Given today’s tough economic environment, chances are that 15% to 20% of the people sitting in most doctors’ waiting rooms are out of work.  Do you know who they are?

You should.

Losing a job is a highly stressful event.  For most employed adults, work is a central part of one’s life and identity and a major source of income.  While job loss affects people differently, research suggests that loss of a job affects how many people feel – emotionally and physically.  Job loss, as well as job insecurity, has been linked to increased mental distress (depression) and physiologic responses such as a weakening of the immune system, increase inflammatory response which is associated with cardiovascular disease as well as an increase in blood pressure.  Depression is also correlated with more physician visits, medical tests, RX medications, hospitalizations and decreased adherence among patients.

As I pointed out in an earlier post:

It costs twice as much to treat a patient with depression ($4,780) as it does to treat a patient without depression ($2,794).

The solution?

Ask your patients what’s going on in their life, including current or potential job loss and problems at home.  Understanding the context of the patient’s life will allow you to provide true patient centered care to patients that desperately need and want your help.

Addendum:  For more information check out the following NYT article:

When Unemployed Means Unhealthy Too

Source:

Cohen, F., et al. Immune Function Declines With Unemployment and Recovers After Stressor Termination. Psychosomatic Medicine 69:225–234 (2007).

Depression Among High Utilizers of Medical Care.  Pearson et al.  Journal of General Internal Medicine. 1999: 14:461-468.

Their solution? Get physicians to share with patients the “evidence” for why their requests are crazy, wrong, ill informed or just plain stupid.  But getting patients to buy into the “Less is More” argument is a daunting task as most physicians already know.

The problem is complicated by the fact that patients have a lot good reasons for not buying into the “Less is More” message.

Here are some examples of those reasons and how people come by them:

Direct personal experiences with current or previous providers

• Doesn’t seem to know who I am or what problems are from one visit to the next
• Doesn’t have lab test results at time of visit
• My doctor can’t know everything
• Medications don’t work for me
• Too busy – feel rushed
• No time for questions/interrupted

Indirect health care experiences of family or friends

• My aunt died from diabetes…insulin didn’t help
• My friend with cancer received radiation and lived…that’s what I want

What people read/hear

• 50% of US adults don’t get recommended care
• Guideline always changing – example: mammography screening
• Medical errors/quality problems
• US health care system broken
• Rationing of care and death panels
• Doctors don’t have enough time and aren’t paid enough

In truth, before physicians can change a patient’s mind about what constitutes “needed care” they need to understand the patient’s health beliefs and expectations.   But that’s not something physicians are very good at.  Nor are they paid to do it.  So until we can create the right incentives for physicians and patients to talk about such things, patients are welcome to and entitled to their own expectations of needed care.

Source:

How Less Health Care Can Result in Better Health.  Archives of Internal Medicine.  May10, 2010.

The approach is clearly well regarded by patients, since it acknowledges that they are the focus of initiatives and that they can take control of their own healthcare.

There is also a realization developing within the industry itself that focusing on the needs of patients is a successful strategy for driving overall sales, regardless of whether the short-term goal is adherence, brand recognition, or switching.

So how can pharmaceutical companies ensure that patients be placed at the center of healthcare?

The number one rule is: don’t assume you know what patients want. Involve patients at the start, not as consumer-testers at the end of the process. Their feedback will provide useful insight into both the educational needs of patients and the way in which they want the information presented.

Patients don’t only want to know what their condition is and how to treat it, but also what they can expect when they start to take a drug. How will their symptoms change and how quickly, which side effects really occur and how frequently?  A truly patient centric approach will focus on what the patient can expect.  Patient stories and case studies may be a way to illustrate this.  Hearing first-hand accounts of other sufferers’ experiences allows patients to make comparisons with their own situation and can help them to put their own concerns into perspective. Personal stories can also inform patients of how others cope with the condition on a day-to-day basis.

How it’s said, is also important. All too frequently patient education materials use technical and scientific language, possibly because they are written by writers or healthcare professionals who are accustomed to writing for a scientific audience. There is also a concern that if you ‘dumb down’ the materials too much, you risk offending some readers. However, when preparing healthcare information, these fears are largely unfounded.

According to JAMA, 46% of American adults cannot understand the label on their prescription medicine and the average reading age of adults in the US is approximately 13 years. This means that if educational material is pitched at a 16-year-old reading age or higher, you may be excluding a large perecentage of your target audience.

