What Kinds Of “Patient Experiences” Are Occurring In Your Doctors’ Offices?

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Hint: They Aren’t As Good As Your HCAHPS Scores Suggest

Now that over 50% of physicians are employed by hospitals, this is a question that should be on the minds of progressive hospital executive teams.  With good reason. Patient-reported outcomes, including satisfaction and loyalty, are going to play an increasing role in determining how much hospitals and physicians are paid. This means that astute hospital marketers will be able to build a strong business case for investing in programs aimed at creating superlative ambulatory and inpatient experiences for patients.

doctor patient communication2But Our Physicians Already Have High Patient Satisfaction Scores

Health care executives should take little comfort in the global patient satisfaction and loyalty ratings found uniformly in HCAHPS  and every patient satisfaction survey.

Generally speaking,  “one can assume that the quality of care is, actually, worse than surveys of patient satisfaction (suggest)”according to Avedis Donabedian, MD, the father of today’s quality movement.   Donabedian goes on to say that “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. ”

Just look at the quality of physician-patient communication, a key ingredient of the “patient experience” in the physician’s office.

  1. In only 26% of the visits are patients allowed to complete their opening statement (agenda) without interruption (by the doctor); in 37% the physicians interrupted; and in 37% physician never asked about the patient’s visit agenda.
  2. Studies suggest that patients do not express their health concerns, expectations or opinions in up to 75 percent of physician visits principally because their doctor never asked.
  3. Primary care physicians typically spend less than 60 seconds informing patients how to take new medications…or why.
  4. Primary care physicians and patient disagree about the diagnosis, treatment, and cause/severity of their condition over 50% of the time.
  5. Over 50% of patients walk out of their doctor’s office not understanding what they were told, including why or how to take their medications.

 

For their part, patients today are hard pressed to rate the effectiveness of their relationship with their doctor.  The evidence shows that poor physician-patient communications is the norm rather than the exception.   As such, most patients do not appreciate all the ways in which their doctor could in fact do a better job communicating with them.

Why Is Any Of This Important?

Simple.  Hospital and physician reimbursement is increasingly determined by things that are closely linked with the a physician’s patient communication skills:

  • improved patient outcomes
  • fewer hospital re-admits
  •  fewer medical errors

 

So if hospital chiefs of staff or health plan medical directors are looking for a way to improve these types of metrics consider improving the way your physicians and patients talk to each other.   In the long run patients and physicians will thank you for doing so.

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

Sources:

Dyche, L., & Swiderski, D. (2002). The Effect of Physician Solicitation Approaches on Ability to Identify Patient Concerns. Family Medicine, 267-270.

Lang, F., Floyd, M. R., & Beine, K. L. (2000). Clues to patients’ explanations and concerns about their illnesses. A call for active listening. Archives of family medicine, 9(3), 222-7.

Howard Waitzkin, MD, P. (1984). Doctor-patient communication – Clinical Implications of Social Scientific Research.  JAMA, 252(5), 2441-2446.

Heisler, M. (2008). Actively Engaging Patients in Treatment Decision Making and Monitoring as a Strategy to Improve Hypertension Outcomes in Diabetes Mellitus. Circulation.

18 Comments

  1. Joyce N. DeWitt says:

    I guess I’m very lucky then, since I rate my internist highly because he deserves it. From my very first visit with him 8 years ago, we have had very good communication. He does ask what’s new, what’s different, how I”m doing. He asks about my mood, alcohol intake, exercise, and sleep. I have blood pressure issues and he looks at the data that I take and give to him. We talk about diet, stress, exercise, and other factors. He does listen, and he does not interrupt. When I have had other health issues, he has been quick to recognize when I’ve needed to see a specialist, and has referred me to other excellent doctors. He is cognizant that his looking at the computer is a distraction to some, and he once asked if it bothered me. No, it doesn’t, because he is good at looking at the information he needs while still able to continue a conversation. He educates about medicines and conditions, and always checks for understanding. He will draw something out if he has to. He doesn’t talk down to me. He listens to my thoughts about my own health and he never says, “this is what you have to do,” rather he suggests or recommends. He’s very personable and we’re usually able to share a laugh. He is very respectful of everyone and just a wonderful man in addition to being a top notch doctor.

    • Joyce,

      While I would like to think that every physician relates to patients as you describe…that is not what research shows. Nor unfortunately is it consistent with many people’s experience, including me.

