The Power Of Conversations Between Physicians And Patients

People always ask me how I got started with my work in physician-patient communications. Like so many people, I had a story that I felt needed to be told. Much of my inspiration over the course of the last five years of writing Mind the Gap have come from my wife and my journey as we deal with her Stage IV Lung Cancer.

But there was also a video I saw back in my blog’s early days that really gave me a sense of direction. A video featuring Maggie Breslin, at Mayo Clinic’s Transform 2009 Symposium. (Maggie is no longer with Mayo) At the time I was so taken with Maggie’s presentation that I pick up the phone and spoke with her about her “Power of Conversations” experiences. Well I rediscovered that video in a recent guest blog post on Mayo Clinic’s Center for Innovation Blog. The piece was written by by Nolan Meyer, a student at the University of Minnesota Rochester .

Here is Nolan’s post which includes the video. I hope it inspires you as much as it does me.

If you were to guess why patients consistently return to the Mayo Clinic and recommend the Mayo Clinic to friends and family, what reason would you venture? Unparalleled medical expertise? Superior technology? Prestige? Tropical weather conditions?

In contrast, the number one reason is not solely due to the excellent quality of care they receive. It is not that they receive pioneering procedures at a world-class academic medical facility, nor is it space-age medical technology. It’s not that they were prescribed miracle medications that exist nowhere else.

The reason patients return to Mayo Clinic is that providers here take the time to connect with their patients—to talk with them and ensure all their patients’ questions are answered. This connection forged between Mayo Clinic healthcare staff and their patients ensures the concerns of patients and their families are understood and fully addressed. Although the Mayo Clinic is a premiere and world-class academic medical institution, the meaningful connections made here between providers and patients are what bring people back again and again.

In a time of healthcare reform, extensive regulations, standardization, and malpractice suits, when many healthcare institutions have turned to emphasize numbers of patients seen over the overall quality of healthcare delivery, the Mayo Clinic has remained steadfast in its familiar maxim: “The needs of the patient come first.”

“I believe that if we make satisfying conversations and human connection the focus of our healthcare delivery development—if we make connecting people and having them talk to each other the single most important metric by which we judge all of our efforts—we will get everything else we want our healthcare system to be. Rich conversation is the pathway to quality, to efficiency, to affordability… when we have good conversations, we are practicing individualized medicine in its most authentic—it’s most human—form.”

Maggie Breslin, in a research-and-design effort put forth by the Center for Innovation’s Spark Design Lab, set out to find and address elements that enhance or impede quality of healthcare delivery. Maggie was granted access to observe healthcare interactions in various departments of the Mayo Clinic. During her time working on this project, Maggie observed thousands of healthcare interactions ranging from the mundane to the life-changing. Maggie observed everything from annual influenza vaccinations, to radiological studies, to discussions of unforeseen treatment complications, to emotionally wrenching diagnoses of debilitating conditions.

These thousands of observed interactions qualifies Maggie to tell us what quality healthcare delivery looks like, and according to her, it looks like a satisfying conversation. According to Maggie, quality healthcare delivery is “the most human thing you’ve ever seen in your life!” Working on this groundbreaking project, Maggie became familiar with four powerful insights regarding conversation in healthcare:

Conversation is how people determine quality and value.
Conversation has therapeutic value.
Conversation allows us to deal with ambiguity.
People seek out conversation, even when we make it hard for them.

While some of these observations may seem intuitive, they have fallen by the wayside in many modern medical institutions. The power of a simple conversation in a medical setting seems to have been deemed “nice-to-have,” but unnecessary and extraneous by many modern designers of healthcare delivery. This is an unfortunate trend, as the importance of translating advanced scientific and medical knowledge from provider to patient is more important now than ever. Maggie asserts that these satisfying conversations are not a “nice-to-have,” an extra, an unnecessary and time-consuming luxury in modern medicine. Quite the contrary: satisfying conversations are what Maggie calls “the very essence of healthcare delivery.”

Maggie relates a story in which she and her colleagues set about the hospital in search of factors which enhance or impede human connection. Her team found a startling pattern: the presence of human connection in healthcare delivery was, by and large, the result of the actions of outgoing individuals. In contrast, the absence of human connection was the result of often-unforeseen systematic hurdles. Maggie argues that in modern medicine, too many decisions are being made in the name of efficiency, standardization, legal requirements, documentation, and numbers.