Educational messages are often seen as the single most important aspect of healthcare education. But in building a lasting relationship with patient groups, you need to build trust and give them information that allows them to take control of their own health, rather than simply educating on the product.

Providing patients with tools such as lifestyle action plans, adherence reminders or symptom trackers can empower patients to manage their condition more effectively and make any behavioral changes needed. This approach helps to build trust among patients and assures them that you are working in their best interests, rather than simply promoting a product.  Providing patient support and tools that are not directly product-related is also in the interest of the healthcare professionals who prescribe the products and are well aware of the problems of non-adherence to medication. Since adherence influences product effectiveness in the clinical setting, healthcare professionals are more likely to prescribe a medication if there are support materials available for patients.

Healthcare education is not simply about educational messages; it is about empowering patients to make improvements in their health. Contact SRxA to learn more about how we can help you build programs that are relevant and engaging.

Over 50% of physician practices are now owned by hospitals according to the Medical Group Management Association. As such, many one-time private practitioners are now hospital employees.

Having done physician recruitment in a prior life, I know that before buying a practice hospitals look at a variety of things including the practice’s patient volume; number of hospital referrals, estimates of patient turnover and so on. One of the things we did not consider years ago in evaluating and buying a physician practice was the quality of the physician’s patient communication skills and supporting practices. I doubt that things have changed much since.

Hospitals today are under a lot of pressure from Medicare to address inpatient medical errors that compromise patient safety and often result in costly re-hospitalizations. As the line between doctor and hospital becomes blurred clinically and legally, hospitals need to start paying close attention to the way their doctor-employees communicates or doesn’t communicate with patients.

Consider the Problem of Medication Errors

Miscommunication between doctor and patient is thought to be a leading cause of such medication-related errors as patients not knowing:

• The names of all the prescribed medications they are taking
• Indications for using or not using the medications
• Dosage and frequency instructions

According the Institute of Medicine, approximately 500,000 drug errors or adverse drug events are reported every year in doctor’s offices and other outpatient settings.

In fact the evidence suggests that medication-related errors in ambulatory care settings may be substantially under reported. Consider a recent study of patients prescribed a blood thinner – Warfarin. Among older patients, Warfarin, and similar oral blood thinners, account for 10% of all preventable adverse drug events. In this particular study, 50% of all patients differed from their doctor in term of understanding how they we supposed to take the medication. In other words, one half of the study population was taking a Warfarin, a medication with serious side effects, incorrectly.

These finding are consistent with another 2006 study of physician-patient communications during primary care visits in which the physician prescribed a new medication. This study found that physicians:

• Did not tell the patient the name of the new medication in 26% of the cases
• Did not explain the purpose of the medication to patients in 13% of cases
• Did not tell patient about adverse side effects of the medication in 65% of cases
• Did not describe to patients how long to take the medication in 66% of cases
• Did not tell patients the number of pills to take in 45% of cases
• Did not tell patients about medication dosing and timing in 42% of cases

Doctors rely on patients to accurately tell them what prescription medications — and what dosages. In instances where the patient sees another doctor unfamiliar with their medication history, not knowing the name or dosage of a medication can cause serious problems. This is because “the other physician” may unknowingly prescribe a course of treatment that may have an adverse interaction with the patient’s primary course of treatment.

Failure to Inform Patients about Abnormal Test Results

Failure to inform a patient of an abnormal outpatient test result is another example of a serious error. The “failure to inform” rate was estimated at 7.1% in a 2009 study of 5,434 older adults in 23 primary care practices. “Failure to inform” rates for practices in the study ranged from a high of 26% to 0%. In cases like cancer where time is of the essence, any delay in treatment can have serious consequences for the patient.

Today hospitals are under pressure from regulators and payers to clean up their act with respect to inpatient quality, safety and outcomes. As hospitals employ more one time private practitioners, the list of quality, safety and outcomes issues faced by the hospital will grow to include issues like those described here. Issue previously handled by physicians in their own office.

My advice to hospitals? Know exactly what you are buying. Conduct a communications audit of the physicians in the practice before you buy. You will be glad you did.

