Tag Archives: shared decision making

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.

Death By A Thousand Cuts – Physicians’ Surprising Response To My Wife’s Lung Cancer Recurrence

This is a true story….

My wife was about to celebrate her 10th anniversary as a Stage IV Non-Small Cell Lung Cancer survivor (a pretty remarkable feat) when it happened.

It started out as a cough.  We had just returned from a family trip and assumed she had picked up a “bug” from one of the boys. It also “lite up” on her semiannual PET/CT scan down at MD Anderson as small dark masses where there weren’t supposed to be any. We all hoped the cough and the PET/Ct results was the result of a cold or allergy….it had happened before. Her medical oncologist, one of the top thoracic oncologists in the world, doubted a recurrence after 10 years.  But if it was a recurrence, he told us he would put my wife back on Tarceva, the oral chemo that had worked so well for her before.

But we were all wrong. Her lung cancer was back and appeared to have spread.  The cough escalated into a 24/7 serious hack-a-thon.  She couldn’t finish a sentence without coughing.  We avoided being around other people as the coughing got worse. My wife didn’t want “bother” people.  Nor did we want our family and friends to get the wrong impression….that my wife was dying. She had beaten the odds once and she would do it again we told ourselves.  Turns out we were the only ones that believed it.

Within the space of 2 months, my wife saw a local pulmonologist (we live in Northern California not Houston, Texas where MD Anderson is) to rule out any other causes for the cough.  She also kept two long-scheduled appointments with an endocrinologist and a cardiologist for issues unrelated to the cough or cancer.

That’s When I Noticed It – Every Physician My Wife Saw Acted As If She Would Be Dead Soon

To be sure none of my wife’s physicians ever said she was dying. But knowing something about the nuances of how physicians “communicate” with patients I could tell that’s what they were thinking.  After attending every one of her doctor’s appointments over the last 10 years you recognize the tell tale signs.   Neither the endocrinologist or cardiologist were familiar with my wife or her condition as these were our first visit to both.  But they clearly could not get past her coughing.  They politely cut short the initial appointment and told my wife to contact them after the lung cancer had been dealt with.  You have bigger problems than a thyroid nodule or a rapid heartbeat they told us.

Mind you my wife was concerned enough (let’s say she was engaged) about her thyroid nodule and heart health that she 1) made the appointment to be seen and 2) actually kept the appointment because she/we believed that she would be around long enough to have to deal with these problems sometime.

The pulmonologist, after ruling out allergies or infectious disease as the cause of my wife’s cough, threw up his hands in apparent defeat and said “your cancer’s back and there’s nothing more I can do for you. “ He referred us to a local a local thoracic surgeon in order to get her cancer re-biopsied before starting chemo.

The thoracic surgeon, like the other doctors, couldn’t deal with my wife’s coughing and shortness of breath which was pretty bad by now.  Rather than come up with a definitive plan of action regarding the biopsy, the surgeon hemmed and hawed about the different approaches to doing the lung biopsy – one more invasive than the other.  The surgeon gave me the distinct impression that the biopsy in the long run wouldn’t matter given the apparent seriousness of my wife’s condition.  He promised to discuss the biopsy options with my wife’s oncologist the next day and call us with the “game plan.”  The doctor never called us back.

By this time it was 5:00 pm on a Friday afternoon.  We felt we had already wasted too much time between the pulmonologist and the thoracic surgeon and my wife started her oral chemo at 5:01 pm.  We immediately felt better because at least we were finally doing something positive to address my wife’s problem.  Anything is preferable to watching sympathetic physicians, nurses, office staff, radiology techs, etc.  shake their heads saying to themselves “poor woman” doesn’t have long to live.

Post Script

Within 10 days of starting her oral chemo, my wife’s cough and shortness of breath completely disappeared.  After 2 months of being on Tarceva the first follow up the first PET/CT scan revealed what the radiologists called a significant response to the treatment.

Not bad for someone whom so many clinicians had written off!

The Take Away

Physicians need to be aware of the fact that they both bring pre-existing attitudes and biases to the office visit…and check them at the door.  These attitudes and beliefs color the decisions clinicians make.  The extent to which clinicians inform patients of all their diagnosis and treatment options, engage patients in shared decision making, or decisions as to how aggressively treat the patient’s condition are all influenced by physician’s beliefs and attitudes.

Lung cancer that presents as a bad cough is like a red flag to a bull. It invokes a whole set of assumptions about 1) how the person got the disease (you must have been a smoker) and 2) the person’s odds of survival – slim to none.

You have to wonder how many people’s lives are cut short or whose care is not what it should be simply because their doctor jumped to the wrong conclusions.

