Archive for March, 2011

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Guest Blog: One More Reason Patients Ask Doctors So Few Questions

Stephen Wilkins
Thursday, March 31st, 2011

Stephen Wilkins MPH is a former hospital executive, consumer health behavior research and recent care giver. He has witnessed incredible oversights and gaps in physician-patient communications that have had “near catastrophic” consequences for patients like his wife who was diagnosed with Stage 4 Lung Cancer in 2004. He is the co-founder of a Health Messaging Inc., which focuses on developing ideas and solutions for improving the quality of communications between physicians and patients. He blogs on Mind The Gap.

The most popular post on my blog is entitled Five Reasons Why People Do Not Ask Their Doctor Questions. Well it seems there is a sixth reason.

The Reason?

 

I am forever reminded of this when I see my retinal surgeon for follow-up for my surgery to fix a recently detached retina.   Every time I try and ask a question, I am told to wait until he’s finished with the exam…at which point I have forgotten the question.
 
Turns out today’s “medical exam” (aka medical interview) is actually a highly structured process which has changed little in many ways since its inception in the early 1900s.  Both the patient and physician have defined roles which have evolved over time.
 
The physician’s role is that of scientist and problem solver.  He or she listens, albeit often briefly, to the patient’s presenting complaints.  Next they examine the patient asking questions as they go along. Then comes a working diagnosis followed by tests (if needed), then a treatment plan is presented to the patient and viola…the physician is out the door.
 
The patient’s role in the medical exam is two-fold: 1) present their problems in a clear and concise fashion and 2) answer the physician’s questions when asked.  That’s it.  Remember it’s all about arriving at a diagnosis and treatment.  In fact the patient’s opening statement – describing their reason for the visit – is the only place in the medical exam where patients are supposed to talk freely.
 
Otherwise, if not explicitly asked by the physician, most patients, including “empowered patients,” are unlikely to bring up unvoiced concerns, expectations or questions.  After all who wants to interrupt their doctor.  There is just no place in the medical exam process formally designated for patient questions.  It isn’t that they are unimportant; they are just not needed by the physician to make a diagnosis.
 
All the talk about patient-centered care aside, the medical exam is a physician-directed affair.  Research shows that primary care physicians on average dominating 60% of available visit talk time.  The predominant communication style employed by the majority of primary care physicians is what is called biomedical.  This style relies on closed ended questions, evidence and hard science to arrive at a diagnosis and treatment plan.  In studies using conversational analysis (audio-recording and coding of physician-patient exchanges during the medical exam) patient questions are the least frequent form of patient verbal utterance during the typical office visit.
 
To be sure, the medical exam as taught in medical school over the last 5 years has taken on a more patient-centered orientation.   But physicians are busy people.  Like the rest of us, busy physicians gravitate to what will get us where we need to be in the least amount of time.  Unfortunately that means little time for unscripted patient questions.
 
That’s what I think.  What do you think?
 
Sources:

Kaplan CB, Siegel B, Madill JM, Epstein RM. Communication and the Medical Interview Strategies for Learning and Teaching.; 49-55.

Putnam SM, Stiles WB, Jacob MC, James S a. Patient exposition and physician explanation in initial medical interviews and outcomes of clinic visits. Medical Care. 1985;23(1):74-83.

Cegala DJ, Street RL, Clinch CR. The impact of patient participation on physiciansʼ information provision during a primary care medical interview. Health Communication. 2007;21(2):177-85.

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Does My Doctor Trust Me (and Does It Matter)?

Jessie Gruman
Wednesday, March 30th, 2011

Jessie GrumanMembers of the  American public are frequently surveyed about their trust in various professionals.  Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians.  Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).

How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.

So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients.  This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”

Hmmm. I hadn’t really thought about trust being a two-way street in my relationship with the doctors and nurses who take care of me.  But given the push for us patients to become actively engaged in our health care, it’s not surprising that questions would arise about how dependable we are as partners. And it is a sign of the times that as clinicians increasingly face incentives to deliver evidence-based medicine and are held accountable for our health outcomes, our trustworthiness as partners has become professionally, if not economically, important to them.

While this new scale is only a research tool, its creation nevertheless raises interesting questions about how traditional notions of trust in medicine are changing in the new clinician-patient relationships that the media urges us to forge. So let’s examine it as a reflection of the idea of physicians’ trust in their patients.

