A Prescription For Doctors

Enough about patients: What is a doctor to do?

Picture 42In the past few months, since The Decision Tree book came out, I’ve had the privilege to talk with many doctors about the opportunity and challenge of engaging patients in their own health. Some physicians, not surprisingly, have been suspicious, and even hostile to the idea that patients have a role to play. But thankfully, those have been rare exceptions. Most doctors I’ve spent time with have been eager to hear about new tools that might engage their patients, and they’ve been eager to share well-earned advice on where there’s work to be done. It has been a delight and an education to talk about the potential of healthcare with these physicians who are, after all, doing the hard work of providing medical care every day.

A high point in my continuing education came a couple weeks ago, when I was invited to speak at the Minneapolis Heart Institute Foundation‘s Fall Nursing Conference, where I met a number of nurses who are eager to help patients gain some control over their health. A few days later I gave a lecture on patient engagement at the University of Minnesota Medical Center. The invitation came from Dr. David Rothenberger, an esteemed surgeon who has consistently emphasized the importance of innovative thinking in medicine. Dr. Rothenberger also runs a program for physicians with promising leadership potential, and part of my day involved talking with them about the changing nature of clinical medicine, and the challenge of engaging patients in their healthcare.

These were good doctors, deeply motivated to help their patients, and there was scant resistance to the notion of an empowered patient who might seek to engage in their care and treatment. Indeed, they seemed to relish the opportunity to work with such patients.

But as they shared their experience in the clinic, it was clear that empowered patients in the model of ePatient Dave are the exception. Most of us aren’t so savvy, nor so motivated, to roll up our sleeves and drive our care decisions.  Most patients don’t ask to see their records; most patients don’t take their drugs as prescribed; most patients don’t research their treatment options (though most seem to use the Internet); indeed many patients don’t actually do what their doctors advise at all. Most of us don’t follow the basics of good health: get exercise, eat properly, avoid stress. Just judging by the national obesity rate, too many of us squander our chances to improve our health, and the result is what medicine unfortunately calls “non-compliance” – the failure to follow doctors orders. These good doctors of Minnesota see non-compliance every day in their offices and they are frustrated and baffled by it. As we spoke, it became clear that they were searching for some way to get through to those patients who don’t do what they surely know they should.

In part, this frustration was fueled by the increasingly use of pay for performance measures where doctors are scored and evaluated by their patient outcomes. Though I am in favor of pay-for-performance as a strategy for reducing costs and emphasizing health over illness, it’s evident that there’s lots of work to do getting the metrics right. Too often, it seems, physicians are scored by absolute measures without taking into account their patient demographics or the delta between where a patient entered their care. This blunt measure incentivizes doctors to selectively churn through patients, dropping the unhealthy ones who don’t follow orders (or never accepting them as patients in the first place), and it has the opposite of its intended effect.

More than anything, the conversations underscored what I’d known but hadn’t frankly given much thought to: how difficult and vexing it can be to care for patients. Doctors have a hard job, and I am personally deeply awed by their tenacity and perseverance. As one physician noted, “90 percent of my job is education, and I have no training for that. What I learned in medical school only counts for a fraction of what I’m actually doing every day.” Talking to patients, encouraging patients, getting them on board with the task of improving their health is all about cajoling, persuasion, and lots and lots of education. And that’s a daunting thing.

Every doctor, no doubt, has their own quiver of techniques to address this. Places like Sermo help flush some of these strategies out. But it would be disingenuous of me to advocate for patient engagement so vociferously if I didn’t consider the other side of the equation: How physicians might successfully engage their patients. So drawing on the insights of Dr. Rothenberger and his ace stable of practitioners, and inspiration gleaned from the cardiology nurses of Minnesota, I’ve put together a humble five-point prescription for doctors and other care-providers: Five things they should seek to give every patient, strategies to tap the most underutilized resource in medicine, their patient.

1) Transparency: The all-knowing-physician is a myth that no longer serves patient nor doctor. It sets up false expectations for patients, who often come away from the doctor’s office without the definitive diagnosis or treatment, and it holds the physician to an impossible standard of perfection. Better that everyone lay their cards on the table. Physicians might share what they know about a patient’s condition or course of treatment –  and also make clear what they don’t know. When mulling a course of treatment, let the patient know what the range of choices is, and then explain why the recommended course seems to make the most sense. The presumption that patients can’t handle ambiguity, that they can’t parse probabilities, is entirely wrong. Life is ambiguous, it is uncertain, and we all inherently understand that. Outside of medicine, we experience it every day. Making the ambiguities evident, shining a light on the dark, so to speak, lets patients reckon with their health just as they do with other parts of life.

