Archive for the ‘Communicate with Your Doctors’ Category

Guest Blog: Are You Afraid of Being Labeled a Difficult Patient?

Barbara Bronson Gray
Wednesday, May 16th, 2012

Barbara Bronson Gray, RN, MN is an award-winning writer and nationally-recognized health expert who blogs at bodboss.com. She has worked in hospitals, helped run hospitals, led a major healthcare magazine, wrote articles on healthcare for many national magazines and newspapers, developed a website for WebMD, served as a leader of global communications for biotech giant Amgen, and has a communications consultancy based in California.

There’s a wonderful Seinfeld episode  where Elaine grapples with being labeled a “difficult” patient. She’s on the examining table, waiting for her doctor, when she sneaks a peek at her medical chart. She discovers that she is described as “difficult” in her record. Elaine reacts to this harsh reality in later scenes: her “difficult” label is passed from one physician to the next via her patient history. Her reputation precedes her, and she gets crummy care as a result.

Turns out we’re a nation of doctor pleasers when it comes to health care.  A recent study conducted by the Palo Alto Medical Foundation Research Institute and the Dartmouth Center for Health Care Delivery Science found that patients avoid challenging their physicians because they’re afraid of getting the “difficult patient” label.

Researchers conducted six focus groups, with mostly Caucasian, well educated and above average income patients.  All characteristics that might make you assume they would be comfortable and self-confident dealing with physicians. The researchers were surprised to discover that participants reported that they frequently hold back from sharing their preferred care choices with their physicians and from asking questions out of fear that it might damage their relationship with their doctor.

Have you ever felt this way?

Here’s an example of a common health care experience and some suggested replies:

You want to hear more about the pros and cons of a recommended diagnostic treatment, procedure or surgery. You’re interested in getting more information or maybe even a second opinion. But you’re concerned that pushing back a bit to get more information might hurt your relationship with your doctor.

Say something like this: “I need more time and information to help me understand and make my best choice. How can you help me learn more about my options?”

Or “This is a big decision for me. I want to get more information and talk to my family and other experts before I decide what to do next.  How quickly do you think I need to make a choice?”

The answers you get will provide you with some insights about how likely it is that this clinician will be comfortable with helping you make choices about your care that are best for you.

If your physician steps back, grumbles, resists, or worse, scribbles “difficult patient” in your chart, you might consider finding another physician.

There’s an effort underway, supported by organizations like the Informed Medical Decisions Foundation, to increase comfort with and skills in what’s called Shared Medical Decision-Making.  The Foundation (and others) is advising physicians that patients often find it difficult to express their preferences to their doctors.  They suggest doctors need to explicitly tell patients that their opinion matters and that it’s “OK to disagree.”  In addition, the Foundation is creating patient-physician decision support tools that help both walk through the pros and cons of many common medical procedures.

Changing patterns of patient-physician behavior is going to take time. In the meantime, try to see your physician as your consultant. Develop your questions in advance when possible and do ask them. Listen. Interact. And then, ultimately, decide.

Try not to worry about being called “difficult.” Your questions can help you make the best choices for you and your family. That’s worth it.

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Self-Efficacy, part 2

Connie Davis
Monday, May 7th, 2012

Connie Davis MN, ARNP is a geriatric nurse practitioner, health care consultant and William Ziff Fellow at the Center for Advancing Health. This blog was originally posted on Connie’s website where she blogs about improving the patient experience. You can read Connie’s blogs and subscribe to her RSS feed here and follow her on twitter at @ConnieLDavis.

Self-efficacy keeps coming up everywhere I go. I have the honour of working with the California Institute for Mental Health on the Small County Care Integration collaborative. The teams are working on integrating behavioral health and primary care. The clients they work with have serious mental illness and are often also facing physical illness, sometimes partially due to the medications they take for their mental illness. The teams are measuring the self-confidence of their clients using the question Dr. John Wasson and his team developed: “How confident are you that you can control and manage most of your health problems?” Responses: Not very confident, somewhat confident, very confident. (This question is copyright FNX Corporation USA and the Trustees for Dartmouth College.)

Dr Wasson has actually suggested that what the world needs is a “Campaign for Confidence.” I agree with him. What would happen if we stopped focusing on clinical outcomes and specific behaviors and helped people feel more confident? I’m looking forward to finding out.

