Why patient engagement is reciprocal

It is said that “turn around is fair play.”

So if providers (physicians, hospitals and other health care professionals) expect patients to become more engaged in their own care, isn’t it fair for patients to expect their physicians to also get more involved in their care?

If you look closely at “proxy measures” for physician engagement, you will see that this is a legitimate if not equally important line of inquiry.

Hello? Hello? Anyone there?

Take “listening” as a proxy for physician engagement.  The importance listening was underscored back in the 1880’s by of Sir William Osler, the founder of modern medicine, who said “listen to the patient they will tell you what’s wrong.”   Listening to patients was and continues to be a challenge for providers.   Research shows that on average, physician interrupt our (remember we are patients sometimes too) opening statements within 18 seconds.  This is significant since the “opening statement” is where we are telling the doctor the reasons for our visit.   Not surprisingly, being a “poor listener” is a chief complaint patients have about their physicians.

How do you feel when a friend, a colleague, or your spouse interrupts you when you are trying to make a point?

Ignoring certain patient “cues” is another proxy for physician engagement.  Depression is a great example of an entire category of topics, e.g., psycho-social issues, systematically ignored by many physicians.  Opening the Pandora’s Box of depression, anxiety, etc. can take a lot of time and push the physicians’ skills limits, but patients who bring it up are suffering and want to be heard.

How would you feel if you were obviously bleeding from a wound and your best friend was too busy to bandage your bleeding wound?

Telling patients to do something that they are philosophically against is yet another proxy measure of physician engagement.   A lot of patients for example don’t believe in taking RX medications as the first course of treatment.  Yet a lot of patients feel that is exactly what happens.  Physicians, due to a lack of time or a belief that patients are inherently adverse to life style change, prescribe an medication for high cholesterol, high BP, etc. as the first course of treatment.

How likely are you to fill a prescription that you didn’t ask for and don’t want?

Yes, physicians are too busy … yes physicians are not reimbursed enough.  But you can say the equivalent for us patients – we are not listened to, we are objectified as a disease, and we are not understood or respected as a person.

You get the point.  Engagement is a two-way street.  If physicians and hospitals want patients to become more engaged then they are going to have to become more engaged.   Engagement, like so many social behaviors, is reciprocal.   So, how are you measuring physician engagement in your organization?

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

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  • Anonymous

    The patient will get what they are willing to pay for. If you are not handing your own money to someone providing a service you are not the customer and will be treated like what you are — the product.

    • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

      It is unfortunate when a person is viewed by their method of payment instead of as a person.  Note, I did not say PATIENT/CLIENT.  A PERSON.  Yes, healthcare professionals deserve to be paid for their time, service, and expertise, but let’s remember that we’re in this business to help PEOPLE, not push out treatments, diagnosises, or prescriptions

      • Anonymous

        I agree. But I didn’t build the system. I didn’t create all the horrible incentives to drive medicine into assembly-line practice. The fact is that every incentive in medicine right now is set up to drive minimally acceptable care and minimal time spent. Relying on someone’s goodness of heart or professionalism or charity is heartwarming but has resulted in the 10 minute visit, lost your lab work, forgot to call you back, my next appointment is in 3 months system that we have now. How’s that working out for everybody?

        • Anonymous

          Thanks bladedoc, for putting us in your shoes.  I understand the bitterness a little better now.  I sense it with my own physicians too.

          • Anonymous

            I didn’t mean to sound bitter. As I am a trauma surgeon on salary I’ve opted out of the system for the most part. It’s just that I don’t think people understand why the system is as it is and they rail against the very edifice they have created.

        • Anonymous

          Bladedoc you are right on. I am a PCP that has the luxury of 20 minute office vists so I can connect with my patients and actually listen to them. I also make 60% less $ than my counterparts, due to seeing less patients per day. The thanks I get for this is only the occasional patient saying thanks for spending time with them and getting to the bottom of what their problem is. Some days it makes it all worth it but lately all the paperwork, prior authorizations for medications, and complaints I get from patients if it takes more than 3 hours to call in a medication makes me want to quit forever. I went into medicine because I genuinely care for people and want to make their lives better, but I work in a system that goes against these core values and I am punished financially for caring. I also see business thriving that do little to improve ones quality if life and I am bashed for being greedy asking for a 25$ copay.

