Tag Archives: medication adherence

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.

AdoptOneBigButtonFourth, 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?

Ten Reasons Why Hospitals, Health Plans And Medical Groups Should Invest In Developing Their Physicians’ Patient-Centered Communication Skills

“Patients are, in fact, overly patient; they put up with unnecessary discomforts and grant their doctors the benefit of every doubt, until deficiencies in care are too manifest to be overlooked.  Generally speaking, one can assume that the quality of care is, actually, worse than surveys of patient satisfaction would seem to show.  Patients need to be taught to be less patient, more critical, more assertive.”

Avedis Donabedian, MD.   Father of Health Care Quality

Black Woman and DoctorIt’s no secret that poor communication tops the list of patient complaints about their physicians.  Who hasn’t heard a physician or an enabling administrator say that they “don’t have time to talk to patients” or that they “don’t get paid for talking to patients.”  While understandable, that kind of a response seems to demean the interpersonal exchange which is the very essence of the physician-patient relationship.

Contrary to what most people think, the quality of a physician’s patient communication skills impacts far more than the patient experience.   The quality of your physicians’ patient communication skills drives the quality of the patient’s diagnosis, treatment, outcome and cost.   And that my friends should get your attention.

If 30+ years of evidence is to be believed, there is a practicable solution to today’s physician-patient communication funk everyone finds themselves in.   It’s called patient-centered communications

Here are 10 evidence-based reasons why providers and payers should go beyond useless global measures of patient communication and give serious thought to assessing and improving their physicians’ patient-centered communication skills.

  1.  Improve visit productivity – collaborative setting of a visit agenda and negotiation of visit expectations by patient and physician have been show as a way to reduce the “oh by the way” comments at the end of the visit and to allow more to be accomplished often in less time.  1
  2. Improve the patient experience – the duration of the visit is not nearly as important to patients as the quality of time spent face-to-face with the physician.  Visits in which the physician invites patient participation and makes the patient feel heard and understood produce higher satisfaction and experience scores. 1
  3. Increase patient engagement – patients come to physicians for a reason(s).  They are already engaged otherwise they wouldn’t be there.  Patient-centered physicians solicit the patient’s reasons for the visit, their ideas about what’s wrong and their thoughts regarding what they want the physician to do.   It helps eliminate guessing and unfulfilled patient expectations.
  4. Improve patient adherence –  “Patient beliefs about medication were more powerful predictors of adherence than their clinical and socio-demographic factors, accounting for 19% of the explained variance in adherence. ”  By understanding where the patient is coming from physicians can avoid wasting time recommending treatments which patients will not adhere to, i.e., prescribing a new Rx when patient would prefer life style modifications. 2
  5. Fewer requests for expensive tests – strong physician-patient relationships characterized by effective patient-centered communication skills report higher levels of patient trust in the doctor and lower levels of patient requests for expensive diagnostic tests commonly found in physician-patient relationships reporting lower levels of patient trust in physician. 3
  6. Fewer ER visits and hospital readmissions – patients in strong patient-centered physician relationships are more likely to engage in the kinds of self care management behaviors which preclude ER visits and rehospitalizations.  3
  7. Better patient outcomes – Chronic disease patients of physicians with strong patient-centered communication skills are consistently found in studies to report better A1C scores, better controlled hypertension and asthma, and so on. 4
  8. Reduce malpractice risk – The majority of malpractice claims involve some form of communication breakdown between physician and patient.   Patient-centered physician-patient relationships are characterized by a high degree of relevant and timely information exchange which greatly reduces the risk of physician-patient communication errors. 5
  9. Reduce disparities in care – The evidence shows that physicians tend to be more paternalistic and directive when talking with ethnic patients, including sharing less information, compared to when communicating with white patients. 6
  10. Increased reimbursement – CMS and many commercial payers now offer incentive payments for outcomes linked to patient-centered communications. i.e., patient experience, reduced ER visits and hospital readmissions, use of generic vs. brand drugs, lower levels of expensive diagnostic tests, etc.

Note:  Later this Summer, Mind the Gap will be organizing a communication challenge called Adopt One! TM.   The goal of the event will be to challenge physicians and their care teams to adopt one new patient-centered communication skill within the next 12 months.

As part of the Adopt One! Challenge physicians and their care teams will have the opportunity to sign up for a free evaluation of their patient-centered communication skills, have their skills benchmarked against best practices and  receive a report detailing their findings and recommended steps for improvement. 

 Sources:

1        Dugdale, D. C., Epstein, R., & Pantilat, S. Z.  Time and the patient-physician relationship. Journal of General Internal Medicine, 14 Suppl 1, S34-40.  1999.

2       Horne, R., & Weinman, J.  Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness.  Journal of Psychosomatic Research, Vol. 47, No. 6, pp. 555–567, 1999.

