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  According to people much smarter than I am about such things, this perspective is outdated.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”:

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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.

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

It’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.

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.

When It Comes To Patient Engagement…It’s The Little Things That Count

I did a dumb thing a couple of weeks ago.   I fell off a ladder on to a cement floor and broke some ribs.

I went to the local ER, was x-rayed, and went home.   There’s nothing they do for broken ribs these days it seems.   The treating Physician’s Assistant told me she had notified my primary care doctor of my fall and resulting injuries.   Mind you this is the same primary care physician who was aware of my 3 recent retinal detachments, major surgeries (Vitrectomies), and prolonged recovery from these events.

It’s been a month since I feel off the ladder….and in all that time I haven’t heard a peep from my personal physician.  That bothers me.

It’s not like I had a problem that needed follow-up…but it would have been nice – perhaps even prudent – for his office to call and see how I was doing.   Why?  The fact that he didn’t call just reminds me that my physician really doesn’t think or care very much about me – as a patient or a person.   Either that or he has yet to read the ER report of my injury from 4 week ago.

In truth everyone I have spoken to about this has had a similar experience.  This is unfortunate for patients and the medical profession.   As patient’s we are continually reminded that physicians don’t have time for us or our problems.  We chide ourselves for not looking for a new doctor in the hope that things might be better.   For their part,  medical professionals meanwhile are clueless why their patients are not as engaged in their health or adherent as they should be.

Want to Engage Your Patients?  Act Like You Care

We all know primary care physicians are very busy and not properly reimbursed for all the work they do.  We also know you all had mothers that “taught you better.”  We all had those same mothers.  Mine used to tell us kids that you “catch more flies with honey than you do with vinegar.”

If you really want to blow the socks off even the most jaded of patients….call them up and ask them how they are doing.  Start with a phone call – it’s more personal than an e-mail.  Just tell the patient that you “know there not ever enough time during office visits to show you care…so when you had a free minute you wanted to remedy that.”

Start with your chronic and frail patients – one call is all you need.  Do this one simple  albeit time consumer thing and your outcomes ill improve, patient adherence will improve, patient satisfaction and loyalty will improve…and you will feel better about yourself.  Think of it as a long-term investment.

You need more proof?  Calculate the ROI of buying and installing an EMR system and hiring a care coordinator and then compare it to the cost of making a single phone call to your sickest patients.   When you compare the saving from the EMR and the cost of your time to make the phone calls….you will be amazed that you didn’t do it sooner!

This ain’t rocket science!  Go out now and make your Mamma proud!

That’s my opinion…what’s yours?

If you like this post you will love my White Paper on Patient Engagement send me your email and I get you a copy.

Sources:

Stein, T., Nagy, V.T., Jacobs, L. (1998). Caring for Patients One Conversation at a Time : Permanente Journal, 2(4), 62-68.

Why It’s So Important For Physicians To Listen – The Patient’s Perspective

A recent qualitative study (structured interviews) of patients conducted at       McGill University School of Medicine underscores the importance of listening in physician-patient interactions.   In this study, patients were asked to identify the qualities of a good physician.   The following is a typical patient response:

“A good physician is somebody who will listen to what the problem is and explain to you what it is and what is being done.’’

When people were asked why listening by the physician was so important, researchers discovered three important themes that have apply to every provider today.

Theme #1 – Respondents (people/patients) believed that listening was essential if the physician was to arrive at the right (and credible) diagnosis. 

Representative Comments:

• ‘Physicians “should trust the person in front of them and hear what they’re saying. . .because I know my body better than anybody else.“

• ‘‘Listen to what they [patients] have to say; not just what other people wrote about them in the doctor’s notes.

• ‘‘[If] I feel that I haven’t had enough time with you to tell you exactly what my story is, even when you give me a prescription I’m going to say, ‘Really? Is this prescription right for me and for my illness? Or [is it] going to give me more complications?’. . .and I think sometimes that’s why you find patients will take it for 1–2 days and after that they forget about it, because they say, ‘He didn’t hear what I had to say about this pain.

Theme #2 – Listening is healing and therapeutic.

For years researchers have written about the therapeutic value of strong physician-patient communications.    Turns out patients recognize the same benefits.  For example,  a physician who listens and “validates the patient’s perspective or expresses empathy may help a patient experience improved psychological well-being—fewer negative emotions (e.g., fear, anxiety) and more positive ones (e.g., hope, optimism, and self-worth) ”

Representative Comments:

• ‘‘If a doctor doesn’t respect the patient, or doesn’t listen, the patient feels more worried and unsettled and this has an impact on their health.’’

• ‘‘Sometimes, listening to a person will cure half of your problem. . . like it takes two or three months to get an appointment. In those two–three months, you make your problem worse by thinking, ‘Oh maybe it is this, or that or that or that.’

• ‘‘if you listen to the patient and give the patient respect, what you are actually doing is helping that person take responsibility for their own health – that they are also in control of the healing process and are involved somehow. So the doctor has to not take all the power away from the patient.’’

For related patient (and physician thoughts) on this subject, check the following story and COMMENTS on CNN

Theme #3 – Listening can foster and strengthen the doctor–patient relationship if it is authentic

Representative Comments:

• ‘‘I want the doctor. . . to have empathy and to listen and to look into my eyes and to make me feel that for that short moment…you are hearing me, you are there for me, and you give me that sense that I matter

• ‘‘It still makes me angry when I think about how I was. . .how I sort of felt ridiculed for my looking into alternative options.’’

• I think they [physicians] should listen out of respect. Sometimes I think that caring and compassion can be patronizing, if it is insincere. You can still be arrogant and project this caring and compassionate facade.

Take Aways

Over all I was struck by the following as I read this study…particularly the respondent comments.

• People/patients in the study clearly recognized the link between effective listening (by providers) and quality of care.    Too often providers are quick to discount the accuracy or validity of patient perceptions of quality whether in the hospital or doctor’s office.  The comments reflected in this study suggest otherwise.

• Listen skills are essential to patient engagement and positive patient experiences.   To be engaging, providers must be “relevant” from the patient’s perspective.   To be relevant, providers must solicit and listen to what patients want to tell them.

• If listening is therapeutic and has the power to heal…does this mean that physicians who 1) do not solicit or 2)  ignore or gloss over patient input are not practicing at the “standard of care?”  Given that poor physician-patient communications is a leading cause of malpractice suits it would seem so.

• Health care providers (physicians and hospitals) would do well routinely do a “deep dive” into their patient satisfaction research to get a true and realistic handle on the quality of their provider’s listening and other communication skills.   I am not sure that the standard HCAPS and CHAPS survey instruments  probe physician-patient communications far enough.

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

Source:

R. L. Street et al.   How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling, 2009. 74(3), 295-301.

J.  Jagosh et al.  Patient Education and Counseling.  85 (2011) 369–374