most of us (90%) would like be able to make a doctor’s appointment and check lab results online….85% of us also still want the option of be able to talk to our physician face-to-face.  These are the finding from a recent 2012 study conducted by Accenture.

These finding will no doubt come as a surprise to many of those high tech newcomers to health care looking to make physician and trips to the doctor’s office a thing of the past with some new “killer health app.” You wouldn’t believe how little many of these software and app developers know about how health care works.  Then again, if you have looked at some of the EMRs, PHRs, and patient portals solutions being hyped out there maybe you could believe it.

What is significant about the finding cited above is that patients at least get it.  They understand the value of a having a relationship with a knowledgeable physician or similar health care provider.  In spite of, and for some, because of the plethora of health information outlets on the web people want to know that they always have access to your family doc when the chips are down.

What newbie software engineers and  smart phone app developers fail to understand is that health care is fundamentally about social interactions…not technical data transactions like depositing a check or making an airline reservation.

Here’s what I mean…based upon some 20+ years working in health care:

• From the get go…going back to Hippocrates…health and health care delivery has been about the relationships between people starting with the  physician-patient.relationship.

• The most important diagnostic tool a physician has at their disposal is not a smart phone…but their ability to talk with and observe  patients verbal and non-verbal behavior.

•  “Talk” is not only how physicians diagnose problems and recommend the appropriate treatments…talk is also how patients are able to engage in the health care.  Perhaps the most overlooked aspect of talk (and touch) during the medical exam is the therapeutic benefits patients derive from being able to express heart-felt fears and concerns to someone who hopefully cares.

The unfulfilled promises of so much of health information technology today (like Electronic Medical Records, Personal Health Records, and Patient Portals), with some notable exceptions like Kaiser, Group Health and the VA, can be traced directly back to developers not understanding that their job is to enable physician-patient relationships not get in their way or try and replace them.

Check out this related post – Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

I don’t consider myself a Luddite when it comes to health information technology…nor would I put most physicians in this category.  The health industry is going through massive change, and unfortunately in such time, there is also a lot of false starts and waste that comes from ill conceived HIT solutions.  I suspect that tech vendors that take the time to learn the business that is health care, and commit themselves to improving the physician-patient relationship…will do just fine.

 The Take Away…

The physician-patient relationship remains paramount for us patients.  Yes there are problems…yes physicians and patient need to learn to do a better job communicating with one another.  But when everything is said and done…when the chips are down…we don’t want to be forced to diagnose and treat ourselves.  We want to be able to see and talk with our doctor when we want.  And honoring the patient’s perspective after all is what patient-centered care is all about right?

And oh by the way…we still want the convenience of being able to go online to schedule an appointment and check out lab tests.

That’s my opinion…what’s yours?

Sources:

Squeezing out the doctor -The role of physicians at the center of health care is under pressure.  The Economist. June 2012.

Could mobile apps replace doctors?  KevinMD.com