2) Repetition: For doctors and nurses, the hospital or clinic is their office. They’re used to it. It’s routine. For patients it’s anything but. White coat syndrome extends way beyond higher-than-usual blood pressure. Every comment from a doctor or nurse is charged, every word choice studied for inflection. But that doesn’t mean we’re actually grasping what the doctor is saying. Even if our needs are minor, for patients the doctor’s office is charged with anxiety and fear. That look on our face? It means you’ve lost us.

And then, when we’re out the door, anything we did understand is gone. I know this personally:  I have listened deeply to a suggestion that I take an over-the-counter medication, and then, by the time I get to Walgreens, blanked on the dosage and frequency my doctor suggested. Anything that’s not written down – i.e., everything except a prescription – is going to be lost. If your patient doesn’t bring a pen and paper, write your advice down for them.

3) Resources: It’s no surprise that I think patients should get full and immediate access to their records, notes, and lab tests. Even if the patient can’t make heads or tails of it, it’s an important gesture of reciprocity, partnership and, I would argue, ownership. This stuff is ours. But there are other resources that a doctor can help their patients with. I’m not talking brochures and pamphlets – I’m talking about the Internet (again). In part this is simply pragmatic. Patients are going to go there in search of more information and answers, and they might as well start where their doctor suggests they do. And there’s no reason this shouldn’t augment the doctor’s care; they’re already overworked and pressed for time. Use the outside world, identifying informative websites and online support groups.

And about the Internet: Physicians should flush out this elephant in the room. You know your patient is already on there, doing all sorts of research. What they find may not be relevant, but it’s filled their heads with ideas. Even if they don’t come in with papers and print outs, they’ve already got preconceived notions about what’s wrong and what they might do. Get it on the table. Ask patients what they’ve read online about their condition (this is quid-pro-quo transparency). Listen. And then, if necessary, explain why it doesn’t pertain. Even the most misguided patient has taken a worthy first step towards engagement – they care about their health. Start there and use it.

4) Patience: Just because patients don’t do what you tell them to, that doesn’t make them irrational. They may have what, to them, seem like perfectly reasonable reasons to ignore their doctor’s advice. Understanding these reasons, flushing them out, can be a way to pursue other, more promising approaches. Conversely, just because patients may not do what they should doesn’t mean they’ve given up, that they’ve decided to live in ill health. Failure is a part of life, and it certainly is a part of our health (witness the eight or so times it takes a smoker to successfully quit). But humans are resilient creatures, we are persistent, and helping patients understand that they can make their way towards better health with a few missteps comes as a great relief. Take it from a Catholic: Going to the doctor’s office is very much like going to the confession booth, and in both places the confessor is probably embarrassed to tell the full story. Diffusing that anxiety, forgiving the missteps, can be a great motivator.

5) Goals: A great impediment to sustained and better health is the fact that we don’t think about it that much. Most doctor’s visits, after all, are about a problem (it bugs me to no end that the intake form at many doctor’s offices, including mine, presumes poor health with the first question: “What is your Chief Complaint?”). Even if that’s why we walked in the door, that shouldn’t be how we walk out. Rather than send patients out with a to-do list, physicians might send them out on a path, with milestones and purpose. Fact is, we do better when we have an objective, when we feel that we’re making progress towards something – that’s human nature. A great way to create engagement about health is to create a sense of purpose, that the drudgery of tasks required – new drugs and new diets – isn’t just managing our health, but is in fact building towards something.

So that’s my prescriptions for doctors. No doubt putting these into action would require, first and foremost, time – perhaps the most precious resource a physician has. But my hope would be that they could be worked into the habits and dialogue that already take place, and that they might make that communication smoother, less fraught, and more productive. I would be eager to hear if there are other strategies out there.

