Doctors with great bedside manner can also provide great clinical care

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes.  From a New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal.  She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.

Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”

She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card,

I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both.  She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death.  They aren’t in the office and yet are suffering.

Until we as doctors begin to take responsibility for our performance in hard clinical and objective outcomes like glycated hemoglobin levels, cholesterol, and blood pressure, our patients will pay a price.  We should not pretend that bedside manner should trump clinical outcomes nor that clinical outcomes should override the humanistic part of medicine.

It is possible to do both today.  It isn’t theoretical.  I only serve as one example.

I’m a front-line primary care doctor who also takes care of patients. I like Dr. Ofri also get a report card on my performance in caring for patients with diabetes.

Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.

I suspect critics will immediately begin to make a lot of assumptions of how these scores were achieved, when Dr. Ofri, another primary care doctor had very different outcomes.  Is it that I am not a quality doctor? Perhaps I’m too driven by data and have no – “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.  Perhaps I “fire” those patients who are not able to achieve good outcomes.

I can tell you many patients wish to join my practice and rarely do people choose to leave it.  The organization I work for also takes the softer side of medicine, a doctor’s bedside manner, seriously.  My employer randomly surveys patients on their experience. Does your doctor listen and explain? Do they know your medical history? Do they partner with you in your health? Do you have confidence in the care they provided you?

For 2010, 92.8 percent rated me very good or excellent on these elements.

So what does this all mean?

We should not automatically assume that doctors with great bedside manner cannot also provide great clinical care.

I can achieve the goals, which patients would want, and still be a doctor with great bedside manner because I work in a functional system like Kaiser Permanente. Primary care doctors are blessed with a comprehensive electronic medical record, are partnered with staff who help patients get the care they need, and are surrounded by specialty colleagues equally as focused to keep patients healthy and well.

So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes.  Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn’t necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves.  Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.

Until we as doctors lead, we cannot or should not expect improvement in patient outcomes.  We can no longer hide behind the reasons of our Herculean effort or bedside manner as what should really matter and account for something.  Patients expect these attributes intuitively.

With already so many examples of success in the country marrying the art, science, and humanistic part of medicine, the only thing stopping us to re-invent American medicine in the 21st century is simply ourselves.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

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  • Anonymous

    Thank you. I wrote a quite extensive response to Danielle Ofri’s NEJM piece last year from the perspective of UK primary care http://wishfulthinkinginmedicaleducation.blogspot.com/2010/08/quality-measures-and-individual.html

    You are obviously achieving good primary care in your practice. Can I ask how similar your practice population is to that which Danielle Ofri works with?

    • http://twitter.com/davisliumd davisliumd

      Unfortunately I don’t know Dr. Ofri’s patient population and how it would differ from mine.  I do think however that great clinical outcomes and great bedside manner do not need to be mutually exclusive.

      • Anonymous

        I agree. To set these up in opposition is quite dangerous in my opinion. I know that her practice is in a public hospital with an under-served population. It is hard for good clinical care to make up for the effects of poverty.

        • http://twitter.com/davisliumd davisliumd

          I certainly agree that the health care system as it currently exists may not be able to address the poverty issue which impacts health outcomes.   As Dr. Atul Gawande noted in the January 2011 New Yorker piece – The Hot Spotters – Can we lower medical costs by giving the neediest patients better care, it may be possible, even among those who have little.  It is simply thinking differently about how to solve problems and requires radically different thinking.  http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all

      • WhiteCoat Rants

        Your admission here that you do not know Dr. Ofri’s practice environment, combined with your willingness to compare your “quality” scores to Dr. Ofri’s “quality” scores to make the argument that your care is somehow superior perpetuates several logistical fallacies.

        First, you assume that your sample size is the same as Dr. Ofri’s. You admit that you don’t know any of the information about Dr. Ofri’s practice. Do the sample sizes for your scores meet statistical significance? Do hers? Does CMS even care about statistical significance in publishing its data?

        Then, you lead readers to assume that your patient populations and demographics must be similar. After all your scores are better than Dr. Ofri’s scores. I’d say that there’s perhaps a lit-tle difference in the patient populations between the Sacramento suburbs where you practice and inner city New York at Bellevue Hospital where Dr. Ofri practices.