Sources:

Schillinger, D. et al. Language, Literacy, and Communication Regarding Medication in an Anticoagulation Clinic: Are Pictures Better Than Words? Advances in Patient Safety. 2007.
Tarn, D. et al. Physician Communication When Prescribing New Medications. Patient Education and Counseling. 2008.
Casalino, A. et al. Patient-Physician Communication about Out-of-Pocket Costs. JAMA 2003.
Casalino, L. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine. 2009.
Preventing Medication Error. Institute of Medicine (IOM). 2006.,

Probably not. A quick examination of just some of the key drivers of  physician-patient communications reveals why:

• More Time Will Not Change How Physicians View the Physician-Patient Relationship

A physician’s communication style is a “window” into how they view the physician-patient relationship, e.g., physician-centered versus patient-centered.  One landmark study of physician communication styles found that almost two-thirds of physicians (IM and FP) in the study had a physician-centered view of how physicians and patients should relate to one-another.

• More Time Will Not Change a Physician’s Communication Style

While even the most physician-centered physician can incorporate elements of patient-centered communication in the medical interview process, the reality is that providers revert back to type. A provider with physician-centered directed orientation will still most likely interrupt the patient, not ask if the patient has questions and not use “teach-back” to make sure the patient understood what the physician said and so on.

• More Time Will Not Likely Change a Physician’s Reliance on Observable Patient Characteristics When Deciding How to Treat Patients

In addition to observable patient characteristics like age, gender, race and education, there is the person “behind the disease” who comes to the doctor with their own set of health beliefs, life experiences and treatment preferences.   When the physician recommends a treatment that the patient does not believe will work, the likelihood of patient non-adherence is much greater than if the physician took the time to ask the patient their thoughts and collaborate with the patient on exploring the treatment that will work for both parties.

Time is not the problem when it comes to improving physician-patient communications.  I don’t really believe that additional reimbursement to physicians for sub-optimal patient communications is the answer either.

Numerous studies have shown that patient-centered communication techniques in primary care practices can improve patient outcomes, change behavior and increase patient and provider satisfaction without increasing the length of the office visit.

So how do we improve the quality of physician-patient communications?  I have some thoughts that I will share with you in future posts.  In the mean time…please let me know what you think.

Sources:

Roter, D. et al.  Communication Patterns of Primary Care Physicians. JAMA. 1997:277:350-356.

Mauksch, L. et al.  Relationship, Communication, and Efficiency in the Medical Encounter. Archives of Internal Medicine. 2008;168(13):1387-1395.

Aita, V. et al.  Patient-centered care and communication in primary care practice: what is involved? Patient Education and Counseling. 58 (2005) 296–304.

Braddock, C. et al.  The Doctor Will See You Shortly – The Ethical Significance of Time for the Patient-Physician Relationship. Journal General Internal Medicine. 2005 November; 20(11): 1057–1062.

The Patient-Centered model of care is predicated among other things on physicians factoring in knowledge of the “person behind the patient” into their treatment.   That’s means understanding and, where practical, honoring the patient’s beliefs, values and preferences.   In order for a communication between a physician and person (patient) to be “patient centered,” it must be congruent with patient preferences for how they want their physician to communicate with them.

So Just How “Patient Centered” Is Social Media?

Let’s consider test result reporting to patients.   If you are among the 5% of patients who (in very recent large-scale studies) indicate they want to receive normal test results by e-mail for example, e-mail results reporting is very patient-centered. Only 1% of patients prefer receiving abnormal test results via e-mail.   Social media, e.g., e-mail, is not very patient-centered however if you among the other 95% of patients that prefer to be notified of normal and abnormal test results by telephone, snail mail, or in person visits with your doctor.   I understand that e-mail is not necessarily considered “social media” like Twitter, Facebook, or blogs, but it is the only “indicator” we have to date in the research literature.   I also acknowledge that non-physician blogs and social networking sites such as PatientsLikeMe show great promise in building self care management skills, confidence and support among people with similar chronic disease conditions.

Implications?

This is not to say that physicians should avoid social media when communicating with patients.   I am just saying that, according to the evidence, social media is not for everyone at this point.    No doubt patient preferences involving social media will evolve with the development of new applications and privacy protections…but we are nowhere near that point yet.

From my vantage point, when it comes to communicating with patients, physicians’ time would be much better spent by:

1. Learning what their patient preferences are (with regards to communications, medications, exercise, nutrition, etc.).
2. Tailoring conversations with patients during office visits to their preferences and concerns. The evidence shows that by doing, physician can more effectively engage patients, increase patient adherence, reduce cost and improve outcomes and satisfaction.

I have yet to see large scale studies that shows how social media can do that.