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  2. I like the following points in the article
    Each and every thing should know patient and doc should tell the patient

  3. Unfortunately we must confess that simple people (who are not involved in medicine) have a very poor knowledge of treatment in general. For example, lets take antibiotics drugs. Far not everyone knows that antibiotics do not cure virus infections like cold or flu!!! For such diseases there are special antiviral medications. As a consequence people started to take antibiotics for nearly every malady, creating bacteria resistance. Therefore I’m strongly convinced that health care organizations and medical institutions should work at special medical involvement programs.

  4. This isn’t a bad article but frankly the truth of the matter is that you don’t need to ’empower’ patients who are already well-educated and have good lifestyle habits but get non-compliant patients to actually follow medical provider’s advice.
    Another thing that doesn’t get brought up in patient-physician communications – is how much patients omit, obfuscate, or flat out lie to their providers. Happens a ton and almost never gets brought into the conversation.
    One of the biggest flaws about P4P (besides the complexities of using primarily administrative data to measure process-based outcomes) is a having a valid way to exclude patients who are repeatedly non-compliant despite numerous efforts by their provider.

  5. No doubt putting these into action would require, first and foremost, time – perhaps the most precious resource a physician has. But my hope would be that they could be worked into the habits and dialogue that already take place, and that they might make that communication smoother, less fraught, and more productive. I would be eager to hear if there are other strategies out there.

  6. e-NOTHING
    OweBama “tweeted” on MTV last week. His dupes are still going to be defeated on Nov. 2.
    So much for technology. e-BFD — incompetence is still incompetence — GIGO.

  7. This is why the internet hampers as much as helps patient care. It just reinforces the mentality of “if I read it on the internet, it must be true/have validity”.
    Doctors have to get feedback/input from their patients, but, if people walk out the door annoyed/confused/uneasy/indifferent, then they won’t be back happy until proven otherwise. So, both parties have to be able to communicate to each other. And, quick fixes are usually short fixes. And aren’t we about long term fixes as able? Hence why the internet is not a primary source in the end!

  8. Patients are not cars on an assembly line. Each one is unique and their signs and symptoms harbor ambiguity. The computerized order setted care being pushed by Zinks and others surely stinks when it comes to the individual patient. These are disruptive to the creative thinking needed to manage the ambiguity.

  9. Very insightful post, especially your point on ambiguity –
    The problem is that patients vary in their needs and education. Some I’ve seen can’t handle uncertainty, or simply find it unsatisfying; if you tell them something they perceive as indefinite, they’ll find a doctor who “knows.” Others appreciate truthfulness, even if that means leaving an appointment without a pat answer or ready solution for a complex medical problem.

  10. Ahier states: “Giving patients and their caregivers reliable Internet sources for information is an important part of the relationship…”
    e-Patient Dave likes this approach but few patients will take the time to read, even if the report is handed to them, and many patients have broken computers that they can not afford to fix. Brian, get real!
    This is a case of a vocal minority making a case for a expensive and nearly useless component of medical care.

  11. The five “prescriptions” – transparency, repetition, resources, patience and goals – are all laudable approaches to patient care which clearly indicate that the author is a well-informed patient interested in his own health and willing to work to improve it, and that he has no clue whatsoever about the environment in which medical practice actually occurs.
    Although the author makes a passing nod to the time demands of medicine today, he clearly doesn’t recognize (or refuses to recognize) that a primary care physician required to see a pt every 12 minutes, at the risk of job loss for non-productivity if s/he does not, has no opportunity to engage in any of the prescribed recommendations to any significant degree.
    Payors are beginning to place these recommendations in their reimbursement proposals precisely because they know they can’t be met – like EMRs, they’re a neat and easy way to reduce reimbursements by 5% while ensuring that the PR fallout is favorable.
    Patients like the author – engaged, knowledgeable and concerned about their health – are as rare as hen’s teeth. Many (most?) doctors will actually adopt the prescribed behaviors for those patients, but can do so only because they are so rare. To consider this idealized combination of patient attitude and physician behavior as a potential model for health care, however, really does demonstrate a stunning inability to grasp the state of real world health care today.

  12. I deal daily with “non-e”-patients who have no jobs, no insurance, and no transportation. The least of their worries is lack of high-speed internet access to their medical records at 2 AM.
    The “e” in “e-patient” frequently stands for “economically empowered elistist.”

