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Posted in Uncategorized
Tagged Accountable Care Organizations, Adopt One Challenge, collaborative decision making, cost of poor physician-patient communication, doctor-patient communication, Health Care Reform, patient engagement, Patient-centered Communications, PCMH, physician directed decision making, physician-patient communication, physician-patient communication. doctor-patient communication, shared decision making
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 According to people much smarter than I am about such things, this perspective is outdated.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:
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.
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”:
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.
Posted in Uncategorized
Tagged cost of poor physician-patient communication, doctor-patient communication, doctor-patient relationship, Electronic health record, health behavior, Health Information Technology, HIT, patient adherence, patient attitudes and beliefs, patient compliance, patient engagement, patient non-adherence, Patient-centered Communications, physician directed decision making, physician-patient communication
“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.
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.
Posted in Uncategorized
Tagged chronic disease, doctor-patient communication, doctor-patient relationship, evidence-based research, financial incentives, lack of time, medication adherence, patient adherence, patient engagement, patient experience, patient requests, physician directed decision making, physician-patient communication. doctor-patient communication, visit agenda setting
When it comes to delivering truly patient-centered care…how are providers supposed to know when they have “arrived”? According to Michael Berry, MD, President of the Informed Medical Decisions Foundation, providers will know they have achieved the “pinnacle of patient-centered care” when they routinely engage their patients in shared decision-making (SDM).
In theory, shared decision-making (aka collaborative decision-making) is what is supposed to happen between patients and their doctors when faced with a difficult choice. Clinicians engaging in shared decision-making would provide patients with information pertaining to the need for the treatment, the available options, as well as the benefits and risks. But patient-centered clinicians would also do something else. They would attempt to work with patients to arrive at a decision they could both live with. A kind of “shared mind” that takes into consideration their clinical perspective as well as the patient’s perspective – their preferences, needs, and values (which ideally have been captured over the course of the patient-provider relationship).
The Problem Is That Most Physicians Don’t Really Engage Patients In Either Shared Decision Making
A 2003 study surveyed U.S. physicians (N=1,217) preferences and actual practices regarding shared decision-making. Table 1 presents a summary of findings from this study.
Table 1
Decision Making Style |
What Physicians Preferred |
What Physicians Actually Do |
Shared decision-making |
58% |
37% |
Physician-dominant decision-making |
28% |
43% |
No patient involvement |
9% |
13% |
Patient dominant decision-making |
5% |
7% |
While most physicians in the study may philosophically believe in and prefer shared decision-making…as this data indicates that is not what most physicians in the study reported actually doing. In fact, 56% of physicians reported that they actually engaged in decision-making that was physician-dominated (with some patient involvement) or totally physician-dominated decision-making behavior (absent any patient involvement).
The Barriers To Shared Decision Making?
The barriers to SDM include the usual suspects:
The Take Away – Why Shared Decision Making Matters
As readers of Mind the Gap know, I am a proponent of the adoption of patient-centered communication by providers, beginning with primary care. Shared decision-making has rightly been identified as a leading indicator when it comes to assessing the “patient-centeredness’ of a physician practice. So before you go around telling everyone how patient-centered your provider teams are first do a reality check. Because if you aren’t regularly engaging your patients in shared decision making you are not there yet.
That’s my opinion…what’s your?
Sources:
Heisler, M. et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illness. 2009 Sep;5(3):165-76
Street, R. et al The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice 17 (2011) 579–584.
Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.
Posted in Uncategorized
Tagged Accountable care organization, Accountable Care Organizations, ACOs, collaborative decision making, doctor-patient communication, patient attitudes and beliefs, patient engagement, patient-centered care, Patient-centered Communications, PCMH, physician attitudes, physician directed decision making, physician-patient communications, Primary care, SDM, shared decision making, trust