All of these decisions contribute to the construction of what Maggie calls a wall between providers and patients. The inspiring thing, though, is that both patients and providers make what Maggie calls a Herculean effort to jump over that wall and find ways to connect with one another.

The Mayo Clinic’s efforts to recognize and address impediments to meaningful patient-provider interactions are an example of how it strives to provide the best patient care possible. Maggie Breslin calls on everyone involved in healthcare delivery and its design to ask themselves one question as they do their work: what kind of conversation will result from this concept? If the answer is “a better conversation,” then have that mean something!

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.

The Adopt One! Challenge – The First Step To Better Patient Engagement & Patient Experiences

A journey of a thousand miles begins with a single step.  Or in the case of the Adopt One! Challenge…by encouraging physicians across the U.S. to commit to adopting one new patient-centered communication skill in 2014.

Anyone who has followed my work here on Mind the Gap knows that I am passionate about improving the way physicians and their care teams talk to and interact with patients. My passion stems both from my personal experiences as a health care executive, a patient advocate and patient.  I honestly believe that if we could improve how doctors and patients talk with one another beginning in the exam room we would fix much of what is broken with today’s health care system.

“I have discovered that the biggest problem with physician-patient communications is the illusion that it ever occurred! “

Many physicians readily admit that their patient communication skills need work. But when faced with a burdensome daily practice schedule they make do with the physician-directed patient communication skills they learned in medical school. Besides…most physicians operate under the mistaken impression that patient-centered communications – the alternative to physician-directed communications – takes too much time and requires longer visits.

So How Will The Adopt One Challenge Fix Things?

The Challenge, to be launched later the Fall, is designed to accomplish three objective – behavioral objectives modeled after the Health Belief Model. These three objectives are:

• Help physicians understand that their patient communication skills are not all they could be
• Show physicians how their lack of patient-centered communication skills is a barrier to their ability to effectively engage and activate patients or to provide exceptional patient experiences
• Serve as a “Call to Action” to prompt physicians to take action to improve their patient-centered communication skills

Here’s how the Adopt One! Challenge will accomplish these objectives:

Help physicians understand that their patient communication skills are not all they could be

Using audio recordings provided by participating physicians a team of independent, trained professionals will identify, measure and assess the patient communication skills employed by each physician. This research method – called conversation analysis – is the same method used in medical school. Unlike patient satisfaction surveys like HCAHPS which are not very prescriptive, the Challenge will provide participants with objective, detailed and actionable findings and recommendations.

Show physicians how their lack of patient-centered communication skills is a barrier to their ability to effectively engage and activate patients or to provide exceptional patient experiences

In addition to measuring and assessing their patient communication skills, each physician’s patient communication skills will be benchmarked against patient-centered best practices.

Over 30 years of research has linked the use of specific, patient-centered communication skills to more productive visits, increased patient engagement, better patient health outcomes, lower health care use and superior patient experiences.  By comparing physicians’ skills against these “best practices” we show them how their communication practices may be affecting patients, their practice and the organizations they work for or with.  We also show them which communication skills they may want to focus on improving.

Serve as a “Call to Action” to prompt physicians to take action to improve their patient-centered communication skills

The Challenge serves as a concrete call to action to physicians to take a specific action to learn a new patient-centered communication skill over the course of 12 months.  This call to action will require participants to 1) commit in writing to adopt/develop one new patient-centered communication skill of their choosing and 2) provide them with access to online training and resources needed to help them learn that new communication skill.

Because the Adopt One! Challenge is expected to become an annual event, participating physicians can measure their year-over-year progress as they add new patient-centered communication skills.

In future posts I will share more about the Adopt One! Challenge. In these future posts I will profiling members of the Adopt One! Challenge Advisory Board as well as the Partners that are making the Challenge possible.

The Adopt One! Challenge is Free To Individual Physicians.

If you are interested in offering the Adopt One! Challenge to all the physicians in your provider network?  E-mail us at contact@adoptonechallenge.com.