      Thanks for your thoughtful comments! You are indeed lucky to have such a physician.

      Steve Wilkins

  2. Hi Steve,
    Could you please provide your sources for the numbered statements you mention above?
    Thank you,
    Cynthia Calmenson
    Executive Director
    Integrative Medical clinic Foundation
    http://www.imcfound.org

  3. Lori says:

    Joyce is indeed a lucky gal!
    I do agree with you that poor doctor-patient communication is the norm and not the exception. I could write a thick book about my experiences with doctors misunderstanding me, misdiagnosing me and blatantly disregarding any of my queries, and I am only 48.

    We hear on Dr. Oz and WebMD that we are supposed to enter our doctor’s offices with lists of questions and concerns to make sure we understand our conditions and get the proper treatment. Do this in “real life” and you, the patient, is often seen as “troublesome,” or “difficult.” Some doctors become downright nasty if you try to engage them in a two-way conversation about your condition. I find this the case with specialists moreso than PCPs, and much more prevalent here in the Northeast as opposed to the Mid-Atlantic and West.

    My PCP is pretty awesome. He is the exception to the rule in many ways – now that I know him and I can tell when he is feeling rushed by the forced double and triple booking made necessary by recent laws (thanks Obama!!). Most of the time I can get my questions answered – but I have to ask them in a machine-gun fashion. Years ago, I learned to bring a printed update listing of all my medications, my current complaints, past diagnoses and any changes to my care made by my specialists. I give this to the MA when I check in, so my PCP gets it when he picks up my chart before he enters the treatment room. I now do this routinely with all my doctors, but I find that I have to “train” them to read what I have provided. It really is a huge time-saver and cuts down the chatter time considerably, leaving time for questions and concerns.

    I have a medical background and take an active role in trying to figure out what is wrong with me (my PCP calls me a “real medical mystery” due to some complex ailments and genetic anomalies). I thoroughly research my conditions in professional publications and texts on PubMed and Medscape for possible clues as to what may be going on with me, since I know doctors rarely do a 15-second Google search much less research any matters and just try to fit the symptoms into the usual pigeonholes, except on TV. (This is what I call the “sounds like horses, must be horses” myth. In my case, its not zebras, its emus!).

    It is incredibly fantastic that my PCP likes that I research my conditions, as the evidence-based movement and the new practice guidelines being issued by medical and non-medical (governmental) agencies telling doctors that certain tests are a waste of time and money (most recently, mammograms and PSA levels), or how to treat back pain, for example. (New guidelines published in Journal of the American College of Radiology’s October issue are horrifying. If I walked into a doctors office today, and doctors followed these guidelines to figure out my back pain issues, my situation would have gone completely undiagnosed and untreated. Thanks to my research, and my PCP’s willingness to be open-minded to treatments other than antiquated and tunnel-visioned approaches practiced by the stogy New England docs around here, I’m 70% better than I was 5 years ago. I’m not talking alternative med stuff, I’m talking about diagnostics and procedures developed in the past 20 years. Had my PCP followed these narrow-minded guidelines, I would be quite possibly be unable to walk without assistance and most definitely dependent upon bladder catheterization the rest of my life!!

    However, most of the specialists I see do NOT respond well to any questions I have about my conditions, and remain silent about any research I bring to the table. However, appointments are booked so close together so docs aren’t really permitted time to answer any questions, much less discuss anything with patients. The result is that I (and I am sure a lot of others) are not getting the best care. For example, it is frequently suggested that I take a medicine contraindicated by my underlying abnormalities, or I am misdiagnosed completely.

    Why do the studies reflect that patients are more “patient?” I think it is because at some internal level, we fear our doctors. We don’t want to anger them, lest we be deemed a “difficult” patient, and possibly receive less than optimal treatment. (Yes, this happens. I worked in a medical office and a hospital and saw it happen on numerous occasions.) The “Seinfeld” episode when Elaine gets labeled as a “difficult” patient and she cannot find a doctor to treat her anywhere in NYC illustrates this fear that is at the heart of many patient’s patience. I think that social media/blogging is allowing many of (like me) to work past this fear and advocate for better care for ourselves. I just hope doctors will start reading the blogs, Medscape updates, and other articles that are meant for them.

