Would Increased Reimbursement And Longer Visits Improve Physician-Patient Communications?

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In a word…no.

It has been said that a physician’s patient communication skills are just as important as their clinical knowledge.   After all, it is only by “talking to and listening patients” that physicians are able to accurately diagnose and treat their conditions.   I have yet to meet a physician who did not agree with the importance of effective physician-patient communication…in principle.

In practice, a surprising number of physicians tell me that they “lack the time” and “don’t get paid” to communicate with patients.  Physicians euphemistically explain to me how current reimbursement schemes fail to incentivise physicians  to spend time talking to patients.

At face value, these objections appear to make sense.  After all we know that physicians, particularly primary care physicians, are already overextended.  We also know that the traditional fee for service model, which pays physicians on a kind of piece work basis, is not well-suited to managing “episodes of care” for a burgeoning chronic disease population.   In other words, today’s reimbursement is not properly aligned with the realities of care delivery.

The conclusion one draws from these two objections is that doctors would communicate better with patients if they simply had more time and were paid more.   But is that what would happen?

I don’t think so…and here’s why.

Many physicians, until recently, were never taught (in medical school) how to be good patient or person-centered communicators (the gold standard for physician-patient communications).   Studies show that the majority of primary care physicians today employ a physician-directed, paternalistic style when talking with patients.   This is the same style of communication practiced by physicians for the last 80 years.  This style is characterized by the physician control of the medical interview by asking the questions, focusing patient input, and providing pertinent information.  Some physicians now limit patients to asking one question per visit.  Over the course of their career, the typical physician will employ these same “conversational habits” in 120,000 to 160,000 medical interviews.

Patients, for their part are trained as well – socialized from childhood to assume the “sick role” wherein the doctor does all the talking and their job is to passively respond to questions when asked.  The average 60 year old for example will have experienced 180+ visits in which they were likely expected to assume the sick role.   Even the most engaged and empowered patient finds it difficult to avoid reverting back to this passive role.

What’s My Point?

The “communication habits” developed by and employed by physicians and patients took years to develop.   Simply increasing the length of the office visit (more time) and increasing reimbursement alone will not compensate for nor change the way physicians and patients communicate with one another.   Physicians will continue to be physician-directed and patients will continue to play the passive sick role.  Absent interventions aimed at breaking this cycle of unproductive communication by promoting more patient-centered communications, longer visits and more reimbursement will mean that physicians have more time for and get paid more for perpetuating the same physician-directed communications challenges we face now.

Patient-Centered Communication Can Lead To More Productive Visits

Physicians are concerned that patient-centered communications will increase the length of office visits.  Initially it probably will.  But imaging how much more productive office visits could be over time if patients came in focused and prepared, i.e., with a prioritized agenda, clearly articulated expectations, realistic requests for referrals, tests and medications, understanding of time limitations, and so on.  The average patient makes 3 visits to the doctor a year.  Patients with chronic conditions see the doctor up to 7 times a year.   Research shows that the adoption of specific patient-centered communication techniques in your practice could “reset” the physician-patient dynamic in ways that could increase visit productivity as well as patient outcomes and satisfaction within the course of a few consecutive visits.

That what I think…what’s your opinion?

Source:

Frankel, R. et al. Getting the Most out of the Clinical Encounter: The Four Habits Model . The Permenante Journal. 1999.

6 Comments

  1. explanthis says:

    The physicians who continue to employ the paternalistic 80 year-old model will not receive a return visit from me! The paradigm is shifting and you are right-more money and more time are not going to incentivize change in those who do not recognize they must change, too. Patients and physicians will benefit when we have shared health goals and mutual respect.

  2. kinda broad with the ole brush we paint folks with today? Lucky for you that I don’t take offense easily…………..

    The Patient Centered Medical Home shows that with more time and established criteria for performance and financial models that support the concept that we can get better care with lower costs.

    I do agree that just throwing more money at a problem without fundamentally changing the expectations and way we do business wouldn’t accomplish much. We have a desperate need to change the fundamentals and expectations from how we train Doctors to how medicine is practiced and the social and economic systems that operate them. I fear for our country and the profession that I love if we don’t push partisanship aside and do what needs to be done…….

    • Kerry,

      Thanks for your thoughts….and tough skin.

      I am a big fan of PCMH and agree that the results being shown by many of the pilots have been encouraging. But…there always a but…the savings have more than likely come from improved care management.rather than from “patient-centered care or communication”. The focus of every PCMH pilot I have seen has been on building out the HIT, team care and case management infrastructure needed to become an accredited or recognized PCMH. Very little attention has been paid in this first generation of PCMH to developing the patient-centered communication skills of physicians or other members of the PCMH provider team. This is evidenced by the lack of substantive requirements for :patient-centered” communications by NCQA, the Joint Commission, etc.

      For this reason, I suspect, and soon hope to demonstrate, that physicians practicing in accredited PCMHs are (at present) no more patient-centered in how they communicate with patients (as defined in the Kalamazoo Consensus Statement) than their non-PCMH counterparts. I am not trying to be negative or derogatory. This brings to mind a favorite quote regarding communications: “The problem with communications is the illusion that it has occurred.” That goes double for patient-centered communication. I can’t wait for the day I can say this is no longer true!

      Steve Wilkins

    • Kerry,

      Thanks for your thoughts….and tough skin.

      I am a big fan of PCMH and agree that the results being shown by many of the pilots have been encouraging. But…there always a but…the savings have more than likely come from improved care management.rather than from “patient-centered care or communication”. The focus of every PCMH pilot I have seen has been on building out the HIT, team care and case management infrastructure needed to become an accredited or recognized PCMH. Very little attention has been paid in this first generation of PCMH to developing the patient-centered communication skills of physicians or other members of the PCMH provider team. This is evidenced by the lack of substantive requirements for :patient-centered” communications by NCQA, the Joint Commission, etc.

      For this reason, I suspect, and soon hope to demonstrate, that physicians practicing in accredited PCMHs are (at present) no more patient-centered in how they communicate with patients than their non-PCMH counterparts. I am not trying to be negative or derogatory. This brings to mind a favorite quote regarding communications: “The problem with communications is the illusion that it has occurred.” That goes double for patient-centered communication. I can’t wait for the day I can say this is no longer true!

      Steve Wilkins

  3. Thank you for a great post! I am an advocate for improved patient-centered communication and have experienced first hand the push back when trying to promote the concept through policy and practice. I don’t have any magic formula for improvement in this area but believe that part of the solution is having these dialogues and raising awareness of effective communication models.

    I would be interested to know your thoughts about The Joint Commission’s recent new and revised standards for hospitals to advance patient-centered communication. Do you think they contribute usefully?

    Thank you for a great post!

  4. Stephen — It’s difficult to understand what you are proposing. Perhaps if you gave an example of a good doctor patient interaction it would help. Something like a movie script: (please add what you think would be ideal)
    Doctor: Hi John, what brings you here today? (shaking hands)
    John:

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