3        Thom, D. H., Hall, M. a., & Pawlson, L. G. (2004). Measuring Patients’ Trust In Physicians When Assessing Quality Of Care. Health Affairs, 23(4), 124-132.

4       Stewart, M. . et al. (2000). The Impact of Patient-Centered Care on Outcomes. Journal of Family Practice, 49(No. 9), 1-9.

5        Levinson, W., Roter, D. L., Mullooly, J. P., Dull, V. T., & Frankel, R. M. (1997). Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA : the Journal of the American Medical Association, 277(7), 553-9.

6       Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. a. (2004). Patient race/ethnicity and quality of patient-physician communication during medical visits. American journal of public health, 94(12), 2084-90.

Physicians With High Productivity And Satisfaction Scores Employ Strong Patient-Centered Communication Skills

People are forever telling me that I am wasting my time talking to providers about the need to improve their patient communication skills.  Naysayers typically cite one of the following reasons for why things will never change:

Reason 1 – Every physician thinks they already have good patient communication skills.

Reason 2 – Physicians don’t get paid to talk to patients

Reason 3 – Physicians don’t have time to talk to patients

Reason 1 is relatively easy to debunk. After all, if all physicians were really such good communicators:

  • poor communications skills wouldn’t consistently top the list of patient complaints about physicians
  • patient non-adherence wouldn’t be so high since physician and patients would always agree on what is wrong and what needs to be done
  • patients would not be walking out of their doctor’s office not understanding what they were told
  • patients would not experience so many communication-related medical errors

Reason 2 requires a little straightforward logic:

Since physicians are paid to diagnose and treat patients presenting problems…and the accuracy of their diagnosis and treatment depends upon their physicians’ ability to elicit and listen to the patient’s story…then indeed physicians are already being paid to talk to patients.

Productivity QuoteReason 3 (physicians don’t have time) has always been hard to address. That is until now.

Most us tend to think about physician time on a zero sum basis.  Take the office visit for example.  Providers will argue that they either spend more time trying to be patient-centered (associated with great patient experiences) or they can use less time to diagnose and treat patients the way they have always done – but no way can they do both at the same time.

A recent published study conducted by HealthPartners in Minneapolis suggests that physician time is not a zero sum game – that providers can in fact be productive while at the same time creating a satisfying patient experience.

Individual productivity and patient experience scores were calculated and plotted for 22 HealthPartners physicians using a scatter diagram like that shown in Figure 1 (for demonstration purposes only). What the study found was that a relatively equal number of physicians fell into each of 4 quadrants – strong productivity/strong satisfaction, strong productivity/weak satisfaction, weak productivity/strong satisfaction and weak productivity/weak satisfaction.

Figure 1Productivity-Satisfaction

The researchers then looked to explain the difference between physicians in each of the quadrants. They ended up identifying a set of “behaviors and characteristics” to help explain why some physicians had strong productivity/strong satisfaction scores while others did not.

Physicians in the strong productivity/strong satisfaction quadrant exhibited the following behaviors and characteristics:

  • Focused on teaching and explanations
  • Conveys warmth from the start
  • Well-planned flow of visit with focus on patient’s agenda
  • Controlled script with clear parts
  • Extremely personable—connects with every patient
  • Always looking for buy-in from the patient that s/he fully understands
  • Recap the history: “I read your chart …”
  • Confident but not arrogant
  • Finishes dictation and coding each day
  • Clinic staff enters orders and prepares after-visit summary

Physicians in the weak productivity/weak satisfaction quadrant exhibited the following behaviors and characteristics:

  • Lack of “being there” emotionally
  • Lack of smiling
  • Abrupt actions
  • Behavior changes when not interested in the “case”
  • Patients kept waiting and wondering
  • No handshake
  • Sense of interrogating to get a diagnosis
  • No attempt to match the patient’s energy

What struck me about these lists was that were dominated by the presence (strong productivity/strong satisfaction) or absence (weak productivity/weak satisfaction) of communication-related “behaviors and characteristics.”

Perhaps not so surprisingly, the behaviors and characteristics of physicians in the strong productivity/strong satisfaction are consistent with those traits commonly associated with a patient-centered style of communications. This evidence belies the conventional belief among physicians that they will be less productive (rather than more productive) by adopting a patient-centered style of communications with their patients.

Based upon the evidence, HealthPartners has since gone on to provide its physicians with useful guidelines for how to improve their productivity and patient experience scores.

Take Aways Physicians and practice managers need to seriously reexamine:

  1. their assumptions about the value of and barriers to improving their patient communication skills
  2. the evidence in support of the adoption patient-centered communications skills and styles

Physicians and managers should consider assessing the quality and effectiveness of their existing patient communication skills. The last time most physicians focused on their patient communication skills was back in medical school.

Implement interventions and guidelines designed to improve the patient-centered communication skills of physicians and their care teams.