What could we do to improve confidence? First of all, remember that we need to be focusing on the problems the person has, not what health care professionals think they should focus on. Corbin and Strauss, in their qualitative study of people with chronic conditions, Unending Work and Care: Managing Chronic Illness at Home (1988), provide the guidance we need. People with chronic conditions face three tasks:
1) To manage the illness (to take medications, do treatments, monitor the condition, work with the health care team, etc.)
2) To adapt life roles (how to manage daily life and demands of life in light of the illness)
3) To manage emotions (most often anger, fear, frustration, and depression)

Whenever I am in an interaction, I know these three ideas can help shape the encounter. How is the person doing with these three tasks? What can I do to help? Are they confident in these three tasks?

The next thing to do is to build confidence through mastery. This is one of the techniques known to increase efficacy. Learning new skills is important. Making action plans based on self-determined goals and achieving them is another. There are many ways to do this. The Five A’s grew out of successful smoking cessation interventions and can be useful. The way that I have found most useful recently is Brief Action Planning. Dr Steve Cole initiated the idea, and several of us have worked together to refine it. The Action Planning process of the peer-lead Chronic Disease Self-management Program is another excellent example.

The basics are the same:
1) Take a goal, which is usually something that is accomplished over months, like “become for physically fit so I can play ball with my grandson” and break it down into smaller steps that can be achieved in a week or two, like “walk around the park three times this week on Monday, Wednesday and Friday after breakfast.”
2) A good check on the plan is to complete a confidence scale of 0-10, 0 indicating no confidence to complete the plan and 10 is totally sure. A confidence higher than 7 indicates increased likelihood of success, and if the confidence level is lower, the plan is revised until confidence is high, remembering that success increases confidence.
3) The check-in on the plan is important, too, either with the person who helped make the plan or a self-check in.
4) When plans go awry, problem solving is used. The basic steps are identifying the REAL problem, brainstorming ideas and picking one to try, really try for a week or two, to see if it helps. If the first idea doesn’t help, try another, or get ideas from another. If that doesn’t help, sometimes now isn’t a good time to work on this issue and something else might help.

Self-efficacy is a many faceted concept. Hopefully these ideas provide some guidance on what to do to build it.

Read Connie Davis’ Self-EFFICACY, Part 1 here.

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Guest Blog: Waiting Too Long for the Doctor? What to Do

Barbara Bronson Gray
Tuesday, May 1st, 2012

Barbara Bronson Gray, RN, MN is an award-winning writer and nationally-recognized health expert who blogs at bodboss.com. She has worked in hospitals, helped run hospitals, led a major healthcare magazine, wrote articles on healthcare for many national magazines and newspapers, developed a website for WebMD, served as a leader of global communications for biotech giant Amgen, and has a communications consultancy based in California.

“I wasted time, and now doth time waste me.” – William Shakespeare, Richard II

A friend recently asked me: Why do we have to wait so long for doctors and not for other professionals, like lawyers, accountants or dentists? And is there anything we can we do about it?

A 2009 study estimated that we spend 24 minutes waiting to see a health care provider.  I suspect new data would show that we are waiting much longer. As you might guess, overall satisfaction drops the longer we have to wait.

Waiting to see a physician is much, much different from waiting for an airplane or a bus.

You’re often anxious about the appointment, uncomfortable, in pain or worried. I have a friend who had to wait three hours for her first chemotherapy appointment, which seems cruel. Another friend had to wait almost an hour to get oral surgery: sitting in a cold office, having had no food or water since dinner time the night before, and very nervous.

Why Are You Kept Waiting? 

There are many different reasons why you may be kept waiting a long time.  While there is always the possibility of an emergency having caused an unusual delay, most practices seem pretty consistent; they either always keep you waiting or rarely make you wait. That’s due to the health care providers’ basic beliefs about their time and money; how much they value their patients’ time; and their ability to run a smooth and efficient practice.

A practice that doesn’t make you wait has undoubtedly made a decision that it’s not right to make patients sit very long in the waiting room. They respect your time as much as they respect their own. So they are careful to reserve a few slots every day in their schedule in case a patient’s visit takes longer than expected or there’s an emergency. They also create some “breathing time” in the schedule to help ensure the ebb and flow of people in and out won’t create a frustrating and tiring delay for their patients.

