Patient-Centered Communications – Does “Lack of Time” Justify Physician Reluctance To Adopt It?

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I talk with lot of physicians about the need to improve the quality of communications between physicians and patients.   Regular followers of my work will know that I am an advocate for the adoption of patient-centered communication skills by the physician and provider community.

Waiting Collage2Physicians with whom I talk seldom disagree as to the need for better physician-patient communications.   They know that physician communication skills top the list of patient complaints about their physicians, i.e., my doctor doesn’t listen,” “my doctor ignores me,” and so on.   Rather, they simply dismiss the subject out of hand as being impractical due to a “lack of time” on the part of most physicians.

I can understand their perspective.   Primary care physicians in particular are faced with sicker, more demanding patients, increased payer and regulatory requirements, and are constantly pressured to see more patients.

Yet physician waiting rooms and exam rooms are full of engaged patients (otherwise they wouldn’t be there) who have nothing to do but read outdated magazine.

What would happen if physicians actually put patients to work during wait time?

Here’s what I mean…

What if physicians integrated patient “wait time” into the office visit by:

  • Talking to patients (via printed handouts, electronic media, patient portals, etc.) about their evolving new role (and that of the physician and other providers) under health reform.  Contrary to the popular press which touts the empowered patient, most of us still assume the traditional “sick role” during the office visit.  The sick role is characterized by patient passivity, limited information sharing, and minimal question-asking.
  • Teaching people while waiting how (using the same media as above) to become “better patients.”   I recall an article where physicians were asked 5 things they wished their patients knew.  At the top of the physicians’ “wish list” was a desire for patient’s to be better prepared and more focused during the visit.  The point being that more prepared patients would help the physician get to the correct diagnosis and treatment plan faster

All of us, beginning in childhood, are socialized into playing the sick role when interacting with physicians.   Just as chronic disease patients needing to develop self care skills and confidence in their self care skills…patients need to be taught skills for (and develop confidence in) how to more effectively talk to and collaborate with their physicians.

  •  Laying out a game plan (over a series of visits) for teaching new and established patients when and how to effectively contribute to the medical interview (exam).   Given an average wait time of 22 minutes per primary care visit, it is not reasonable to assume that patients can be taught the above in the course of 1 or 2 visits.  But patients with chronic conditions often visit their PCP 6-8 times a year.  This would afford plenty of time (2-3 hours a year) for physicians to teach (and practice) individual skills to patients (i.e., agenda setting and prioritization, question asking skills, self-care management skills, new medication considerations, etc.).   By reinforcing lessons learned by patients over the course of several visits, it is reasonable to expect that both patient and physician will become more proficient in the use of their time together.

 

How Exactly Will Better Physician-Patient Communication Lead To More Productive Visits?

Research has consistently shown that patient-centered communications (versus traditional physician-directed communications) can result in more productive office visits as measured by 1)  the amount/quality of information shared by patients, 2) the number of questions asked by patients, and 3)  and the level of patient retention of information shared by physicians.

These same studies show that the adoption of patient-centered communications adds little if any more time to the length of office visits.  Once patients and physicians become proficient in the use of patient-centered communications methods,  physicians may well be able to do more during the visit but in less time.  Here are some of the techniques  characteristic of patient-centered  communications associated with increased visit productivity:

  •  Concise visit agenda setting and prioritization wherein both physician and patient  agreed to what can be discussed within the time allowed.  This  also eliminates  the “oh by the way” introduction of last-minute patient agenda items that can occur at the end of the visit.
  •  More concise  sharing of relevant information by the patient.
  • Greater physician-patient agreement as to the diagnosis and treatment.
  • More collaborative decision-making
  •  More information retention by patients (how to take new Rx, etc.)
  • Greater patient adherence

 

That’s my opinion…what’s yours?

Related Post:

Do Medical Home Physician Really Communicate Any Better Than Non-PCMH Physicians?

Six Seconds To More Effective Physician-Patient Communications

Sources:

Politi, M. C., & Street, R. L. (2011). The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17(4), 579-84.

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine : JABFM, 24(3), 229-39. doi:10.3122/jabfm.2011.03.100170

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

4 Comments

  1. I am always being asked just what does being “patient-centered” mean? I have learned the meaning of this phrase varies with the role the person plays in patient care – from drug manufacturer to provider to payer, etc. What you have written here provides a very comprehensive definition and set of steps to be patient-centered from which ANY stakeholder can learn. You have also clearly laid out a role for the patient – this helps create a collaborative approach that puts some responsibility on the patient themselves. I know there is ongoing discussion about the value of this responsibility as some patients do not want this nor can accept it. However, I strongly believe, especially as the responsibility for managing care changes, the patient does need to learn just how valuable they are in ensuring the outcomes of their own care – as many activist patient will attest.

    • Dyan, Thanks for your thoughts! The term patient-centered has been around for 30 years. It is not new. For a standard definition of patient-centered care check out the Institute of Medicine (Crossing the Quality Chasm) – here’s a link to a series of slide which addresses this. http://www.ahrq.gov/about/annualconf09/barr.htm.

      Indeed patients will have to assume a new role in health care – like it or not. It remains incumbent upon physicians and other providers to help patients adapt to their new role however. After being socialized from childhood to accepts the passive “sick role” it will take some time, training and support to help patients become “better, more engaged patients.” This is the part that everyone seems to overlook.

      Steve Wilkins

  2. Stephen, I appreciate (all of!) your posts, and am intrigued by the prospect of using the waiting room as a teachable environment. I think you’re on to something. Becoming more empowered and prepared could also help allay some of the inevitable anxiety about talking to the doctor/being in a healthcare environment.

    I work for a health system that has spread the patient-centered medical home model in all of its 25 clinics, and it would only serve to reinforce the patient-centeredness if our exam rooms and waiting rooms had cues to action to guide patients (everything from posters in the exam rooms urging patients to communicate and be active partners in their care, to notepads in the waiting area where patients can jot the three most important items to cover during that visit).

    Thanks for calling out this opportunity.

  3. kathy Torpie says:

    This issue is a bit of a chicken & egg thing. The entire culture of physician as expert and patient as passive recipient has a long history of conditioning on both physicians and patients. For the relationship to change, BOTH need to change.

    Currently doctors interrupt the patient within the first 18 (?) seconds of an interview. Some learning is needed on both sides about effective communication. And both need to be engaged in the process. Pamphlets can teach, not engage. Unfortunately, for those patients well conditioned to being passive participants in their care, getting them engaged in taking more control (and responsibility) in the medical encounter with take being personally engaged by their physician in a supportive and trusting relationship.

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