Here are nine of the 18 items of the trust scale.   Clinicians are asked:

How confident are you that this patient will:

  • Understand what you tell him/her?
  • Accept your medical judgment?
  • Tell you about all the medications and treatments he or she is using?
  • Believe what you say?
  • Follow the treatment plan you recommend?
  • Be actively involved in managing his/her condition/problem?
  • Respect your time?
  • Provide all the medical information you need?
  • Not make unreasonable demands?

Far from reflecting the new kind of partnerships we are encouraged daily to develop with our doctors and nurses, these questions presuppose that we are trustworthy only if we assume that old-fashioned passive position relative to our clinicians’ authority.

As someone actively engaged in my care, I ask a lot of questions: Sometimes I don’t understand the explanation or directions I’ve been given.  I prefer to come to an agreement about a treatment plan, rather than just follow my doctor’s directions, and agreeing on the plan takes time.  Does this mean that I am making unreasonable demands and disrespecting my clinicians’ time? If I am sufficiently knowledgeable to be wary of my clinicians’ possible conflicts of interest, am I questioning their medical judgment?  If so, am I untrustworthy?

Consider also how my recent treatment for stomach cancer would affect my oncologist’s rating: I was too woozy to be a good historian about my symptoms or a good reporter about my medication taking.  I wobbled frequently in my adherence to my treatment plan and frequently misunderstood what I was told due to the fog of illness and treatment. My appointments often ran over their allotted time because we were discussing complicated changes in my treatment.  Have I therefore misunderstood what I was told?  Have I disrespected his time?  In short, am I trustworthy?  Apparently not.

This scale is a work in progress for use only as a research tool.  It is notable primarily as a bellwether. Its development elicited fairly broad agreement from physicians that we patients are most trustworthy when we cede unilateral authority and control of our care to them.

But the scale does identify a technical challenge for future efforts to measure our clinicians’ trust in us. While the dimensions of our trust in physicians are well established (technical competence and fiduciary responsibility, that is, moral obligation to place patients’ interests above his own), the components of our clinicians’ trust in us are tougher to nail down.   Questions must be sufficiently robust to accommodate enduring characteristics of personality, culture and communication style that vary among individuals in our willingness and ability to engage in our care as well as account for those that vary within individuals as we cycle through sickness and health.

Maybe it is premature to measure clinician trust in patients.  Maybe all of us – patients and clinicians — just don’t have enough experience yet to identify the dimensions of trust that are relevant to these new partnerships.  There is evidence that many people are deeply ambivalent about being active and engaged in their care, and many of us lack the skills, knowledge, resources and confidence to become so.  It is easier to be passive, especially when we are ill.  And if the small, non-random sample of physicians who contributed to the development of this scale is any indication, clinicians are similarly ambivalent about changes to this familiar dynamic.

But as the requirement that patients participate actively in preventing illness and getting well has become more consequential, it is clear that patients and clinicians alike must recognize that we share these aims and that we are mutually dependent on one another to reach them.  We patients are no longer just the recipients of our clinicians’ ministrations.  Rather, in order to benefit fully from our care, must share in making decisions about it and take responsibility for carrying out the treatment plans during the 99.999 percent of the time when we are on our own, unsupervised by health professionals.

Only when such partnerships become more common and the evolving relationships between physicians and patients become better established will the matter of physicians’ trust of their patients become relevant and interesting.

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Guest Blog: Quality or Value? A Measure for the 21st Century

Marya Zilberberg
Thursday, March 24th, 2011

Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. She is also a professor of Epidemiology at the University of Massachusetts, Amherst. Dr. Zilberberg is a member of multiple journal editorial boards and is frequently invited to speak about evidence-based medicine, research methods and healthcare-associated complications. She blogs about healthcare at Healthcare, etc.

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Fascinating, how in the same week two giants of evidence-based medicine have given such divergent views on the future of quality improvement. Here (free subscription required), Donald Berwick, the CMS administrator and founder and former head of the Institute for Healthcare Improvement, emphasizes the need for quality as the strategy for success in our healthcare system. But here, one of the fathers of EBM, Muir Gray, states that quality is so 20th century, and we need instead to shine the light on value. So, who is right?

