Tag Archives: paternalistic communication style

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.

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.

Wonder What Your Doctors And Patients Talk About…Or Don’t Talk About…Behind Closed Exam Room Doors?

Soon you can stop wondering…

For the most us, our first patient experience was a trip to the Pediatrician’s office with our mother. As we age things don’t change much…the doctor’s office remains the center of most people’s “health care experience” except that now we are taking our parents to see the doctor.

The physician-patient relationship is and will continue to be the key stone holding together the rest of U.S. health care system. Why? Because the primary care physician’s office is where the vast majority of health care decisions are made and where most health care is delivered. We are still 13 times more likely to visit our doctor’s office than we are to require an overnight stay in the hospital.

What happens behind the closed doors of the exam room between doctor and patient drives everything else in health care – patient health status, patient adherence, referrals, ER visits, hospital admissions and re-admissions, patient satisfaction and so on. Other than our own personal experience and some vague top line satisfaction survey data, we health care professionals (non-physicians) really know very little about how doctors in our organizations talk with and relate to patients one another once the exam room door closes.

We Know Even Less About The Impact Of Different Styles of Physician-Patient On Our Organizations

For example, what impact does a paternalistic, physician-directed communication style have on patient activation and engagement in hospital-owned physician practices? Or how successful will a physician with poor patient- centered communication skills be when it comes to managing the health of a patient population in an ACO?  Can physicians with poor communication skills hope to retain members attributed to the ACO?  How much money will your organization forfeit next year in incentives and penalties due to poor physician-patient communications resulting in preventable re-admissions and sub-optimal patient experiences?

Exciting New Research Will Soon Provide You Invaluable New Insights Into How Physicians And Patients In Your Market Communication With One Another…And The Implications For Your Organization

It is not often that one gets the chance to become involved in landmark research.  I guess this in my luck day.  Working together with a corporate partner Verilogue in the upcoming months I will be analyzing the patient communication skills of 2,500 HIPPA-compliant physician-patient interviews collected from across the U.S.  The goal of the research will be to deconstruct what primary care doctors and their patients say (and don’t say) to one another and how they say.  We will then benchmark the patient communication skills of physicians in the study against agreed upon industry best practices – aka patient-centered communications.  Ideally the results can be used by hospitals, physician groups, ACOs and health plans to improve the patient-centered communication skills of primary care physicians across the country.

Stay Tuned

As more details of this excite new research become available you will find them here at Mind the Gap first. I look forward to helping advance the field of physician-patient communications. More importantly, I look forward to doing what I can to disseminate and make actionable the finding on behalf of those who will benefits the most – patients.

What things would you like to learn from this research?  Please let me know.

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.