        How much time are you allotted to see each patient? How much time is Dr. Ofri allotted?
        How much ancillary staff do you have to follow up with patients? How much ancillary staff does Dr. Ofri have?
        How many homeless patients see you in your suburbian clinic? How many homeless patients does Dr. Ofri see in her inner city clinic? What happens when she cannot follow up on her homeless patients? Or those without telephones? Or those who cannot afford their medications?

        The “attribution error” you allege when doctors assume they “can’t do both” is a false argument.

        What you have tried to do is comparable to taking two pots of soup and comparing them. You don’t know any of the ingredients except to say that your pot has twice as much oregano, twice as many beans, and twice as much salt as the other pot. Therefore, your pot must taste better than the other pot. There are many other aspects of patient care that affect clinical outcomes.

        Yes we have to re-invent medicine. Yes bedside manner is an important aspect of patient care. No we can’t compare patient outcomes between hospitals and somehow attribute those outcomes in whole or in part to a physician’s bedside manner.

        Providing “both” good bedside manner and good medical care doesn’t guarantee better outcomes any more than adding more lentils to your pot guarantees you’ll have better tasting soup.

        It would be interesting to see if  you could maintain your stellar
        scores satisfaction scores and patient outcomes working at Bellevue Hospital alongside Dr.
        Ofri.

        • http://twitter.com/davisliumd davisliumd

          I agree with everything you say.  I made no assumptions about anything.  Dr. Ofri simply listed her outcomes.  I listed my outcomes. 

          My concern was her assumption as she certainly has a very public platform (NY Times, NEJM) to present her perspective.  My piece was simply to ask the question – can patients have both great clinical outcomes and bedside manner?  As you know, Dr. Ofri comforted herself by noting that those who criticized her were “mostly
          [from] doctors who were not involved in direct patient care (medical
          administrators, pathologists, radiologists). None were in the trenches
          of primary care.”  She suggests that because they weren’t peers that somehow that criticism wasn’t valid.  I wanted to suggest that a front line primary care doctor, a peer, can disagree with her point of view.

          I agree that I have a very robust system at Kaiser Permanente that helps me provide the outcomes I noted.  I also list other systems that exist like Virginia Mason and Intermountain Healthcare, which though not Bellevue Hospital / NYU, demonstrate it is possible to have both great clinical outcomes and bedside manner. 

          I do agree with Dr. Ofri that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes.  You are correct that is very possible that any doctor working in Dr. Ofri’s practice may not do any better than she does and that does include me.

          However, if the doctor’s mindset is automatically set that the two can’t be done – great clinical outcomes and bedside manner – then even surrounding and supporting doctors in thoughtfully designed systems will also generate mediocre results. 

          If doctors believe that, so does the public.

          And that is my concern.

          • WhiteCoat Rants

            Anyone can disagree with Dr. Ofri’s point of view, but one of Dr. Ofri’s points was that the motives, experience, knowledge, and credibility of those who judge her should be taken into account when weighing their opinions. Would you agree or disagree that administrators and doctors who have never touched a patient have less of a basis to criticize Dr. Ofri’s outcomes? In fact, have *you* ever worked in an inner city hospital and had your feet held to the fire for patient outcomes?

            It isn’t fair for you to say that Dr. Ofri and “many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both [i.e. have good bedside manners and achieve good 'report card' patient outcomes].” Dr. Ofri appears to be saying that in her practice environment she is having difficulty achieving both, not that “doing both” can never occur.

            You list other systems that have achieved the goals you write about, but still, you have not told your readers whether you are comparing apples to apples. Are Virginia Mason and Intermountain Healthcare equivalent to Bellevue in their demographics and support systems? If not, your argument is akin to saying “I earn a good living, other people I know earn a good living, therefore everyone in the United States should be able to earn a good living. Why are there so many people on unemployment?”

            The only point that you should be making is that someone in your position, with your patient volumes and demographics, and with your support system has the ability to achieve both good patient outcomes and good bedside manner scores. That’s it. Expanding your argument to apply to other systems – especially when you admit that you have no idea how those systems operate – is inappropriate.