    • DevonTexas says:

      “now that I know him and I can tell when he is feeling rushed by the forced double and triple booking made necessary by recent laws (thanks Obama!!). ”

      There’s nothing in “ObamaCare” that tells doctors how many patients to treat in an hour. As pointed out below, your doc seems to double and triple book and you are blaming the wrong person. President Obama and the ACA have nothing to do with it. The fact that you read something on the internet, doesn’t make it true. For example, there are wild claims that anyone over the age of 75 will no longer get treatment for diagnoses like ESRD. Totally false but it is a popular myth that proverbially “gone round the world before the truth puts on its shoes”.

      I have written about the implications for dialysis patients if the ACA is repealed. They are pretty gruesome and that’s just one small class of patients with a specific diagnosis. For whatever you might have read about the “bad” in the ACA, it is far outweighed by the good. You’re welcome to read my posting at: http://devontexas.wordpress.com/2012/10/20/dialysis-and-aca-repeal/

      • Lori says:

        I really dislike the fact that you meed to insult me and get off topic of this initial pot. This has NOTHING to with my personal experiences with my doctors offices.
        Just b/c you don’t believe what my doctors are telling me, doesn’t mean you have the right to insult me. I didn’t “just read something on the internet.” I am not one of those people. I have the ENTIRE text of the ACA on my iPad. I read THAT – not -”stuff on the internet.” YOU are the one blindly defending Obama – you have no idea what the impact of his policies have had on the doctors I see – they tell me themselves. These docs are all located in the greater Boston area. Are you telling me that they are lying? REALLY? These are doctors that practice for some of the most prestigious hospitals in the world, and teach at Harvard University. So – once again – insulting me doesn’t make YOU right. I don’t go to websites like CNN, MSNBC or the like. I get my facts from the sources that produce the original stats – and even then, I doubt about 50% because I know that the deception this political climate has created runs deep.

  4. southern doc says:

    How in the world is Obama forcing your doctor triple booking appointments? I would guess that it’s much more related to low payments by for-profit insurers.

    • Lori says:

      Apologies for the delay in responding to your query.
      Without referring to the ACA section by section (although 1210 is one section that covers why drs offices are now or will be much busier…especially if they are run by a for-profit VC group like my PCP’s office is-Steward), here it is in a nutshell:
      -expansion of coverage
      -insurance companies offering plans that compete with Medicaid (in MA, Fallon Community Health, Neighborhood Health, BMC NetWork) which jack up the number of patients that fill the PCP offices that participate in the plans, simply by virtue of them being “in network” with a particular group of hospitals. In other words, doctors cannot say, “no, we don’t accept MassHealth (MA welfare plan) patients” like they used to. The doctors have lost their ability to say “no” – in fact, I read a blog written by a family practitioner about thus exact topic recently. I should have bookmarked it.
      -payments (see the aforementioned section 1210) are increasing by 10% to catch up with Medicare payments (great for docs, which deserve even more, but not so great if they are working for a for-profit company that has increased their workload by mandating they see X number if patients per day to meet the new demand.
      Hence, triple booking. That meets the demand. There’s always a few that won’t show up at all, and those few that show up hours early, so juggling of patients can usually be done w/o anyone really noticing.
      BUT, when these new patients start brining their entire family units to appointment (5-7 people) and they ALL go into the treatment room when the patient is called in, it’s fairly obvious to those waiting that they are taking up more than their slotted 15min time – it’s more like 45min. It’s frustrating and maddening. Yes, these people may have the “right” to healthcare, but they don’t have the right to monopolize the entire system.
      Average wait to see my PCP used to be 15min. Now it’s up to 2 HOURS. If I didn’t really like my PCP, I’d find a new one, but many have closed their ranks recently. I wonder why???

      • southern doc says:

        Yes, doctors may be required to participate with certain insurers, but nothing requires them to open their practices to more patients than they are comfortable taking care of. Your doctor is triple booking patients because he works for a for-profit corporation: President Obama has nothing to do with the way he schedules patients.

        Sounds like it’s just a very badly run organization that’s after the bucks

        • Lori says:

          I agree that Steward isn’t exactly running this practice in the best way – but the changes in healthcare policy ARE the driving force behind their decisions. Steward is very generous to their employees – but their practice guidelines seem to be causing some unrest amongst the practitioners. I made this comment based on what I was told by the people in my PCP’s office – it is not my own conclusion plucked from the air.

