A medical home does not guarantee increased patient satisfaction

One of the more notable findings from the special report on the TransforMED National Medical Home Demonstration project was that “patient satisfaction doesn’t automatically go up.”

Terry McGeeney, CEO of TransforMED, attributed the lack of increased patient satisfaction experienced by the 18 participating physician practices to a variety of factors, chief of which “was the turmoil of change experienced by patients as practices implemented after-hours access, quick access to laboratory results and the chance to schedule e-visits or make a same-day appointment.”

But there is another likely cause for the less than stellar patient satisfaction results — the lack of effective physician-patient communications.

Don’t mistake activity for achievement

To be sure, patients in the TransforMED Medical Home Demonstration sites now have access to a myriad of new ways that patients could communicate with physicians – e-mail, telephone, web portals.

But there is no evidence in the TransforMED pilot of substantive efforts to improve the quality of the dialogue between physicians and patients. It is after all the quality of the physician-patient conversation — not the quantity of opportunities to communicate — that drive patient trust, behavior change, outcomes, and satisfaction.

McGeeney’s own comments allude to the long-standing problem physicians have communicating with patients. Physicians could have done a better job of “informing patients about what their practice was doing and why.”

The goal is patient-centered communication

Every physician conversation with patients ideally should begin from the patient’s perspective. As a physician, there are lots of things you want to say to your patients. The trick is how to say it in a way that individual patients will relate to and understand.

I am talking about more than health literacy. I am talking about understanding where the patient is coming from. This means understanding their living situation, their beliefs about their health, disease etiology, medication and the treatment you recommend … and couching what you have to say with that “patient context.”

I am talking about asking the patient what they want to accomplish during the office visit, asking about their “health story” and letting them finish without interruption.

Offering secure e-mail, web portals and access to their EMR will help with the physician-patient communication process. But unless the physician believes in patient-centered care and makes an effort to communicate in a more patient-centric fashion, the promise of the medical home will go unfulfilled.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • r watkins

    The rationalizations of the PCMH proponents in light of the disastrous results from the NDP are becoming increasingly convoluted.

    The truth of the matter is very simple. The PCMH model requires an enormous amount of administrative and bureaucratic busywork from everyone involved. And not only do you have to do the work, you have to document that you did it, and then you have to document that you documented it. Inevitably, physicians and staff have significantly less time available for true patient care, and patient satisfaction suffers.

    If you read the fine print in the “Future of Family Medicine Task Force Paper Six,” you find that the PCMH model assumes that the physician will spend LESS TIME with each patient (passing off important parts of patient care to other members of the “team”), in order to generate the higher charges needed to cover the increased overhead!

    • jsmith

      Spot on comments.

  • MB

    I was aware that my doctor’s clinic was participating in the TransforMED project. I had spend the last few years dealing with several difficult medical issues and was looking forward to finally having a doctor-patient relationship. I followed the reports written by Dr. Greeney. The experience with TransforMED was awful. I got passed around the office and didn’t see the same provider twice. There was no communication between my doctor and patient. If there had been, she would have seen how depressed and anxious I was about being passed around the office. I now see a great nurse practitioner who is sensitive to my needs and has the time to interact with me on a meaningful level. The e-mails are nice, but I like the trust I have with the nurse practitioner, the time she spends with me, and the availability when I really need help.

  • ninguem

    You look at some of the comments here, you realize there are some people who won’t be satisfied no matter what you do.

    • Dean

      @ninguem – Which comments? When I read your reply I thought, “OK, there must be something below that’s unreasonable and lacks substance.” However, the comments to this article seem very coherent – people want to be cared for, not administered by, their physicians.

      I work with outstanding clinicians every day, so I take umbrage with people who blame physicians for health care’s poor situation. The respondents here, though, are not blaming physicians, they (respondents) are simply stating what they want/need out of the patient care visit. That seems reasonable.

  • jsmith

    Over and over on this blog we hear from pts that they want one doctor to spend time with them, to answer their questions, to think seriously and deeply about their health. See the comments on the post on the value of primary care. What people complain about most is fragmentation and lack of attention. If people thought that doctors really listened to them and cared about them, many customer service complaints would simply go away.
    The PCMH, where each task is done by the most minimally trained person able to do it, goes in exactly the opposite direction. Moreover, it suffers from the peculiarly American delusion that more technology is the answer to any problem, even a broken personal relationship between doctors and their patients. Utter insanity.

  • primaryMD

    This is no surprise at all.
    Patients do not want a relationship with a “team.” they want a relationship with a doctor.
    Medical home models that seek to increase patient panels and have the team do much of the communication and handle the “routine” things that come up (as if that can be known ahead of time) will undermine the foundation of good primary care: the doctor-patient relationship.

    I am consistently amazed that more people aren’t talking about losing what is arguably the most important thing in medicine.

    • boundbyinsurance

      Good response! I wouldn’t mind developing a close relationship with a team if that team were small and stable. Unfortunately, in today’s climate nurses and office people tend to come and go out of a revolving door. The one person on the team who’s the constant is my doctor. I need to feel comfortable with everyone in the office, but the doc is the one with whom I have to have trust and bonding on a higher level.

