The 10 Commandments of Patient Engagement

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As a patient, care giver, researcher and a human being, here ‘s my “take” on what physicians and hospitals, and all the entities that work with them like health plans, ACOs , etc. need to do to effectively increase patient engagement in 2013 and beyond.

  1. Act like you are glad to see them (patients) and have time for them… no matter how busy you really are
  1. Say something relevant to suggest that you actually remember who they are – don’t get this one wrong
  2. Ask how they have been since their last appointment and what brings them in to see you today
  3. Probe for the patient’s ideas as to the cause of their complaints and what they would like you to do for them
  4. Listen to what the patient has to say without interruption – ask clarifying questions
  5. Tell the patient what you recommend doing in the way of tests, treatments and new medications…and explain why you are making those recommendations – ask if that’s ok with the patient…if it’s not ok find out why
  6. Pay attention to patient-initiated cues (loss of a job or loved one, sighing…) – they probably are a call for help
  7. Express empathy and support to patients
  8. Find out what your patient’s health goals are and what steps they believe they can take to achieve them, e.g.,  care planning
  9. Ask about or suggest ways that you and your team can support  patients’ long-term care plans

 

The challenge most physicians and other providers face is not one of how to engage patients.  Most of us patients (people) are already engaged to the extent we:

  • went to the bother of calling your staff to make an appointment (never a pleasant experience)
  • took time off work to travel to your office
  • wait an average of 24 minutes to see you
  • sit for 24 minutes thinking about what we want to talk with you about and how you are too busy to listen

 

Rather the challenge for providers is how to be engaging to patients.  Health care after all is an intensely personal and social interaction between human beings.   My apology to all the health information technology folks who suggest EMRs, web portals and smart phone health apps are the best way to engage patients (they are not).  I for one am convinced that people would be more engaged in the care (they way providers expect and prefer) if only providers were more engaging…lack of time and reimbursement notwithstanding.

I am sure I have missed something so please feel free to add to the list.

Check out more posts on Patient Engagement:

Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

 Patients Are Often More Engaged In Their Health Than Providers Think

Patent Portals. PHRs, & On-line Decision-Support Tools Alone Will Not Lead To Greater Patient Engagement

Patient Engagement  Infographic

23 Comments

  1. mggoldstein says:

    Stephen, I am surprised you left off the key message from your December 4th column, asking about our patients’ personal health goals! I also think asking the patient about their agenda for the visit…repeatedly…is key, though you noted that step in number 4 on your list. In addition, it is also useful to ask our patients what they are already doing to manage their health. So, my favorite 3 questions are: 1) “What would you like to address today?” ; 2) “What are you currently doing to improve your health and wellbeing?”: 3) “What would you like to work on to improve your health?”.
    Best wishes for the holidays…Michael

  2. jannaass says:

    Gosh to get half of those steps met, would be great. I feel you have itemised a well balanced set of points, to be the foundation of starting an engagement, that can then be customised as needed.

  3. Carolyn Thomas says:

    I am already imagining the frustrated reactions from many docs I know to your 10 Commandments, Steve: “I have no time as it is!” during a rushed office visit.

  4. southern doc says:

    ‘I am already imagining the frustrated reactions from many docs I know to your 10 Commandments, Steve: “I have no time as it is!” during a rushed office visit.’

    Ok, I’ll bite.

    Facts:

    An office visit is still 15 minutes (though trending towards 10-12 in large corporate clinics), but fully 50% of that is now eaten up by data entry, meaningful use chores.

    The average patient in primary care has four medical concerns per visit (some studies indicate as high as six).

    Seven and one-half minutes, four problems, ten patient engagement bullets.

    Do the math and tell me the answer

    • Thanks for stepping up…

      Who said you need to do all 10 of these “things” in one visit?? Think about chronic disease patients. Older diabetics for example tend to see their doctor 7-8 times a year. What would happen if you were actually able to wave a magic wand wherein your patients would come in for their visits prepared and focused. And that these patients became more focused and engaged with each subsequent visit such that at the end of say 6-8 months, you could get more accomplished during each visit “in less not more time.”