      • southern doc says:

        I know plenty of docs in Massachusetts who have not increased their patient panel and do not triple book. If Corporation X is telling you that “healthcare policy” requires that, they’re feeding you a line: it’s all about the bucks.
        It’s interesting that you blame Obama for the things you don’t like about Romney care!
        Romney didn’t create the primary care shortage in MA. Obama didn’t create the primary care shortage nationwide. The shortage is the intended result of 30 years of policies adopted by the medical schools, AMA, and insurers to destroy primary care.

      • Lori says:

        I never said I disliked Romneycare!! I enjoy the fact I have been able to benefit from it. It’s Obama’s butchering if Romneycare that I don’t enjoy. (For example, Removal of FSA eligible items, causing tens of thousands of “middle class” people to lose huge chunks of $$ they had placed in their FSA accts last year, thinking they could use it as before – for medical items. )
        And geez, stop harassing ME about the policies of my PCP’s practice owner. Not my fault-they saw an opportunity to increase reimbursement from govt – they took it. Try googling for the opinions of others in the medical field about Obamacare. Not everyone is jumping for joy.

  5. JD Wright MD says:

    Steve, these are important points you bring up, important for a variety of reasons. I am a physician, a hospitalist, and have commented on this blog before. I am again drawn to a forgotten, or at least de-emphasized, “activity” which is listening. Real listening. Certainly doctors are taught to listen to patients, to extract the “history” from them, to get the information necessary to arrive at a diagnosis, a plan of care. But listening is, or can be, much more than that. As Lori points out, doctors usually listen long enough to find a diagnosis (or diagnoses) that they think could explain the patient’s complaints. This is not wrong, but all too often it closes the door on further speculation on what’s really going on. Especially as doctors become busier and forced to see more patients per unit time, docs tend to latch onto the diagnosis that seems most likely at the time, and “run with it.” One problem with this approach is that it effectively shuts down further communication. At this point the doctor is done “listening” and is in diagnosing/prescribing mode. So if the patient tries to offer more information, or expresses some disagreement with the diagnosis or plan of care, the doctor is disinclined to stop and reconsider their analysis.
    The other (and I think just as important) thing about listening is that true “active” listening can have a therapeutic effect and can strengthen the doctor-patient relationship in many ways. And it can save time, money and misery. If a patient has an unusually effective and satisfying doctor visit – like Joyce – they feel more confident that their problem was addressed, that their fears and concerns were “heard”, that they had some control during the interaction. They feel “listened to.” This cuts down on later phone calls to the doctor’s office for clarification on instructions, questions on meds/tests ordered. It also greatly reduces the likelihood the patient will “doctor shop”, ie, go find a doctor who WILL listen to them.
    More later…
    Thanks for “listening…”

    • Lori says:

      Dr. Wright, as a hospitalist, you are tasked with an especially difficult job of listening- you see patients on a regular basis that you are completely unfamiliar with, yet you have to make important decisions about their care essentially “on the spot.” Admirable choice of career! I was just in hospital for 4 days. Since my PCP was not part of the hospital’s “group,” he was not contacted about my history, so everything the hospitalists knew about me came from me. The problem was that the hospitalists did not follow patients during their admission-at least not where I was admitted, they changed daily, so I was forced to give my Hx THREE times. It was quite clear that no information had been shared between these guys, because I had to repeat everything each time. Poor doctor-doctor communication aside, the doctor-patient communication I experienced in hospital was extraordinary. The bedside visits were not protracted, yet they were thorough and communication was two-way. Perhaps hospitalists like yourself could provide some hints to non-hospitalists for improving their communication skills, as you guys seem to have it down to a science.