Take the patient’s opening statement aka “patient agenda” in patient centered lingo.  This is where the doctor asks the patient why they are there.  The resulting patient narrative is an opportunity for the physician to obtain valuable information to help assess the patient.  Patient centered advocates recommend that physicians use open-ended questions like “what brings you in today” to solicit the patient’s concerns and agenda.  Active listening by the physician and paying attention to the patient’s emotional cues are also hallmarks of patient centered communications.

The reality is that regardless of how they are asked, patients are often not able to complete their opening statement.  That’s because many physicians (75% in one study of primary care physicians) interrupt their patients within the first 18-23 once they start talking.  According to Jerome Groopman, MD, author of the book How Doctors Think, this is because doctors often have a hypothesis in mind regarding a diagnosis even before the patient says a word.  When patients do speak, there is always the risk that physicians “take off” on the first concern mentioned on the assumption that it is the most important reason for the patient being there.

Here’s a personal example.  Three times over the last several years my wife developed severe abdominal pain, nausea, vomiting and dehydration. Each time I took her into the emergency room as the problem always seemed to occur at night.  The physician would come in and ask my wife what the problem was.  No sooner did her opening words “I am a lung cancer survivor” get out of her mouth and the physician was off to the races apparently assuming that her being in the ER was due to her cancer.  Chest X-rays were ordered…the whole works.  Yet each time all she apparently needed was to get rehydrated (an IV) and given something to stop the nausea and vomiting.  After 6 hours we would go home and she would be fine the next day.

My point is that a lot of time and resources can be misdirected when the patient is not allowed to say what they think is wrong.  Not only is there a risk of wasting time, but physicians also risk losing the respect and trust of patients who feel they are not being listened to.  Had my wife been allowed to fully explain what she thought she needed, based upon previous experience, she would have been quickly treated and out of the ER.

The Take Away – The use of patient-centered communications techniques like agenda setting and active listening can go a long way in: 1) obtaining useful diagnostic information, 2) giving patients a sense that they are being listened and that what they have to say is important and 3) building rapport between the physician and patient.

The Bottom Line – According to researchers, the use of open-ended questions and active listening during the patient’s opening statement added 6 seconds to the average visit length.  In exchange, according to researchers, patients are more satisfied, adherent and report better outcomes.   Not a bad investment for 6 seconds!  What do you think?

Sources:

Beckman HB, Frankel, RM.   The effect of physician behavior on the collection of data. Annals of  Internal Medicine. 1984 Nov;101(5):692-6.

Marvel, K, Epstein, R, Flowers, K, Beckman H.  Soliciting the Patient’s Agenda, Have We Improved?  JAMA. 1999;281:283-287.

Groopman J. How Doctors Think. Houghton Mifflin. 2007.

• Sistemas de información electrónica
• Gestión de base población (crónicos)
• Orientación a necesidades de los pacientes
• Combinar acreditación con la certificación de centros
• Desarrollar medidas de resultado de atención primaria
• Alinear los sistemas de incentivos financieros

Hiện nay trên thế giới, quan điểm bệnh nhân là trung tâm trong chăm sóc sức khỏe ngày càng phổ biến. Ở nhiều nước phát triển, quan điểm này đã được đưa vào giảng dạy cho sinh viên y khoa. Với quan điểm này, bác sĩ cần thực hiện các nhiệm vụ sau:

• Giải thích cho bệnh nhân hiểu về tình trạng bệnh lý của mình

• Khuyến khích bệnh nhân thắc mắc, đặt câu hỏi

• Trao đổi với bệnh nhân về ảnh hưởng của bệnh lý và việc điều trị đối với sức khỏe và cuộc sống

• Để bệnh nhân tham gia vào quyết định điều trị sau khi được thông tin đầy đủ

Đồng thời, với sự bùng nổ về thông tin hiện nay, kiến thức của bệnh nhân về sức khỏe và về bệnh tật ngày càng được nâng cao thông qua tài liệu, sách vở, internet và các hoạt động giáo dục sức khỏe cộng đồng. Do đó, nhiều bệnh nhân đã nhanh chóng thích nghi với quan điểm bệnh nhân là trung tâm trong chăm sóc sức khỏe. Trong mối quan hệ này, thầy thuốc quan tâm hơn đến hoàn cảnh và điều kiện của bệnh nhân. Đồng thời bệnh nhân được hiểu rõ tình trạng bệnh lý của mình và tham gia một phần vào các quyết định ảnh hưởng trực tiếp đến sức khỏe và cuộc sống của chính mình.