            You want to make a point that both outcomes “can” be achieved. Fine. Point taken. Humans “can” go to the moon, men “can” run a 4 minute mile, and the New York Yankees “can” win the World Series. That doesn’t mean that all humans or baseball teams are able to achieve those accomplishments.

            Now all that those without support systems such as yours have to do is raise a few hundred billion dollars to improve their infrastructure so that they have equal potential to achieve acceptable results according to CMS.

            Hey … it “can” happen, right?

          • http://twitter.com/davisliumd davisliumd

            I appreciate your comments.  I don’t however agree that for a person to have observations about a process or outcomes that one must be exactly the same peer as the other.  Dr. Don Berwick, head of CMS and also previous of the IHI and the 100,000 lives campaign is a pediatrician – http://www.boston.com/Boston/whitecoatnotes/2011/09/don-berwick-medicare-best-job-ever-had/maKDZpJymeXqJBQz1fM8xN/index.html.  There are many families, patients, and other advocates saying that we must do better.  Since they are not MDs should we discount their opinions as well?

            In terms of addressing the poverty issue and problems with getting good health care outcomes, Dr. Atul Gawande, a surgeon and New Yorker writer, had an excellent January 2011 New Yorker piece – The Hot
            Spotters – Can we lower medical costs by giving the neediest patients
            better care.  He shows that it is possible, even among those who have little. The article shows that it
            requires thinking differently about how to solve problems. Our health
            care system as it currently exists may not be able
            to address the poverty issue which impacts health outcomes which is
            likely more prevalent in Dr. Ofri’s practice.
            http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all

            The other reference I’ve found helpful is from the book Switch – How to Make Change When Change is
            Hard –
            http://www.fastcompany.com/magazine/142/switch-how-to-change-things-when-change-is-hard.html
            and looking for bright spots.  I suspect that even within Bellevue / NYU there may be doctors,
            despite the system and societal challenges they and their patients face,
            who have better clinical outcomes – the bright spots. Like the excerpt
            in the book, even among impoverished villagers in Vietnam, a few
            families were able to raise healthy children despite the challenges they
            all faced. The key is learning from those positive deviants and
            insuring everyone knows.

            This only happens if one believes that
            it is possible.  Using your example about men can run a four minute mile, no one believed that a person could run faster than 4 minutes until Roger Bannister did in 1954.  Why did it take that long?  He believed it was possible.  So yes, great clinical outcomes and bedside manner are not
            mutually exclusive. If one does not believe solutions exist or that it
            is possible, then you simply see what you want to see. 

            Dr. Ofri says in her NY Times piece that “We need to remind ourselves and the public, though, that these quality
            measures miss much of what makes a good doctor good. If you want every
            blood pressure below 130/80, hire a computer to dose the drinking water
            with antihypertensives. The quality measures will be perfect, and every
            hospital will be No. 1 in the U.S. News & World Report rankings.”  I understand she says this in jest and appreciate that is comes from a place of frustration in working in a dysfunctional health care system.

            Nevertheless, this statement suggests she and I suspect many other doctors believe it is impossible to have both great bedside manner and great health care outcomes.  I like others am simply asking is it possible to have both?  Dr. Ofri could have written her article the same way you suggest I write mine and be explicit where she works (an inner city hospital and probably with many people who are homeless) and that she could have said her impressions applied only for her situation.

            But she didn’t.  As a result her observations are equally as valid as mine.  We simply disagree and have two different points of view.  One is not wrong any more than the other.

  • Anonymous

    One of the things that is difficult to achieve in the space of 10-15 minutes is t learn what the patient would like to do, what s/he is willing to do, and what s/he can do realistically for his/her condition. Used extensively in addiction disorders, motivational interviewing can make all the difference in the world for achieving clinical goals. Motivational interviewing is just now gaining favor in treating diabetes.

  • http://www.facebook.com/people/Glen-Jeremiah/100000903160927 Glen Jeremiah

    Frustration is when you cannot afford to get treatment in a private hospital.