That’s what I think…what’s your opinion?

Sources:

Boffeli, T., et al. Patient Experience and Physician Productivity: Debunking the Mythical Divide at HealthPartners Clinics. The Permanente Journal/ Fall 2012/ Volume 16 No. 4.

Patient Activation Is Only Half The Solution – Physicians Need To Be Activated As Well

Not long ago Nick Dawson, a friend and fellow blogger, paid me the compliment of saying I had inspired a post of his.   Well Nick now you have inspired me…and this post is the result.

Regarding the February Health Affairs edition on Patient Engagement the and follow-on Washington D.C. briefing, Nick writes:

Personally, I was disheartened by some word choices. Implying patients need to be activated suggests patients are passive and something has to be done to them in order for them to care about their health and interactions with healthcare providers. That misses the mark.

What about physician activation? … We should be helping health systems and providers find ways to reduce the stress and fear for patients who are already engaged.

Nick is right. 

The “Belle of the Health Affairs Ball” based on the social media coverage was Judith Hibbard’s interesting work linking health care costs to a person’s level of health activation.   While Dr. Hibbard takes pains to differentiate “activation” from “engagement,” most people are quick to conflate the two.  (Patient-centered communication bears a close resemblance to patient activation as well.)  Nick’s point is that focusing just on what the patient brings to the party in terms of their “knowledge, skills and confidence” is only half the problem.

What about physician activation?  Where in the Health Affairs special, or anywhere else for that matter, are discussions about the need to make sure that physicians (and other clinicians) have the knowledge, skills and confidence to effectively manage all the “already engaged” patients among us?

It Can’t Just Be About Fixing Patient Behavior

For too long, the focus among health care thought leaders has been all about fixing the patient.   If only patient were more engaged, more knowledgeable, more compliant, more trusting, more prepared, ask more questions, etc. 

There is a significant body of research which suggests that provider behaviors (like their communication style) are just as responsible as patients for many of the short coming in health care today.

Just as PAM research has shown that more activated patients generate lower costs…studies have shown that the physicians with strong patient-centered communication skills have lower costs as well.   I guess you could say that physicians with a physician-directed, bio-medical communication style have an equivalent of a 1-2 level of activation whereas physicians with a patient-centered communication style have an equivalent activation level of 3 to 4.

Pt Centered Communications and Outcomes2

Which Comes First – Activated Physicians Or Activated Patients?

I would argue that the real challenge facing providers today is to how to avoid disengaging or deactivating otherwise engaged and activated patients.

That’s because most people are already engaged in their own care, albeit not necessarily in the same way that providers want or expect.   So too, patients may well believe that they have the skills and knowledge they feel they need to deal with their own health…even if it is different from those skills, etc. measured by tools like PAM.

See : Patients Are Often More Engaged In Their Health Than Providers Think

In fact there is evidence to support this.  Patients with a regular source of care displayed significantly lower levels of patient activation that those without a regular source of care.  According to the researchers, “one possible explanation is that respondents with a regular physician are more likely to take a passive, deferential role in their care, believing their health care needs are being met by their provider(s).” *

The degree to which there is a “meeting of the minds” on engagement and activation between patient and physician, particularly during the office visit, will determine if patients are as engaged and activated when they leave the doctor’s office as they were when they entered.  It all boils down to how well the physician and patient are able to communicate.

Here’s what I mean.  How engaged or activated is a person going to be if what they have to say is interrupted, ignored or otherwise dismissed by busy, stressed  clinicians?  Is a patient going to share information or new skills they found on the internet with their physician if they are dismissed as a Googler?

The Take Away?

Nothing against PAM or Dr. Hibbard’s work which stand on its own merits.  Rather, it’s about health care being a two-way affair…with patients and clinicians both have a stake in health outcomes.  The sooner health care providers, academic researchers, and health publications like Health Affairs realize this…the sooner things can improve.

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

Sources:

Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient-centered care. Health Affairs, 29(7).

Olson, D. P., & Windish, D. M. (2010). Communication discrepancies between physicians and hospitalized patients. Archives of Internal Medicine, 170(15), 1302-7. doi:10.1001/archinternmed.2010.239

Roumie, C. L., Greevy, R., Wallston, K. a, Elasy, T. a, Kaltenbach, L., Kotter, K., Dittus, R. S., et al. (2010). Patient centered primary care is associated with patient hypertension medication adherence. Journal of Behavioral Medicine.

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.

* Alexander, J. a, Hearld, L. R., Mittler, J. N., & Harvey, J. (2011). Patient-Physician Role Relationships and Patient Activation among Individuals with Chronic Illness. Health Services Research, 1-23.

Patient Engagement – Here’s Why It’s So Hard For Health Care Providers

E-mail me at stwilkins at gmail.com for a complimentary copy of my Patient Engagement White Paper