  13. An octagenarian patient with CAD who survived an infected aorta presented anew with “severe pain in the lower back”, abbreviated as LBP, after a fall out of bed. What follows relates to your comment:”They may have what, to them, seem like perfectly reasonable reasons to ignore their doctor’s advice.”
    An LS spine radiograph was ordered to r/o compression fracture and the statin was held, in addition to prescribing the usual medical treatments and physical therapy for the symptom, and a return visit.
    This e-patient Dave wannabe, executing health care responsibility as e-patient Dave prescribes, carefully read the requisition for the radiograph: “LS Spine, dx: LBP”.
    On the return visit, the pain was more severe. Where were the results and PT reports? NONE. Why did not the patient go?
    The patient was asked and stated:
    “I thought you made a mistake and ordered a left sided spine x-ray, for left back pain”.
    Thus, the notion of innumerable e-patients running around with their records is dangerously flawed.

  14. Thanks for your paternalism, Doogie. Maybe the patients should decide what they want, not you deciding for them.

  15. Couldn’t agree more. “Participatory healthcare”, “the medical home” and “hand-held health” are some of the burgeoning models and clichés used to describe practices and technology that facilitates this movement toward better management of health and more informed decisions about care by patients, professionals and family caregivers. These efforts require that the patient be at the center of planning and management and this has spawned two popular strategies:
    • Winning the loyalty of well-insured patients through the delivery of self-service tools for better health and care will deliver a considerable competitive advantage where intense competition for highly lucrative services exists.
    • Many of the evolving models of care have payment for services and additional rewards programs to physicians and HCOs based on the level of involvement of patients in their own care.
    Although we are in the early days, it seems very clear that many are looking for ways to go past the doctor-patient or teacher-student format that has always been practiced. The new perspective is that sustained patient engagement will become more of a driver as physician’s and HCO’s financial success become increasingly dependent on their ability to help patients discover how to transform their habits to be more engaged in living a healthier life.

  16. I agree with everything you write in this post…BUT as a practicing pediatrician and a grandfather of six I have found the strategy of “transparency” the most difficult to balance for the benefit of the patient. Many new parents are informed, concerned, searching for the best information in an ambiguous world of data overload, and they often look to their physician for “certainty”. They want to know what is “the best thing to do”. A presentation and explanation of possible choices with estimated probabilities can make them more anxious. I call it “transferring the physician’s anxiety about not knowing everything to the patient”. I am not sure that benefits anyone.

  17. Excellent posting which touches on some of the ‘realities’ of patient engagement. I feel my goal as a surgeon is to provide information and educate my patients so that ‘they’ make the decision of whether to proceed with a treatment or procedure. Mixed into this is a dose of paternalistic guidance when the benefit is clear, however the decision in some way must remain with the patient.
    Realistically however, many patients not only expect the decision to be made by their physician but they frequently lack the insight,understanding and desire to engage. Most of my patients do not even know what medications they take “blue pill, red pill, pink pill” and offer blank stares when we even try to explain “the water pill, the blood thinner pill etc.” While age, socioeconomic and education status play into this, transitioning our society as a whole to become savvy consumers will be a monumental challenge.

  18. The American medical machine (doctors and hospitals less, pharma much more) has done a great job for the past two generations of convincing Americans that THEY can diagnose and fix us when something goes wrong. The individual’s role in his own health and well-being is not something that has been at all emphasized by our system. Our culture is out of whack, and individual responsibility for one’s own health is not widely acknowledged or encouraged in many medical sub-cultures. Yet the CDC publishes charts showing that our individual efforts to affect our health have more to do with our health status than our environment, genetic influences, or the least important factor, access to our health care system. Another thing to think about is that a couple of minutes with one’s physician, no matter how persuasive and skilled, will pale in comparison to the effects of the constant barrage of ads from our restaurant industry. As we continue to advance our individual and national productivity, we have been doing so at the expense of our health, and many think that a prescription or a procedure can return their health status in short order-but of course this is not likely to happen. I applaud your efforts, and agree that physicians should continue to follow your guidelines to help individuals improve their own health status. However, we need something else to happen to really begin changing the American culture. Not since President Kennedy required school kids to start exercising (my generation) has a national leader spoken out forcefully about the sorry state of American heath and fitness, and the need to make big changes. We need culture change, and we need it quickly.