  • http://www.facebook.com/people/Gary-Thomas/100002862130227 Gary Thomas

    Doctors with bedside
    manners

    My name is Gary W Thomas and I am a
    patient with diabetes, I have been a diabetic since 2000. I have had
    a few close calls but nothing drastic, but as a patient I have read
    both sides of this theory and have decided to speak up about two
    things. First diabetics are a hard bunch of patients. One reason is
    for most of it scares the heck out of us and for another its a very
    expensive diseases which for some of us gets worse with time and
    money. But lets get back on subject, when I go to my doctor I feel
    relieved, yet when I go to my titian I fell worry. Why is that you
    might say? Because her only job is diabetes and she is more inform
    than my doctor, but she keeps him inform on how I am doing and thats
    OK with me.

    My doctor is very efficient but he also
    has good bedside manners and he works in a place that he must see
    over a hundred patients a day and all of them different. If he
    stresses we don’t know it and every one wants him to be there
    doctor also. I use to wonder why is that ? But after reading reading
    this article, I think I might have an Ideal. To me I want both a
    doctor who truly cares about my well being and a doctor who is
    knowledgeable and efficient. Because I think they should be both and
    I know that I am not the only one who feels this way. But with health
    care as it is, most doctors who are not surrounded by good staff and
    medical teams have to make a choice. Be good to your patient and
    treat them like humans with respect or treat them like cattle and get
    them in and out quickly without really speaking to them hardly at
    all.

    I want to believe that all doctors want
    to give their patients time,but I know that this is not always
    possible and I know that but I also know that at times it is possible
    and the doctor won’t make the time . I have had those doctors also.
    But, I still want to believe that most do want to have time with
    their patients.

    Now from what I have seen and heard a
    doctors report card is mostly about efficiency of them with their
    with their patient care,not truly about how they treat their patients
    which in my opinion makes them good but not personable doctors,they
    do the job but they don’t know you. Do you think as a regular
    patients of yours that I want you to know me ?What would that take
    5min. Out of our time together? Would that help me talk to you more,
    tell you more so that you could help me better? Is not this what a
    doctor suppose to be like ?

    Dr. Lin stated that the only thing
    stopping doctors fro re-venting American Medicine in the 21st
    century is simply themselves. This brings me to my second thing, it
    takes all kinds of doctors to make that change, which means they have
    to respect, support, communicate, and be there for each other rather
    they personally know that doctor or not. But yet everyone of them can
    get to know their patients if they wanted to and that by itself
    changes peoples lives. Don’t you feel good when someone treats you
    like a person and a doctor? Well we patients feel good when we are
    treated as a person and a patient. Nothing can take the place of a
    doctor giving us patients a little of his time.

    Inclosing, I think of a poem that
    states Don’t you judge me till you have walk in my shoes. I think
    doctors are a blessing, and I hope one day they realize just how
    powerful they are, and the standard they set dose not go just for
    them but for us patients also. Thank you,

    Gary W
    Thomas

    • http://twitter.com/davisliumd davisliumd

      Thanks for your comment.  I completely agree about finding a doctor who knows you and has a personal connection.  Helping patients get better and getting to know them as individuals is the best part of being a doctor.  It is what I enjoy the most.  Stay well.

  • Steve Wilkins

    I realize that a patient’s opinion my not count for much but here goes.  The evidence shows that the author, Davis Liu, is correct.  It is possible for providers to have a good bedside manner and provide good clinical care.  There are lots of physicians who do it all the time.  They are the physicians in the top quartile of patient satisfaction, least likely to be sued for malpractice and most importantly – have the best patient outcomes.  What’s their secret? Excellent doctor-patient communications…you know where they actually listen to, touch and empathize with patients.  I understand they still actually perform physical exams on pats as well.rather than just run labs tests. By the way, published studies show that being a good communicator adds 6 seconds to the length of a visit.

    What leads me to believe that things will change is that in 2 years, 30% of hospital and provider Medicare reimbursement will be determined by patient satisfaction/experience scores. In other words…if your bedside manner leaves something to be desired…so will your paycheck.  Just imaging how one patient – with 10,000 followers on Twitter – could influence the quality of a provider’s reimbursement.  Like everything else in life, how you chose to look at this – threat vs opportunity – is entirely up to you.

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