      How might this occur? For starters, physicians and patients need to start looking at and planning for episodes of care (i.e., office visits) beyond the next visit…say the next 3-4 visits instead. Then we need to look at what is done by the patient and by the physician at each of these visits. Today we still manage chronic patients as we do patients with acute problems (hence your comment about 4 complaints/visit) How much of the information gathering that takes place during the visit could be “outsourced” to the patient during wait time via technology? Over time visit expectations and patient behaviors (and physician) can be reset going forward. If patient feel that their doctor is making an effort to improve than most patients will happily go along if they feel the doc is sincere.

      The best part is that these changes don’t involve hiring more staff or major changes in office workflow. What these changes do require is putting the most important and under-employed member of the health care team to work – e.g., the patient.

      Just a thought.

      Happy New Year!

      Steve Wilkins

      • southern doc says:

        Don’t disagree with anything you say.

        But we have to face the new reality, that the time for patient-physician interaction in the typical 15 minute visit is now 50% less than it was a decade ago due to data entry chores (or 66% less if your employed doctor is forced to schedule every 10 minutes). Docs are acutely aware of this. They know that the patient being seen for follow-up on DM, HTN, hyperlipidemia, and depression cannot talk about their new headaches, rashes, and elbow pain at that visit. They know that a patient being seen for a sprained ankle cannot address any chronic medical problems during that visit. Another problem? Make another office visit.The patient, on the other hand, because of higher co-pays and deductibles, wants to cram as much as possible into that one visit. There’s a conflict here that has to be addressed, and ignoring it does not make it go away. It sucks, but that’s reality.

  5. Greg Weidner, MD says:

    Thanks for the great post. These ten items are obviously critical to a successful doctor-patient relationship and encounter. I do think, though, that we in healthcare have an opportunity/obligation to meet people where they are and help them engage with their health during the 99+% of their lives that they don’t spend with us. That type of “engagement” occurs by extending our relationship beyond the clinic or hospital, and by providing tools, data and education to empower patients in the management of their own health and wellness. I agree with the assertion that technology is not sufficient by itself, but it can certainly enable a deeper level of connection and understanding between patients, families and providers. And a more rewarding experience for all parties.

    Greg

  6. Kate Lorig says:

    As a patient I would add “admit that you are sometimes wrong”. My experience with health care, and I have had a lot, is that the patient is never right. It is just fine that I have had 40 hours of wait time in 2012. Docs are busy, other patients are sick, the office double booked…

  7. I realize I am expanding the scope of your article, here, but I also think that emphasizing the need for productive input from patients is necessary. As an interventional radiologist, I rely on accurate, useful, information from both the referring doctors as well as the patients sitting in front of me. No one can work in an information void.

    In addition to your list, I offer a few suggestions to patients who wish to prepare for their visit with their doctor:

    1- have your list of problems in hand, and prioritized so as to accomplish the most in the shortest time and cover the most important problems first.
    2- trust that your doctor has your best interests at heart, despite being pressed for time.
    3- trust that your doctor knows more than you do about many medical-related topics, but that he/she knows less than you do about YOU.
    4- remember that the doctor-patient relationship is best accomplished as a cooperative effort between two parties who formerly knew very little about each other…together you may achieve your desire goals of health and healing.

    Nice post and thanks!

    • Paul.

      Thanks for reading and for sharing your comments!

      One of my wife’s Oncologists, (he recently bought out the previous owners) told me how they (the previous owners) no longer would pursue denials of service (diagnostic tests, post treatment follow-up tests, etc.) from insurance companies. The reason – it took too much of their time. This made me wonder how many patient’s “trusted” that their oncologist would go to bat for them in such situations…but in reality their doctor did nothing on behalf of the patient…including advising the patients to call the insurance company themselves. I wonder how many peoples’ cancer took advantage of this misplaced trust?

      My wife and I have learned the hard way that:

      1) Physicians need to earn the patient’s trust…that goes in spades for Radiation Oncologists
      2) Re-earn that trust with every patient visit

      Unfortunately while you may appreciate patients bringing in a “list” – many patients’ experiences with physicians suggests otherwise…e.g., la maladie du petite papier.

      I would modify your suggestion #1 to read that patients should ask their doctor how they feel about patients who bring in a list of questions, symptoms, etc.

      Happy New Year!