  • Doc99

    “And don’t go mistaking paradise for that Home across the road.”
    Bob Dylan

  • http://Www.healthecommunications.wordpress.com Steve Wilkins

    The bottomline here is healthcare is all about relatioships – between providers and patients as well as between providers. As with any relationship, the strength of the relationship is a function of shared interests, goals and respect…all of which depend upon understanding and communicating with one another.Many physicians approach such relationships from a positiion of authority while many patient approach the relationship from an inferior or subservient position. Patients need to be taught how to become a more active participate in the patient-doctor relationship. Frankly patients could do themselves a big favor by more active participation in routine office visits. If a patient does not want to be seen by a non-physician, then speak up. If a patient doesn’t want to take a new medication…say so. Do worry about who’s to blame…instead focus on how to fix things.

  • inchoate but earnest

    Steve Wilkins comes closest to capturing the potential of PCMH – and where it goes most wrong. The PCMH concept works best as a form of network platform, rather than a conventional, hierarchical ‘bureaucracy’ of actors. “Patient” may be at the putative helm – or “doctor”, or “devoted spouse”, etc – but that determination is something the network should support, rather than dictate.

    And it has to be reiterated: primaryMD’s notion that “Patients do not want a relationship with a “team.” they want a relationship with a doctor.” couldn’t be farther from the essence of the issue.

    First of all, people are people first, patients only occasionally.

    Then, as patients, they want to be healthy. They could really care less if the person (or persons) they relate to, who help them to be healthy, are doctors, lawyers, indian chiefs, nurses, or hobos.

    It’s wonderful if they DO develop a relationship with their physician of the type primaryMD imagines – but that is NOT the central matter at hand.

  • Christine Sinsky

    The PCMH is a work in progress; the first iteration was a good start but the model needs refinement. The comments above point to some of its weaknesses: an over reliance on technology, an under-emphasis on the relationship between patient and physician and a misconception of teams.

    The main drivers of quality, downstream cost containment and patient/staff/physician satisfaction, in my view, are access and continuity. Can I usually see my physician the same day for acute needs? Does my personal physician provide the majority of my care?

    Strong teamwork makes this possible. Not the type of “team” where the clinical care is fragmented among multiple providers: the patient seeing a nurse practitioner for his wellness exam, a physician’s assistant for a rash, a pharmacist for blood pressure management, while seldom seeing his personal physician, who is busy signing off on care provided by others for patients she may no longer fully recall.

    The model of teamwork that has worked well in our practice is a small, consistent core group of people working together for the patient. The nurses prepare the patient and the physician by organizing the data ahead of the appointment, helping the patient set their agenda, and taking responsibility for the standardized, predictable work of the practice, such as immunizations and cancer screening. In this way the physician can focus her attention of the “deep and serious thinking” JSmith refers to above, be attuned to the emotional cues MB realized were being missed as she was being “passed around the office” and create a working environment that the patients, staff and physician can enjoy.

    As the physician I prefer to touch each patient at each visit. Situations that appear simple aren’t always. In addition, management of even straightforward problems builds trust and relationship that help with adherence and rationale consumption of resources down the line. Having sufficient support staff makes feasible. The medical home will continue to evolve; in our experience a greater emphasis on continuous healing relationships and supportive teamwork will lead to a stronger medical home.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Christine..great comments. I agree that the PCMH is and will be a work in progress for some time.

    PCMH is not about rearrange the deck chairs as you know. It involves a fundamental shift in how physicians and patients think about and interact with one another. Claire Trescott, MD, Dir. of Primary Care at Group Health put it best when she told me that everything they do at Group Health begins from the “patients’ perspective.” Put another way, patient centered care calls upon providers to learn about, respect and well possible accomodate patient’s beliefs, expectations and needs.

    In addition to providers needing to be less bio-medical/directive and more patient centered, physicians in particular need to communicate more effectively with patients. If the patient comes in a list of agenda items they want to discuss with the physician, they might not be satisfied talking with the nurse or medical assistant. It may be efficent for the physician to do things that way…but it may not be acceptable to the patient. The literature is full of research documenting the benefits of physicians, not ancillary staff, in listining to and negotiating the visit agenda for example.

    It’s great that you “touch” each patient so to speak. But more variation in patient trust, satisfaction, and outcomes can be explained by doctors taking the time to “inform and educate” patients than is explained by the doctor sticking their head in the exam room to say hi. And if you are looking for a magic bullet when it comes to quality…I don’t think you have to look much further than improving the effectiveness of how physicians and patients communicate about new medications, recommended prevention services, etc.

    My point is that it is that the Medical Home is all about the physician-patient relationship…which includes good communications. The physician-patient relationship trumps EMRs, teams, care managers, e-mail and telephone consults and all the other trapping associated with the process of becoming certified as a PCMH.

    Once providers “get it”, I think the PCMH will fulfill its promise.

    • Christine Sinsky

      Just to be clear–there is nothing in what I advocate that would have the physician just duck their head in at the end of an appointment. Absolutely the contrary.

      As you said, it is all about good communication and building trusting relationships.

      I think most PCPs spend 60-70% of their time with patients and 60-70% of their day doing low value tasks, such as looking for information, doing data entry, and managing their inbox, and then, in an attempt to deal with the stress of this worload, think they must delegate fragments of the diagnostic and management work to others.

      I advocate for a model where the physician’s time with the patient is well spent, with eye contact, listening, pausing, reflecting, goal setting, working out a plan together and getting to know the patient as a full human being.

      I don’t believe you can do this with the common model of a physician working with 1/2 -1 medical assistant.