Wednesday, February 25, 2015

Doctor, It's You, Not Me

We tout the physician-patient relationship as the cornerstone of our health care system, but it turns out it may not be particularly solid after all.  A recent survey by Vitals found that 70% of patients have a somewhat tenuous relationship with their physician.

Fifty-four percent described their relationship as "good enough for the moment," while 14% said "I'm not really into him/her," and 4% complained their physician was "cold and emotionless."  The remaining 30% claimed their relationship with their physician was "the one and only" (it should be noted that Vitals released the results around Valentine's Day).  Half of patients are already stepping out, using alternative sources of care like retail clinics.

Non-clinical factors are leading sources of complaints: lack of professionalism from the physician's staff (57%), difficulty getting an appointment (47%), long wait for the doctor (45%), and the condition of the doctor's office (41%).

Honestly, it's amazing that only half have gone elsewhere.

In-network status was the leading reason for choosing a physician (63%), far surpassing even location (37%).  Factors ostensibly related to quality trail: bedside manner (34%), education/credentials (30%), years of experience (18%), and patient reviews (16%).  I've said before that the approach of using provider networks is not only outdated but also contrary to patients' best interests.  Is in-network status really how we want people to choose their physician?

And we wonder why the physician/patient relationship is fraying, or why patient engagement is a problem.

It's interesting how health care is attacking patient engagement.  A recent report on patient engagement from Chilmark Research looked at the various technological options providers could, but usually don't, use in improving engagement.  For example, staying connected with patients between and after visits through patient portals, apps, or telemedicine.  That's all good stuff, and needs to be part of any solution, but such tools support but don't drive engagement, or relationships.

A perspective from Dr. Thpmas Lee in NEJM  was perhaps closer to targeting the problem.  Dr. Lee wants to reduce patient suffering, in all its many forms -- not just physical but also emotional suffering, such as through thoughtless interactions.  He urges providers to think more from the patient's perspective.  It sounds an awful lot like primum non nocere -- first, do harm -- that is supposed to be one of the guiding principles of medicine.

Still, reducing patient suffering seems somewhat of a necessary but not sufficient goal.  It won't sustain a relationship, and our goals for patient health should be more than "less suffering."

Many physicians, such as those involved in PCMH or ACOs, are using health coaches to try to stay connected with patients.  Health coaches are often nurses, sometimes might be physician assistants or nurse practitioners, but almost never are physicians themselves.  They are a good idea, but they sort of delegate the physician-patient relationship to the health coach.

Again, we should be aiming higher.

Many physicians complain that EHRs are adversely impacting their relationships with patients.  This has caused, among other things, a boom in the medical scribe industry, which some physicians feel allows them to interact with patients more directly.  Only in health care would anyone think having a third person present to take notes during an intimate encounter like an exam might help a relationship.

Opponents of scribes -- and you can include me in that number -- believe that they merely mask the EHR usability issues, instead of addressing them.  Researchers from UC San Diego have developed a "lab-in-a-box" to help do the latter.  It uses sensors and software to track physicians-patient interactions while using EHRs.  The lead researcher, Nadir Weibel, noted:
"With the heavy demand that current medical records put on the physician, doctors look at the screen instead of looking at their patients.  Important clues such as facial expression, and direct eye-contact between patient and physician are therefore lost."
Really, do we need sensors to identify what hampers physicians from connecting better with patients?  It strikes me that if the physician-patient relationship was paramount to physicians, then we wouldn't just now be scratching at the surface of how the EHRs impact that relationship.  Physicians have neither articulated well what makes the relationships work, nor demanded that EHRs support them better.  EHRs vendors should be falling all over themselves to differentiate themselves on how they can help improve patient interactions.

More on the right track, I think, is a tool called SHARE-IT, developed by researchers from McMasters University.  The concept isn't revolutionary at all; it simply allows physicians to present clinical information to patients in an interactive format at point-of-care.  As Thomas Agoritsas, one of the research fellows involved in its development, said:
"The process should be more about the discussion you have with your doctor and about enhancing the conversation, not overwhelming patients with too much information. It's less about showing the evidence than showing it in a way that it becomes a discussion."
Now we're getting somewhere.

Of course, the success of a such a tool depends on the physician taking the time to have that interactive discussion, rather than delegating it to a nurse or telling the patient to look at it later and let them know if they have any questions.  Sad to say, but it is hard to see that happening as often as it should.  Patients are lucky to get fifteen minutes with physicians, as physicians feel increasingly pressured to meet patient (revenue) quotas.

That, my friends, is why we have a physician-patient relationship problem.

We've gotten muddled about what we want from physicians.  They're trained to diagnose and to treat, and somehow the latter has become transactional: prescribe a pill, perform a procedure, refer to some other specialist.  Those are not the kinds of interactions that foster relationships, yet they are what consume physicians' time and drive our payment mechanisms.

With about half of us suffering from one or more chronic conditions, and as much as three-fourths of spending associated with chronic conditions, helping patients manage those conditions is one of the most important roles for physicians, especially for the rapidly vanishing primary care physicians.  They should be teachers (or coaches, mentors, whatever we want to call them) who help people make better lifestyle and other health choices on an ongoing basis, rather than being tasked with maximizing patient transactions episodically.  We need fewer transactions and more conversations.
The traits that make physicians great at diagnosis are not the same as those that make them great surgeons, and neither ensures they can help teach patients how to live healthier lives.  We lump all those skills together into what we ask of physicians, and that's a mistake.

Famed physician leader William Osler once said: "The good physician treats the disease, the great physician treats the patient who has the disease."  If we truly want better patient health, we need stronger physician/patient relationships, and so we need to figure out how to help more physicians become great.

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