      Steve Wilkins

      • Paul says:

        Agreed. Trust is most definitely earned and I work hard every day to that end.

      • “la maladie du petite papier” is when a patient has a huge list of problems that are hypochondriacal. A short list of discussion topics is greatly welcomed by physicians and gets to the point of good communication. Too many patients walk away from visits only to say “I wish I had asked the physician about that”.

        • Perhaps one of the biggest myths of the medical exam is the frequency with which patients ask their doctor “important questions.” The average, according to published research, is 3-4 questions per visit. This is in spite of the admonitions of everybody and their brother that patients should “ask their doctor.”

          A great article on the subject appeared in a recent Health Affairs article. Here’s the citation:

          Frosch, D. L., May, S. G., Rendle, K. a S., Tietbohl, C., & Elwyn, G. (2012). Authoritarian physicians and patients’ fear of being labeled “difficult” among key obstacles to shared decision making. Health affairs (Project Hope), 31(5), 1030-8. doi:10.1377/hlthaff.2011.0576

          • Paul Dorio says:

            It is not WHAT is asked, but HOW a question is asked that may determine the response and the reaction. If the asker wishes to obtain a useful response, asking a question in a non-threatening way is a first step. Most doctors are bombarded with all types of questions from all types of personalities. And doctors, like everyone else, as a group come equipped with their own diversity of personalities. Interactions are always a challenge. Health care questions are not dissimilar from politics in their potential to heighten emotions.

  8. [...] communication rockstar Steve Wilkins wrote a great piece on his blog this week: The 10 Commandments of Patient Engagement. In the post, Steve lists 10 actionable steps providers can take to more meaningfully engage with [...]

  9. Nick Dawson says:

    Steve – what a great post. Thanks for writing the 10 commandments so eloquently and powerfully.

    This inspired me to write a post I’ve been thinking about for a while:
    Finding & Protecting Time for Patient Empathy, my challenge to leaders inspired by Steve’s 10 commandments http://daws.in/WeFOp7

    In short, I think it’s up to us administrative types to make the patient experience a top priority and to protect time for it in the patient process flow. Thanks for being part of that leadership Steve!

    • Nick,

      Thanks for your comments and kind words. I will check out your blog post as well. I get lots of my best ideas by looking at the work others are doing. Although I have to admit that sitting endlessly in doctors’ offices this past 2 years has also been a driving source of inspiration for me as well.

      Physician offices (particularly hospital-employed) are the new “front door” to the hospital’s brand…patient’s first exposure if you will. Hospital execs looking to “make a difference” with respect to the patient experience (and marketing) would do well to start there.

      In early 2013, I hope to be ready with several initiative designed to help hospitals and medical groups do just this very thing…

      Stay tuned.

      Happy New Year!

      Steve Wilkins

  10. Your 10 items are good. Specifically regarding #1 and #2: you use the word “act” like you are glad to see them and say something to “sugggest” you actually know who they are. There is an undertone to the comment that physicians are not genuine. I don’t think that is the problem. Look at the provider side: 2000 patients who you don’t see all that often. Genuine or not, that is a lot of people. Suppose you have 2000 friends, are you honestly glad to see them at 8 AM and can you say something to suggest you know who they are? Frankly, impossible. I am not being critical of your idea, just the mechanics of making the communication better. The concrete solution is for the provider to put a comment in the record about who the patient is and what is important to them — then, at next visit, review the recorded information BEFORE walking into the exam room — with the memory appropriatly jogged the salutatory comments are easy. My revision of your 2 items is to use the medical record (not just the provider’s memory) to enhance comunication. Providers overestimate their ability to remember those key bits of information that really enhance a visit.

    • Paul Dorio says:

      Excellent comment. Thank you

    • Ralph,

      Thanks for your comments and your kind words! I agree that physicians are generally genuine when interacting with patients. That’s not what I intended to suggest. Rather, a kind greeting and an exhibition of familiarity (regardless of the source – perhaps just acknowledging what patients told the MA or LVN) goes a long way regardless of what time of day it is. 8:00 am is early for some patients to be “chatty” but we still expect our docs to “know who we are” and remember the salient points of our medical last medical encounter (the kinds of memory prompts that work are up to the physician, including EMRs). Think patient trust and concordance here.

      Steve Wilkins

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