Tuy nhiên, một nghiên cứu gần đây tại Đại học Iowa, Mỹ (2007) cho thấy quan điểm bệnh nhân là trung tâm không phải không có những nhược điểm. Thực tế cho thấy, một số bệnh nhân có khuynh hướng không tuân theo y lệnh của bác sĩ, mà chỉ làm theo suy nghĩ của mình sau khi có được một số thông tin cơ bản. Nghiên cứu này cho thấy bệnh nhân chỉ thật sự cảm thấy hài lòng và tuân thủ điều trị nếu họ gặp được bác sĩ đáp ứng đúng suy nghĩ của họ.

Ngược lại, một số bệnh nhân, đặc biệt là nhóm lớn tuổi, lại thích thầy thuốc kiểu cổ điển, nghĩa là người bác sĩ là trung tâm của chăm sóc sức khỏe. Với quan điểm cổ điển này, bác sĩ không nhất thiết phải giải thích nhiều cho bệnh nhân, quyết định điều trị chủ yếu do bác sĩ đưa ra và bệnh nhân chỉ cần tuân theo các hướng dẫn của thầy thuốc. Những bệnh nhân này, thực tế lại ít khi hài lòng và tuân thủ tốt điều trị khi gặp các bác sĩ theo quan điểm bệnh nhân là trung tâm. Họ cảm thấy không thoải mái khi được khuyến khích tham gia vào quá trình quyết định điều trị bệnh.

Theo nhóm bệnh nhân này, bác sĩ là người được đào tạo đầy đủ và có trách nhiệm quyết định điều trị cho bệnh nhân. Khi được khuyến khích tham gia và quyết định điều trị, bệnh nhân có cảm giác nặng nề vì cảm thấy bác sĩ đã đẩy trách nhiệm về phía mình và không được hướng dẫn rõ ràng. Bệnh nhân có thể cảm thấy bối rối vì phải tự quyết định và quá tải với các thông tin mà bác sĩ cung cấp. Trong khí đó, những bệnh nhân trẻ, có trình độ lại thích gặp các bác sĩ xem bệnh nhân là trung tâm.

Dựa vào kết quả các khảo sát và nghiên cứu, các tác giả tại trường đại học Iowa cho rằng không nên áp dụng một quan điểm cứng nhắc nào đó cho tất cả các bệnh nhân. Người thầy thuốc cần được đào tạo để nhận biết được nhu cầu của từng bệnh nhân và áp dụng cách tiếp cận phù hợp cho từng đối tượng cụ thể. Qua đó, giúp bệnh nhân cảm thấy hài lòng và tuân thủ tốt y lệnh.

- Bác sĩ Hồ Mạnh Tường -

dissertation.com, amazon.com and barnesandnoble.com 

This is an interdisciplinary study of the conflicts and tensions in the role of NHS complaints managers.  It sets out to explore the contradictions inherent in the role of complaints managers and the ways complaints managers deal with these contradictions.

The interdisciplinary theoretical underpinning of the research is informed by conceptualizations of the complaints manager in the specific socio-legal sense of ‘complaints handler’/ third-party dispute handler;’ a broader public administration framework, of ‘administrator’/ bureaucrat, and finally a wide-ranging sociological/ social psychological framework, as ‘social actor’. Thus the thesis draws on an eclectic range of literature from socio-legal studies, public administration, sociology, and social psychology. It also draws on non-theoretical social policy literature in relation to the policy context of the thesis.

In relation to methodology, the research uses a qualitative approach. It is based on in depth telephone interviews recorded with thirty NHS complaints managers, which were transcribed verbatim and are the focus of systematic analysis. The complaints managers’ interviews are supplemented with documentary analysis of job descriptions and person specifications of NHS complaints managers and email interviews with ‘NHS complaints experts’ (who are not complaint managers) who have a specialist knowledge of the complaints manager role.

Three key areas emerged as the principal findings of the research:

• The complaints manager’s role encompasses inherent contradictions, regardless of the personal style or individual approach of the complaints manager;
• Complaints managers exhibited opposing stances (that is very different responses/ reactions) to the inherent contradictions in their role in relation to ‘organization orientation’ versus ‘complainant orientation’;
• There were different types of complaints managers. Accordingly, a typology of complaints managers was generated with specific reference to their responses and reactions to the inherent contradictions in their role, in terms of complainant orientation versus organization orientation.

In conclusion, it is argued that there are without doubt fundamental contradictions in the role of NHS complaints managers in terms of reconciling complainants’ rights with organizational requirements. However, ultimately, individual complaints managers respond and react very differently to the inherent contradictions in their role.