Tag Archives: modifying health behavior

Satisfaction With Provider Communication In Recent Study Is Lower In Patient Center-Medical Homes (PCMH) Than Non-PCMH

A recent blog headline on the Patient-Centered Primary Care Collaborative (PCPCC) recently caught my attention. It was entitled Patient Satisfaction With Medical Home Quality High. I was intrigued. I asked myself high compared to what? Non-PCMH practices?

The study, which appeared in the November-December 2013 Annals of Family Medicine, asked 4,500 patients (2009 Health Center Patient Survey) of federally-support health centers their perceptions of a number of “patient-centered quality attributes,” including the following measures which the study authors defined as patient-centered communication:

  • Clinician staff listened to you?
  • Clinician staff takes enough time with you?
  • Clinician staff explains what you want to know
  • Nurses and MAs answered your questions?
  • Nurses and MAs are friendly and helpful to you?
  • Other staff is friendly and helpful to you?
  • Other staff answered your questions?

Observations About The Study

The first thing that struck me was that compared to patients in the 2012 CHAPS survey (AHRQ) website, patients in the 2009 study actually reported lower levels of 1) patient satisfaction (81% versus 91%) with their clinicians’ patient-centered attributes (including communication) and 2) willingness to recommend their providers (84% versus 89%).

The second thing I was reminded of is that patients themselves are so used to clinicians’ paternalistic, physician-directed communication style that simply allowing them to ask just one question puts the clinician in the top 5% of patient-centered communicators. Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition? Until recently I never have been and I suspect few if any people in the study cited here have either.

[pullquote]Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition? [/pullquote]

The final thing that struck me was that none of the quality measures used in the study captured the “essential and revolutionary meaning of what it means to be patient-centered.” As Street and Epstein point out, patient centered communication is about inviting the patient to get involved in the exam room conversation.

As articulated in hundreds of studies over the years, patient-centered communication skills include:

  • Soliciting the patient’s story
  • Visit agenda setting
  • Understanding the patient’s health perspective
  • Understanding the whole patient (biomedical and psychosocial)
  • Shared decision-making
  • Empathy

We Need To Raise The Bar For Patient-Centered Medical Homes (PCMH)

Studies like the one cited here set the quality bar (and bragging rights) way too low for PCMH. Patient-centered care has to be different than the paternalistic, physician-directed care we all seem so willing to accept. Such studies trivialize what it means for physicians and their care teams to be patient-centered in the way they relate to and communicate with people (aka patients). Patient-centeredness is a philosophy or care…and does not require team care, extended hours or care coordinators. These are great added features, but to equate such services with patient-centeredness misses the boat…something which professional groups like the PCPCC, NCQA, Joint Commission, and URAC should recognize by now.

The Take Away?

Here’s some thoughts:

1) We need to set the bar higher for PCMHs when it comes to how we define and measure patient-centered communication.

2) We need to find better ways to asses patient-centered communications in actual practice. Patient rating of a clinician’s patiient-centeredness are simply not enough. As part of the 2014 Adopt One! Challenge, we will be using audio recording of actual physician-patient exam room conversations to measure and benchmark clinicians’ patient-centered communication skills.

3) We should stop celebrating being average whether it be in PCMH setting or hospitals when it comes to physician-patient communications.
That what I think. What’s your opinion?

Sources:

Lebrun-Harris et al. Effects of Patient-Centered Medical Home Attributes On Patient’s Perception Of Quality In Federaly-Supported Health Centers. Annals of Family Medicine. 2013; 11:6; 508-516.
Street et al. The Value and Values of Patient-Centered Care. Annals of Family Medicine. 2011; 9; 100-103.

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?

Would Increased Reimbursement And Longer Visits Improve Physician-Patient Communications?

In a word…no.

It has been said that a physician’s patient communication skills are just as important as their clinical knowledge.   After all, it is only by “talking to and listening patients” that physicians are able to accurately diagnose and treat their conditions.   I have yet to meet a physician who did not agree with the importance of effective physician-patient communication…in principle.

In practice, a surprising number of physicians tell me that they “lack the time” and “don’t get paid” to communicate with patients.  Physicians euphemistically explain to me how current reimbursement schemes fail to incentivise physicians  to spend time talking to patients.

At face value, these objections appear to make sense.  After all we know that physicians, particularly primary care physicians, are already overextended.  We also know that the traditional fee for service model, which pays physicians on a kind of piece work basis, is not well-suited to managing “episodes of care” for a burgeoning chronic disease population.   In other words, today’s reimbursement is not properly aligned with the realities of care delivery.

The conclusion one draws from these two objections is that doctors would communicate better with patients if they simply had more time and were paid more.   But is that what would happen?

I don’t think so…and here’s why.

Many physicians, until recently, were never taught (in medical school) how to be good patient or person-centered communicators (the gold standard for physician-patient communications).   Studies show that the majority of primary care physicians today employ a physician-directed, paternalistic style when talking with patients.   This is the same style of communication practiced by physicians for the last 80 years.  This style is characterized by the physician control of the medical interview by asking the questions, focusing patient input, and providing pertinent information.  Some physicians now limit patients to asking one question per visit.  Over the course of their career, the typical physician will employ these same “conversational habits” in 120,000 to 160,000 medical interviews.

Patients, for their part are trained as well – socialized from childhood to assume the “sick role” wherein the doctor does all the talking and their job is to passively respond to questions when asked.  The average 60 year old for example will have experienced 180+ visits in which they were likely expected to assume the sick role.   Even the most engaged and empowered patient finds it difficult to avoid reverting back to this passive role.

What’s My Point?

The “communication habits” developed by and employed by physicians and patients took years to develop.   Simply increasing the length of the office visit (more time) and increasing reimbursement alone will not compensate for nor change the way physicians and patients communicate with one another.   Physicians will continue to be physician-directed and patients will continue to play the passive sick role.  Absent interventions aimed at breaking this cycle of unproductive communication by promoting more patient-centered communications, longer visits and more reimbursement will mean that physicians have more time for and get paid more for perpetuating the same physician-directed communications challenges we face now.

Patient-Centered Communication Can Lead To More Productive Visits

Physicians are concerned that patient-centered communications will increase the length of office visits.  Initially it probably will.  But imaging how much more productive office visits could be over time if patients came in focused and prepared, i.e., with a prioritized agenda, clearly articulated expectations, realistic requests for referrals, tests and medications, understanding of time limitations, and so on.  The average patient makes 3 visits to the doctor a year.  Patients with chronic conditions see the doctor up to 7 times a year.   Research shows that the adoption of specific patient-centered communication techniques in your practice could “reset” the physician-patient dynamic in ways that could increase visit productivity as well as patient outcomes and satisfaction within the course of a few consecutive visits.

That what I think…what’s your opinion?

Source:

Frankel, R. et al. Getting the Most out of the Clinical Encounter: The Four Habits Model . The Permenante Journal. 1999.

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.

Improving The Way Doctors And Patients Communicate – A Silver Bullet For Fixing What’s Wrong With Health Care?

Physician_Patient Communications InfographicSometimes a picture is worth a thousand words…