Patient-Centered Medical Homes Need To Become More “Patient-Centered”

A recent study in Medical Care about Horizon BCBS’s Medical Home pilot reminded me of the expression a “house does not make a home.”   Or in this case how building a medical house to the spec (as laid out 3rd parties like NCQA and JACHO)  is not the same as building a medical home that is truly patient-centered .   As it turns out, researchers involved in the Horizon study claimed not to have found any significant differences between PCMH practices and non-PCMH practices.

Don’t get me wrong, my hat is off to the thousands upon thousands of primary care practices from New Jersey to Hawaii that have put in long hours going the extra mile to become recognized as Patient Centered Medical Homes.  Due to the efforts of these first generation PCMH pioneers, and their health plan partners, millions of people now have unprecedented access to primary care physicians providing:

• Physician-led team care
• Electronic records (EMR/Registry)
• Embedded care coordinators
• PHRs and web portals

Yes, many of the PCMH pilots, now into their 4^th or 5^th year, are showing promising results with reported reductions in ER visits, hospitalizations and 30-day hospital readmissions.  These pilots are also reporting improvements in HEDIS-related quality indicators.

But while team care, care coordination and EMRs may increase practice efficiency, there is nothing inherently patient-centered about these “things.”

That’s because patient-centered care is a philosophy of care delivery…not simply a punch list of HIT and staffing requirements.  Crossing the Quality Chasm defines patient-centered care as “respectful of and responsive (where practicable) to individual patient preferences, needs, and values”; or as Berwick is quoted as saying, “nothing about me (the patient) without me.” Patient-centered care occurs between people – not things – and manifests itself in the way the clinician and patient talk with and relate to one another, e.g. patient-centered communications.

With all the attention placed on building out the HIT and staffing infrastructure,  this first generation of PCMH pilots, with some notable exceptions, has lost sight of the most what makes a medical house and patient-centered medical home – notably the relationship between the patient and the clinician, beginning with the quality of clinicians’ patient-centered communication skills.

Yes, many accredited PCMH’s have patient advisory boards and conduct patient satisfaction surveys.   But as researchers like Street and Epstein have suggested,  relying just on patients’ impressions and ratings of “patient-centeredness” may provide false reassurance given that many patients have never experienced anything but suboptimal care and physicians that employ a paternalistic, decidedly un-patient-centered style of talking to patients.  (Until recently, I myself had never encountered a real patient-centered physician).

As I discussed in an earlier post, the majority of physicians today employ a paternalistic, physician-directed style of communicating with patients.   As such, there is no evidence to suggest that the patient communication skills of physicians practicing in accredited PCMHs are any more patient-centered that their counter parts in traditional practices.

Based upon the literature, what is absent in this first generation of PCMH pilots is any serious, systematic attention given to assessing and/or improving the quality of the patient-centered communication skills of physicians and their care teams.   This oversight is worth noting since the benefits expected by policy makers and underwriters of PCMHs and ACOs under health care reform have been linked in the research to the strong patient-centered communications and not HIT, team care and care coordinators.

Why Is This Important If PCMH Pilots Are Reporting Positive Outcomes?  

The early saving being reported by many PCMH pilots may well represent the “low hanging fruit.” This is not an unreasonable supposition given that most physician practices have never had EMRs, care coordinators, or team care prior to the PCMH pilots.  As is so often the case, within a short few years, this low hanging fruit will disappear.

But there is another way. Thirty years of research has demonstrated the benefits of patient-centered communications when it comes to increased productivity, greater patient engagement; better outcomes, lower health care use/cost and superior patient experiences.

Going forward, PCMHs, ACOs and their sponsors will need to look past HIT and team care to the quality of their patient-centered communication skills if they are to assume the role envisioned for them under health care reform.

That’s my opinion…what’s yours?

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

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

Name(required)

Email(required)

Submit

Δ

Sources:

Epstein RM, Fiscella K, Lesser CS, Stange KC.  Why the nation needs
a policy push on patient-centered health care. Health Affairs. 2010;29(8):1489-1495.

Ming Tai-Seale, et al.  Recognition as a Patient-Centered Medical Home: Fundamental or Incidental? Annals of Family Medicine. 2013;11:S14-S18.

Street, R., et al.  The Values and Value of Patient-Centered
Care.  Annals of Family Medicine.  2011;9:100-103.

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.