How can doctors successfully engage their patients?

by Thomas Goetz

Enough about patients: What is a doctor to do?

In 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 e-Patient 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.

Thomas Goetz is executive editor of Wired and author of The Decision Tree.

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  • imdoc

    If people actually spent their own money for medical care there would be a transformation in the service experience. Already in areas such as cosmetic surgery the doctors know success depends on many of the things the article points out.

  • http://www.drpeterjweiss.com Peter Weiss

    I suggest that doctors refer to personal coaches or health and wellness coaches. Coaches are experts in helping people define and achieve their goals. Doctors are experts in illness and it’s treatment. Why does every family practitiner have well used referral relationships with medical specialists but doesn’t have similar relationships with personal trainers and health/wellness coaches?

    • http://curbside.posterous.com Nuclear Fire

      Because patients aren’t interested in that. I tell a patient I’ve got a toxic drug to put them on and they pay attention. I tell them they need to diet, exercise, do physical therapy or see a life coach then their eyes glass over like a teenagers.

      • HJ

        It’s the patients that you see that want drugs. Those of us that have chosen lifestyle have found our MD’s aren’t knowlegable for these sorts of things. I have suggested on other posts that personal trainers, dietitians, and others are better equipped at prevention-real prevention, not the drug induced kind-and was scoffed.

  • http://fogbegone.blogspot.com/ Penelope

    These are excellent suggestions; which I agree will go a long way to engaging patients. May I add one more thought to your list?
    Explanation: This may fall under the category of transparency, but I notice that when many people will fill out a prescription, they will know how and when to take it, but have no idea WHY they are taking it. One example is antibiotics adherence; people are told to finish their medication, yet often stop taking it once they start to feel better. If the physician invests the time to explain the theory behind the treatment and the risks of stopping and starting, my guess is that the person under their care will be on the same page for their treatment, and that there will be greater satisfaction for both the physician and the patient.

  • Colenso

    My approach is fairly straightforward. I see a doctor as the first port of call for a diagnosis; if doubt still remains, he or she can recommend further tests and the opinion of a specialist. A doctor is also the only person in many countries who can sign a script for prescription drugs such as anti-bacterials.

    I haven’t relied on family doctors however for their “expert” knowledge in over three decades. When my young family was growing up, I used regularly to buy copies of the British National Formulary. A brilliant publication that everyone with half a brain should own.

    With the Internet, in the first instance I make extensive use of Cochrane reviews. If there are none, or the Cochrane review points out how much more good research is needed, as is so often the case, I try to make the best sense I can out of the third rate published research that is out there. Sometimes I use JStor to access the entire article, but increasingly I make do with the increasing number of free peer-reviewed papers listed on PubMed.

    I have a good understanding of physics and mathematics, both of which I used to teach. I also know more chemistry and biochemistry, and more about pharmacology than the average MD. Frankly, it doesn’t take long to bone up on the specific anatomical or physiological issues that I need to. The problem I have most doctors is that most of them are ignorant, arrogant and patronising. I have to bite my tongue throughout most of my consultations with them.

    I distrust almost all so-claimed “experts” in any field, because most “experts” are not expert at all. I’ve discovered the hard way that it’s up to us to sort out our own problems. Doctors cannot help you in just a few visits with difficult or out of the ordinary medical issues. It takes too much time to get to the root of many chronic problems and they have too many patients to see.

    Those of us who are too stupid or too lazy or too indifferent or too cowardly or too timid or too poor, and don’t have anyone to help them, WILL get sick and die. That’s life. That’s death. It’s very distressing to have to see this happen in front of one’s eyes.

  • Louise S

    If a doctor treats me like I’m stupid, I won’t take his advice – unless it *is* good advice. I took bad advice from doctors a couple of times and all it did was cause unnecessary, avoidable stress.
    If I trust the doctor [I trusted my old family doctor and I trust my present one], I will take his advice – because he *hasn’t* treated me like I was an incompetent unthinking, childish fool.
    I *do not* trust or appreciate doctors who lie to me and talk over my head as if I don’t exist and try to convince me that what they want is somehow safer than what I want when I know myself and they don’t – because they *haven’t treated me like a person.* [This is specifically for obstetricians, of whom I met only two who were completely straightforward with me. None of the others explained any risks of what they wanted to do, which, I have a right to know by the Code of Ethics they supposedly follow.]