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

The Lack Of Patient-Centered Communication Skills By Physicians in Your Provider Network Will Limit Your PCMH & ACO Performance

 

Betting the Ranch on your physician patient communication skills

The Push For Patient Engagement – Who Benefits The Most?

It goes without saying that people – you and I – need to be actively involved (Ok…I’ll say it…engaged) in our own health.  After all it is our health we are talking about.   But I have long suspected that there may be motives behind all this talk about patient engagement that go beyond the simple argument that it’s “the right thing for patients to do.”  Motives which I believe constitute a fundamental “unspoken truth” about why policy makers, payers, vendors and at least a few providers are so passionate about patient engagement.

Truths that have remained unspoken until now that is.

Offloading Work To PatientsSam VanNorman, director of business intelligence, from Park Nicollet, shared this unspoken truth about patient engagement at a recent panel discussion on Pioneer ACOs.  In an online Forbes article, Dave Chase quotes VanNorman as saying:

“We have to incorporate the most important member of the care team — the patient. With our finite resources, we must figure out ways to offload what we have thought as tasks that needed to be done by our staff.  In most cases, it’s the patient who can do it more effectively. In the process, the patient is more engaged and it’s more efficient for everyone.”

The heretofore unspoken truth to which I refer is that for some, patient engagement is not about getting patients to do what in their own best  interest….but rather doing what’s in the self interest of policy makers, payers and perhaps providers.

I am not convinced however that most clinicians think this way.

Call me naïve, but I thought patients were the most important member of the care team because of what they can do for themselves, e.g., share information with the clinician to improve diagnosis and treatment, self-care management and so on.  Patient engagement to those thinking this way is about inviting the patient into their care and the care process to advance their activation, quality of care, clinical outcomes and the patient experience.   This approach begins with the patient.  As such, this approach is patient-centered in that the care delivery process begins by the clinician eliciting the patient’s knowledge and perspectives of their health.

VanNorman seems to believe that patients are the most important member of the care team because of what they can do for the provider and payer,  e.g., provide a more efficient, cheaper (free is pretty cheap) labor pool to which clinicians can outsource work they don’t want to do, don’t have time to do or don’t get paid to do.  Patient engagement for those that think this way begins with policy makers, payers and administrators looking for ways of offloading tasks (of their choosing) to the patient (e.g., lowest pay grade), irrespective of the patient’s willingness, knowledge or ability to comply. This approach could rightly be called bureaucrat-directed care which is antithetical to patient-centered care and the principle of PCMH and ACO models as well as the Triple Aims.

Don’t Conflate Outsourcing With Patient Engagement – They Are Not The Same

I complete understand VanNorman’s logic and agree with the notion of putting patients to work – they are a vastly underutilized resource in so many ways.  What I disagree with is conflating with “outsourcing” with patient-engagement.    I feel that the definition of patient engagement I share with most clinicians carries with it a kind of moral authority to do what’s right for the patient.   VanNorman’s attempts to cloak “physician workload outsourcing” as patient engagement feels manipulative, self-serving and  destined to disengage patients instead.

Furthermore I fundamentally disagree with anyone trying to force patients to do anything without the benefit of first:

  • Explaining to patients what you want them to do
  • Why you are asking patients to do something
  • Asking for their feedback on what you want them to do
  • Teaching patients how to do what it is you are asking them to do
  • Providing ongoing support to patients regarding what you asked them to do

The Take Away?

Maybe one of the real reasons patient engagement is so hard is that some of us are approaching it from a patient-centered perspective…while others are approaching it from VanNorman’s beauracrat-directed perspective.

This in turn translates into different motives, messages to patients, different measures of patient engagement and so on.

This may also explain why some of my peers in HIMMS and NeHC get so mad at me when I say that patient engagement is a physician-patient communication challenge and not an HIT challenge.

That’s my opinion…what’s yours?

AdoptOneBigButton1Note:  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”:

Shared Decision Making – Not Ready For Prime Time – Nor Evidently Is Patient-Centered Care

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).

Pinnicle of patient-centered communications

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:

  •  Lack of time during the visit
  • Not having access to the right decision support aids tools and training their use
  • Physician attitudes about patient’s willingness to engage in shared decision-making
  • Provider reliance upon a physician-directed (versus patient-centered) style of communicating with patients

AdoptOneBigButtonThe Take Away – Why Shared Decision Making Matters

  •  SDM is the right thing to do – the benefits associated with SDM include better outcomes, lower utilization and cost, lower malpractice risk and enhanced patient trust and satisfaction
  •  SDM is a great way to be engaging to patients – it is a way to get patients involved in their care in a meaningful way they can relate to.
  • To be eligible to participate in Medicare’s Shared Savings Program, Accountable Care Organizations must implement processes to promote patient engagement, including shared decision-making.

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.