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.

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

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

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

Sometimes a picture is worth a thousand words…

Can Long-Term Physician-Patient Relationships Be Bad For Your Health?

I wonder how many problems like non-compliance, usually attributed to “poor patient behavior,” actually stem from long-term physician-patient relationships in which both parties have just given up.

You know what I mean…physicians who have treated certain patients long enough that they believe they are just plain never going to do what they are told…and patients with expectations for care and service from their physician that never seem to be met.

Like any long-term relationship, people become used to one another and develop coping mechanisms to avoid an outright breakdown.  People in long-term become complacent with one another’s “quirks.”   We are all too willing to settle for the things as they are and not push the boundaries of the relationship hoping to improve it.

But there is a long-term cost to the patient and physician when we ”settle” and try to just get by as the graphic below suggests.

At face value, most physicians and patients don’t do a great job when it comes to communicating with one another.  Take patient expectations .

Most people have certain basic  expectation for what we want to happen when we consult our physician.   At a minimum we expect to have the time and opportunity to tell the doctor why we are there.   After all, if we are concerned enough to make an appointment we want to be heard.  Maybe we also have an expectation for a specific service – say a test, a referral or a new medication.

Quite often however, patient’s expectations, reasonable or not, often go unmet.  According to researchers, physicians failed to ask for patient’s full reason for their visit in 77% of visits.   Maybe the physician has little time to allow the patient to ramble on or maybe the physician has already arrived at a diagnosis already.

The reality is that the patient’s expectations were unmet perhaps resulting in disappointment and perhaps frustration.  Unfortunately, as Avedis Donabedian, MD, once said, “patients are overly patient with their physicians” and are willing to put up with a lot without saying anything (or reporting it on patient satisfaction surveys).

Not every patient request for a test, referral or medication is appropriate.  Physicians have an obligation to deny inappropriate patient expectations.  But again, depending upon how well the physician explained their reasoning for the denial, some patients will be disappointed and perhaps even angry.   Another study found that 56% of patients expressed an expectation for a specific service – a test, referral or medication… with 50% not getting what they asked for.

Now imagine playing this scenario playing out between patient and physician 2 or 3 times a year over a number of years.   I have to believe that in situations like this patients continually lower their expectations of their physicians…and along with it their trust, willingness to share information, and a willingness to comply what the physician recommends.  Physicians for their part probably reciprocate these feeling in some way.

The point is that settling and being complacent can be bad for the patient’s health and very unsatisfying for the physician.   Too bad we don’t measure patient and physician complacency…it could probably explain a lot.

That’s my opinion…what’s yours?

Sources:

Dyche, L. et al.  The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns.  Journal of General Internal Medicine. 2005; 20:267–270

Peck, B. et al.  Do unmet expectations for specific tests, referrals, and new medications reduce patients’ satisfaction? Journal of General Internal Medicine, 2004; 19(11), 1080-7.

Does Physician Denial Of Patient Requests Result In Decreased Patient Satisfaction?

[tweetmeme source=”Healthmessaging” only_single=false]The short answer: No.
 
At least not in the context of a strong physician-patient relationship.
 
Many physicians have legitimate concerns about the prospects of having their salary or level reimbursement linked to patient satisfaction. I would too given the way most health care providers go about measuring and interpreting patient satisfaction data.
 
A major concern of physicians is the issue of patient requests – particularly the impact of unfulfilled (and unreasonable) requests upon patient satisfaction. According to researchers, explicit patient requests for medications, diagnostic tests and specialty referrals occur in between 25% to 40% of primary care visits. This figure is much higher when requests for information are factored in.
 
In studies, primary care physicians accommodate patient requests for medications and diagnostic tests approximately 75% of the time. Physicians however accommodated only 40% of specialist referral requests. Physicians negotiated alternatives solutions to patient requests 22% of the time and denied patient requests the remaining 3% of the time. Information requests were met approximately 95% of the time by physicians.
 
Denial Of Patient Requests Has Little Impact On Patient Satisfaction
 
It is not at all clear from the research that physician denial of patient requests for medications, tests or specialist referrals has any negative effect on patient satisfaction. In the studies referenced here, little to no association was found between unfulfilled patient requests and patient satisfaction.
 
The one exception to this finding is where physicians fail to meet patient requests for health information. In such instances patient satisfaction was lower. This is not surprising when one study categorized the quality of physician responses to patient information requests as follows:
 

• 32% were of requests were fulfilled with a “terse” physician response
• 33% percent were fulfilled with an “intermediate” response
• 32% percent with an “elaborate” response.

 
Experts Advise Negotiating Patients Requests
 
It has been said that clinical encounters such as occur during office visits involve a “process of negotiation between the clinician and patient.” As such, physicians are advised to use the influence accorded them by their patients to help them understand the pros and cons of their request so as to negotiate actions are really needed.
 
Physicians that are truly concerned about their patient satisfaction score are better served by looking after the quality of their patient communications skills.
 
Sources:

Kravitz RL, Bell R a, Franz CE, et al. Characterizing patient requests and physician responses in office practice. Health Services Research. 2002;37(1):217-38.

Kravitz RL, Bell R a, Azari R, et al. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Archives of Internal Medicine. 2003;163(14):1673-81.

Peck BM, Asch DA, Goold SD, et al. Measuring Patient Expectations – Does the Instrument Affect Satisfaction or Expectations? Medical Care, Vol. 39, No. 1 pp. 100-108.

Keitz S a, Stechuchak KM, Grambow SC, Koropchak CM, Tulsky J. Behind closed doors: management of patient expectations in primary care practices. Archives of Internal Medicine. 2007;167(5):445-52.