Well, let’s define the terms. The Merriam-Webster dictionary defines quality as “the degree of excellence.” The same source tells us that value is “a fair return or equivalent in goods, services or money for something exchanged.” To me “value” is a holistic measure of cost for quality, painting a fuller picture of the investment vis-a-vis the returns on this investment. What do I mean by that?

Simply put, the idea behind value is to establish what is a reasonable amount to pay for a unit of quality. Let’s take my used 1999 VW Passat as an example. If my mechanic tells me that it needs to have some hoses replaced, and it will cost me under $100, and the car will run perfectly, I will consider that to be a good value. However, if my transmission has fallen out in the middle of Brookline Ave. in Boston (really happened to me once, many years ago and with a different car), and it will cost me $5,000 to fix, I may say that the value proposition is just not there, particularly given that the car itself is worth much less than $5,000. Given that my budget is not unlimited, I have to make trade-off decisions about where to put my money, so I may instead spend the money on another used Passat that has good prospects.

But in medicine, we routinely avoid thinking about value. There seems to be an overall impression that if it out there on the market, and especially if it is new, it is good and I am worth all of it. This impression is further enabled by the fact that CMS has no statutory power to make decisions based on value of interventions — they are legislatively mandated to turn a blind eye to the costs. Does this make sense? How toothless is our comparative effectiveness effort likely to be if it has to ignore half of the story?

Let us now look at my favorite sticky wicket, ventilator-associated pneumonia, or VAP. Now, the IHI bundle aimed at eliminating VAP consists of 5 points of intervention: 1). semi-recumbent positioning, 2). daily screen for readiness to get off mechanical ventilation, 3). daily sedation vacation, 4). prophylaxis against GI bleeding, and 5). prevention of clots. As I have mentioned before elsewhere, adherence of 95% to all these measures is deemed compliance and may be ultimately used as a quality measure by payers to determine levels of reimbursement. And while each of these interventions is basically “motherhood and apple pie”, applying them blindly and in toto to 95% of intubated patients may be a strategy for disaster. But what is even clearer is that, in order to implement this and all of the other quality improvement strategies, systems need to be put in place that will safeguard against failing to implement these quality measures. The time and resource expenditures needed to institute and maintain these systems, which have not been described in great enough detail as far as I am concerned, have never been quantified. So, what we are left with is a bunch of interventions that, while looking OK individually in clinical trials (until you really start looking at them critically), are likely providing small, if any, gains in quality at the margins, whose investment-return equation has not even been disclosed, let alone balanced. And because budgets are necessarily limited, as are clinicians’ time and cognitive capacities, we need to select a sensible menu of interventions from this practically unlimited feast.

This is the quality conundrum, a clear case of chasing our tails to achieve perfection at the expense of good enough. And while no one in their right mind will argue with the language of improved quality in healthcare, I do think that Muir Gray and his camp are on to something that has been a long time coming. At this time of shrinking budgets, competing priorities and tightening resources, does it not make sense to look at value as a package deal, rather than merely at quality in isolation from its context? Instead of being bombarded by ever-increasing volume of quality measures coming from many directions, would it not be more sensible to prioritize these interventions based on the value that they bring rather than merely on their projected outcomes benefits, so frequently estimated based on data that have very little applicability to the real world? Let’s start asking the question: how much quality and at what price? Without paying attention to this critical balance, we will not only bankrupt the system, but also worsen outcomes paradoxically, as we continue to overwhelm clinicians with infinite minutia that may or may not be generating helpful outcomes.

So, in my book, Muir Gray: score; Berwick: keep trying.

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The “True Grit”-tiness of Sharing Health Care Decisions with Our Doctors

Jessie Gruman
Wednesday, March 23rd, 2011

In the recent Coen brothers‘ remake of the 1969 movie True Grit, Mattie Ross, an intrepid 14-year-old, is determined to hunt down and kill the man who murdered her father.  To accomplish this, she hires U.S. Marshal Rooster Cogburn, (played by a mumbling Jeff Bridges) a rough, one-eyed veteran of many such quests – then announces that she plans to come along.  She figures she is prepared. 

After all, she and her father had gone “‘coon hunting last summer… We sat around a big fire and Yarnell told ghost stories. We had a good time.” 

Rooster retorts: “‘Coon hunting! This ain’t no ‘coon hunt, it don’t come within 40 miles of being a ‘coon hunt!”