  6. Joyce N. DeWitt says:

    I would like to add to my comments about my doctor. He is very forward thinking, and has been heavily involved with all of the technology now becoming fairly routine in most doctor’s offices: EHR, patient portals, Twitter. He is with a big group. The office staff, receptionists, schedulers, nurses, lab technicians… everyone there is very pleasant and eager to assist patients. They all seem happy to be there. They couldn’t be more competent, yet they are also very kind and friendly. When I leave his office, in addition to the “yellow sheet” with all the unintelligible numbers and coding, I also have a complete record of my visit. It includes all of my ailments or conditions, medications, and next scheduled appointment. I can also access online any of this information, including my entire past medical history with the group. This includes procedures done by other doctors, such as the surgeries I have had. I can look up the results of every lab test I’ve had in the past 8 years, and compare cholesterol levels, iron deficiencies, etc. I can print off my entire medicine list and past medical problems to take with me to a new specialist. I recently needed to see an allergist, and I handed in all of this information with the form that I filled out. I didn’t need to write all of that information in, as it could just be attached. However, when I got into the examining room, the nurse proceeded to copy from those sheets every medicine that I was taking onto another form. I asked her if she couldn’t just attach it, and she replied that she could not, and that she had gotten blessed out for doing just that a short time ago,This is the kind of thing that needs to go away in health care. What she was doing is redundant and also subject to human error.
    My internist’s practice also uses a patient portal, if the patient wants to tap into that. I can email my provider about anything,….and I will get a response within one business day, but I often get an answer the same day. I have used the portal to ask questions, to add information to my health record, or to make a comment about how something is working or not working. I recently had a serious health issue and an ER visit, and my doctor was out of town. I described the incident and sent it through the portal. His nurse then contacted him with the info and he gave her instructions. She called me to tell me what he had said about the incident, and that he wanted me to follow up with a visit to an allergist. He was also concerned that some of the medication I’m on might have played a role, and that we would discuss this at my next visit.
    On Twitter, he is always looking for answers to questions about patient engagement, patient adherence to instructions, doctors on social media, and the way health care is changing. I have mentioned teleconference patient visits since we may move in the near future, and he has indicated that it may not be all that far off with his group. He posts many things on Twitter that lead me to look up and read all kinds of health and medical related articles. Some of the articles also deal with the economic and financial side of health care, some deal with illnesses such as new information about diabetes, blood pressure, asthma… and then occasionally he will also tweet about sports, or something amusing.
    I would also like to say that his group is part of Carolinas Health Care Systems. Out of ten doctors that I have had to deal with in this system, eight have also been excellent: professional, proficient, kind, personable, and very accommodating about patient questions and comfort. The other two were not bad, just not as good as the other eight. To me, this system works very hard to maintain top ethical and professional standards, while always remembering that the patients they serve are the most important part of the picture. I have never waited more than 20 minutes for an appointment in the 8 years that I’ve been here, and that includes all of the doctors I’ve seen. I came from a huge city environment where the attitude was not all that focused on patient satisfaction. I often waited hours for appointments, and came away not really clear about the whole visit. I didn’t know what I was missing until we moved here. I’m sorry that it’s not this way for the whole rest of the country. I lucked into my doctor here. He seems to genuinely care and to like what he does, and he has passion about all of the new things happening in his industry. I hope I don’t, but If I do have to change doctors someday, I will definitely know what to look for, and I will actively seek the same kind of care I’ve had here.

  7. As bad as the statistics seem there is a good side. Many patients do leave the provider’s office happy with the care and happy with the information they received. Communication is a two way street. It will probably take a generation before providers improve. So, from a pragmatic standpoint, it is very important for patients to learn how to communicate about their health and get the benefits of the skill now.

  8. DevonTexas says:

    Thanks, Steve, for a thought provoking article. It inspired me to write about this topic and reference your blog posting in my own . I’m considering what I, as a patient, can do to avoid the non-listening and encourage interaction with my doctors. I was hoping some of the comments here would spark ideas. The comment by Joyce DeWitt seems to point in a direction that may help, EHR and the active involvement of the patient with the doctor via electronic health records. If we, as patients, take an active role in a similar manner, it increases the level of communication. But I still believe that too many doctors spend too little time with their patients actively listening. Interaction via EHR can be too little, too late.

  9. Lori says:

    The few of you that insist on attacking me – probably because you are Obama supporters – attacking me perhaps should read other blogs written by doctors that address the issues of Obama’s ACA. Just two of MANY…

    http://healthworkscollective.com/johncgoodman/56831/health-reform-matter-life-and-death?ref=node_related_posts.

    http://healthworkscollective.com/david-fried/57741/how-physicians-can-adapt-affordable-care-act-aca?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+healthworkscollective_allposts+%28Healthworks+Collective%29.

    Then, if you continue to disbelieve what my doctors told me, go and attack these doctors that wrote these blog posts!

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