  • http://engagingthepatient.com Nick Lloyd, Emmi Solutions

    Great article and good suggestions. You are right that unless patients possess an uncommon amount of energy and passion, it is hard for them to become engaged, informed and active participants in their care. To some extent, the same is true for caregivers. We have to help put physicians in a position to succeed—giving them the right tools to help engage patients so that they are not on their own. Here’s a article by Kristine White of Spectrum Health explaining how she empowered clinicians to improve the patient experience.
    http://engagingthepatient.com/2010/04/20/making-connections-improving-the-patient-experience-%E2%80%93-part-i/

  • http://AmericanHealthScare Richard Young, MD

    Mr. Goertz,

    You are clearly a victim of the vast media-medicine conspiracy when you write “Though I am in favor of pay-for-performance as a strategy for reducing costs and emphasizing health over illness,”

    Pay-for-performance does not reduce costs, with very few exceptions. Many of the HEDIS-type indicators that are part of a typical pay-for-performance list are interventions that improve health, at a cost. Examples include cholesterol treatment, lowering diabetics hemoglobin A1Cs, and the newer children’s vaccines. One way to look at this phenomenon is we are now paying doctors to further increase the nation’s healthcare bill.

    The British are way ahead of us on this. They now have several years of experience of how general practitioners respond to incentives and what the final bang for the buck of those incentive is. Keep your eyes out in journals like BMJ for reports on this experience.

    While I agree with your general sentiment about patients not passively doing what their doctors tell them (or the alternative, being “non-compliant”), I can tell you one of the professional joys for me is educating my patients on what’s causing their symptoms and then giving them treatment options that are reasonable. (By reasonable, I mean I’m not going to have a long risk-benefit discussion on the merits of antibiotics for pneumonia). I couldn’t begin to count the number of times I’ve gone through a list of options only to have the patient pause and say, “What would you do if you were in my shoes?” or it’s variant, “What would you do if it were your mother?”

    Medical options can be complex and can be bewildering for patients, despite our best efforts to explain the options in non-medical English. Frankly, I’d rather they pick, but many times I end up deciding.

  • http://Www.Twitter.com/alicearobertson Alice

    I really enjoyed The Decision Tree.  It was a educational, empowering endeavor, and a great diversion for me during the last year.  Because of a costly medical error (an ENT who did a lousy biopsy and did not read the lab notes)  I have learned so much from writers who help us maneuver the system while our tired brains are moving so fast…you wonder if the hamster on the wheel inside your head will ever run out of energy and give you a break.   At one point it seemed to me that doctors had a secret language…..some of them covered for their colleague whose mistake was so obvious you wonder why such supposedly smart men would bother.   I decided they were a group that felt they were practicing some medieval type of pretend Knights of the Roundtable Club.  Medicine was their Holy Grail…but we still do not know if it exists….what does exist is discontentment, disillusionment, and sometimes distortion.

    At one point I desperately desired to learn how to crack their Rosetta Stone type of language, I simply could not understand.   I felt so betrayed I fell apart in a doctor’s office once.   My heart was broken from their vanity, yet I desperately needed them.

    What helped me the most was a kindhearted doctor who not only answered email, but encouraged me to write.   It was my saving grace.  It was like a healing balm to my completely crushed spirit (my daughter was suffering from the radiation, and I would watch her sleep, and I would write).  

    So, to your list I would add that I would hope doctors would be willing to email their patients.  For what little time they would invest they would give immeasurable comfort.  It let’s the patient know you care about them, and that yup are personally vested in their recovery.

    Then I would add a kudos to the transparency and ask that if a patient shares something second hand and you are not sure, or do not know if it is true then eat your pride and tell them you just don’t know.  Our brilliant doctor knows how to say that, but he doesn’t suffer from the insecurity of ego envy :)

  • http://Www.Twitter.com/alicearobertson Alice

    What would you do if you were in my shoes?” or it’s variant, “What would you do if it were your mother?” [end quote]

    Did you see the Dr. Oz show tis week? He was quite impressed with a doctor who asked the exact same question of her colleagues (gynecologists). Dr. Oz was flabbergasted to find that doctors do things quite differently when treating themselves than they recommend to patients. Ultimately, they give themselves superior advice, counsel, and treatment.

    So, how should we be phrasing the question? Should we ask the doctor to go and have a Snow White, “Mirror, mirror on the wall” moment…type of chat with themselves…where we can voyeuristically watch? How does a patient get beyond the surface and really pick a physician’s brain to get to the nitty gritty truth about how they would choose if they were in the patient’s shoes?

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