A practice that always makes you wait has a different perspective. They are typically maximizing revenue, over-booking multiple appointments to allow for some “no-shows,” and might even encourage extended patient visits and un-planned procedures because they increase the day’s revenue. Basically:

More Patients + More Procedures = More Practice and Personal Revenue.

Sometimes, the practice is just lax. I had the first appointment of the day to see my general practitioner and waited a very long hour. When I asked the office staff how that could possibly be and was there an emergency, they said, “Oh, no, she comes in when she comes in.” Hum.

Some of us mind all this more than others. A good friend of ours told me he has come to expect long waits when he or his wife sees a specialist. (He’s right. Average waiting times of specialists are longer than generalists). So he brings a big stack of back issues of the Financial Times and starts plowing through them.

What Can You Do?

Here are a few approaches you can take to deal with this issue:

  • Book the first appointment of the day or the first appointment after the office’s lunch period. This doesn’t always work because some practices book several people for every slot, but it’s worth a try and it’s likely to minimize your wait at least a bit.
  • Call ahead and ask how the day is going in terms of appointment delays and see if you should come in a little later. I’ve tried this with various results. Sometimes they just warn you that they’ll take you based on when you come through the door.
  • If you’re seeing a doctor who is prone to being called out of the office—a specialist such as an obstetrician/gynecologist or a surgeon—call ahead to see how the day is going. If you can reschedule on a bad day, you may save yourself a lot of time and aggravation.
  • After you’ve waited for 15 minutes or so (or whatever amount of time you’re personally comfortable with), ask the office staff how much longer they think the waiting time will be. If their answer doesn’t please you and if your problem doesn’t require immediate attention, ask to reschedule your appointment. Somehow that often gets you seen more quickly.
  • Consider talking frankly with your doctor or writing a letter explaining your frustration about the long waits and ask that the practice improve. See what happens.
  • Be a super patient patient. Bring fun things to do, read or listen to, and hunker down for the afternoon with an amazing attitude. (This would be very hard for me).

More dramatic options:

  • Complain about the waiting times on social media sites like Facebook or Twitter, or websites like Yelp or Angie’s List.
  • Find a new doctor. Ask the new practice’s staff what their philosophy of waiting times is before you book. Listen to what they say.
  • If you don’t want to keep seeing your doctor, you can sue your doctor in small claims court for your time. People have succeeded at this. It certainly makes a point.

The bottom line: Expecting me to wait a long time in a doctor’s office tells me two things. First, I don’t feel respected. The physician is, after all, my consultant. And secondly, I wonder how committed the practice is to my comfort and to reducing my anxiety when they seem to be putting more emphasis on their needs than on mine.

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Hospitals, Practice Administrators and Clinicians: You Gotta Learn to Love Patient Ratings

Jessie Gruman
Wednesday, April 25th, 2012

Jessie C. Gruman, PhD is president and founder of the non-profit organization Center for Advancing Health. Her experiences as a patient — having been diagnosed with five life threatening illnesses — informs her perspective as an author, advocate, and lead contributor to the Prepared Patient Forum blog. Her most recent book, AfterShock, helps patients navigate their way through the health care system following a serious or life-threatening diagnosis. You can follow her on Twitter at @JessieGruman. More…

You are increasingly being held accountable for the outcomes of the health care you deliver. Pay for performance; shared savings in ACOs; public report cards…the list of strategies to monitor and measure the effects of your efforts is lengthening. Many of you seem dismayed by the increased weight accorded to the patient experience of care ratings embedded in most of these programs.  Here’s why you should embrace them: The care you deliver cannot improve our health outcomes or even maintain passable ones without the knowledgeable, active participation of us patients and our families.

If we don’t connect with at least one trusted clinician, show up when we need to, get the tests we agree on, use effectively the drugs and devices you recommend, carefully follow directions after a hospital stay and try our damndest to lose the weight and walk around the block more often, medical interventions are squandered. Our suffering continues. Time and money are wasted: yours and ours.

Read the rest of this post at Health Affairs Blog

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