And Mattie fires back: “It is the same idea as a ‘coon hunt.  You are just trying to make your work sound harder than it is.”

true-grit-mainThis exchange sets the tone for their testy relationship: Mattie is determined to participate in avenging her father’s death and confident that she is capable of doing so.  Rooster is exasperated by her naiveté and impatient at having to slow down to consult with her about how to counter each new threat they meet.

On the second day of their journey, the pair comes across a dead man hanging from a branch high above the trail.  The man may be a member of a gang who could be a threat to their quest, but he’s dangling too high to identify, so Rooster tells Mattie “Well, you are going to have to clamber on up with this knife (and cut the rope). I am too old and fat.”

At this moment, the gravity of what she has undertaken hits her.  Her eyes widen.  She glances around, clearly terrified.  Rooster was right.  This journey is not just like a ‘coon hunt.  It dawns on her that she could be hurt or killed; that Rooster possesses vast expertise and experience about how to approach the dangers they face that she lacks; that they are now dependent on each other for their safety and for achieving their goal.  This realization weighs heavily on her. 

Many of us take Mattie’s attitude at the beginning of her journey when we are asked whether we would like to share in our clinicians’ decisions about our health care. We think it’s a great idea.  How hard could it be? However, when actually faced with sharing specific health decisions – about treatment for cancer or heart disease, many of us defer to our physicians.

Participating in – sharing – specific decisions about our health care is sobering.  Like Mattie, it suddenly dawns on us that the stakes may be high: our health and quality of life are at risk.  Like Mattie, we realize that by contributing to the decision, we assume some responsibility for the outcomes.  Like Mattie, we suddenly see how little we actually know and how poorly prepared we are to make the right decision.  We may lack the information we think we need; we may not understand what information we have; we may feel too ill or upset to think clearly. And like Mattie, we are confronted with the fact that regardless of the strength of our determination and commitment, our efforts may not succeed.

Imagine finding out you have been diagnosed with aggressive prostate cancer after collaboratively deciding with your primary care clinician to skip your PSA test for a couple years.  Imagine realizing, too late, that the diet and exercise now required for full recovery from your back surgery should have been your first choice of treatment instead.  Imagine deciding whether to undergo one more fertility treatment when your chance of success is low and the financial, physical and emotional costs are high.  It is uncomfortable to contemplate the uncertainty that comes with such decisions and even less comfortable to feel responsible for them.

Many clinicians share Marshal Rooster Cogburn’s attitudes about bringing us along for the ride.  For busy professionals, the idea of slowing down to explain treatment options for a serious condition and consult with us about that decision – much less to discuss each new prescription or screening test – produces exasperation and irritation similar to Rooster’s.  Ninety-five percent of primary care physicians report that a major barrier to shared decision-making is that there is not enough time for detailed discussions with patients.  The time pressure increases when patients bring information from the outside to discuss.  Among the 78 percent of providers whose patients do this, three-quarters say this takes even more time and 40 percent say it makes their job harder. It is then undoubtedly vexing when, even though we have been informed, asked questions, and agreed with our clinician on a plan or treatment, some of us change our minds or don’t follow through.  Like Mattie, many of us seek to maintain our independence, doing the best we can to make the right decision for ourselves as we go along.

True Grit ends in a series of complicated maneuvers involving the shooting of many guns, the killing of some people, a tumble down a cavern, a snakebite and a heroic dash by Rooster, cradling Mattie in his arms in an effort to save her life.  Which he does.  In the end, Mattie’s father’s death is avenged but doing so requires an all-out effort by both Mattie and Rooster. Neither of them could have done it alone.

Shared decision-making in medical care is rarely as exciting.  But it can be just as gritty.  Despite our common aim of improved health and functioning, it is not easy task for any of us – patients or clinicians – to disrupt our long-held habits and assumptions about how each other thinks and acts.  And it requires gumption on both our parts to truly engage in sharing both in decision-making and in taking responsibility for outcomes of those decisions.  The growing number of choices patients have about screening and treatment and the trend toward “empowering” us to participate in our health care put pressure on all of us to do more.

Neither doctors nor patients can do this alone, but even when we agree on the goal, as Rooster says, “This ain’t no ‘coon hunt.”

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