    • http://warmsocks.wordpress.com/ WarmSocks

      Maybe you don’t think your patient is paying, but you don’t always know. Maybe the patient has insurance coupled with a HSA and must pay the first $10,500 out of pocket before insurance starts to pay anything (that $10,500 is in addition to insurance premia paid).OR maybe the patient feels that paying $1,800 per month for insurance to cover medical costs, plus $50 per office visit, means that the patient HAS paid to consult you for your expertise – after all, you agreed to take the insurance.  If you sign legal papers agreeing to accept a specific insurance plan, then why would the patient think that you don’t believe you’re being paid adequately?  If the payment isn’t acceptable, then don’t agree to it.  It’s possible for doctors to be out-of-network:  patient pays and gets a partial refund from the insurer.

      • Anonymous

        Due to inapt phrasing I left you with a misconception. I do not mean to imply that the money does not actually come from patients (or at least taxpayers) or that doctors are not compensated enough however the person that has to be satisfied with the service rendered in a third-party payer (TPP) system is in fact the third party. It’s like an all-inclusive reaort, generally the fare is mediocre because they already have your money. That’s why patient visits are down to 10-15 minutes and doctors don’t “engage” — because the payer (e.g. Medicare) doesn’t care.
        All the TPP cares about is that you provide a minimally acceptable level of care and that the appropriate boxes are ticked on the invoice (sorry, the progress note). As long as you don’t anger enough patients that they kick you off the insurance panel (almost impossible for ‘Care/’Caid) or spend too much money per insured life (not as big a deal nowadays) you will continue to get patients no matter what.
        If you don’t believe me ask yourself this – why does the best doctor in the US get paid exactly the same for an office visit as the worst doctor? Why are doctors incentivized to spend as little time as possible with each patient to improve throughput and thereby increase revenue?
        If you build a system where all the incentives go against the things you purport to care about don’t be surprised when those things are left out.

        • http://www.facebook.com/people/Ardella-Eagle/840440226 Ardella Eagle

          “…spend too much money per insured life…”

          HA!  I can’t begin to tell you how many resubs and inquiries I had to put in for under $30 because ‘Care wouldn’t pay for the same procedure on the other eye on the same D.o.S.!  TPP are ALWAYS looking to shave costs everywhere!

        • Anonymous

          I would expect doctors to have some internal incentives to do a good job.  Many of my friends go above and beyond what is considered the bare minimum just because they want to do a good job.  Reading comments by doctors here gives me the impression of some teenage who has to be to get good grades.

          I didn’t build the system and given a choice, I wouldn’t participate in such a system.  The endless diatribe of how we patients “get what we pay for” is sickening. 

          With money being the only incentive to do good work, how do you evaluate whether a doctor is the best or the worst.  I am sure it would not take very long for someone to find serious faults with any metric suggested.

          • Anonymous

            I never said that that money is the only reason to do good work; there are internal incentives and thank goodness for that. It could be a hell of a lot worse out there. The fact is that in the system as it is the payment system incentivizes you to produce BAD work. That is quite a difference.
            There are also some external incentives against doing a poor job (specifically failing to provide “the standard of care”) – all negative such as M&M conference (in teaching programs), lawsuits, state medical boards, and peer review. That all being said look at what the system works like now, today and tell me with a straight face that the incentives have produced “patient centered care.”
            Nobody talks about Apple, or Disney, or Nobu, needing to provide “customer centered care?” Why is that do you think?
            Patients pay too much for sub-optimal care. This is as a result of the TPP system which deemphasizes every factor which that makes markets efficient and drives higher quality and lower costs. The only procedures in medicine that have become both safer AND less expensive are cosmetic surgery, LASIK eye surgery, and abortion; coincidentally enough these are the only procedures that are exposed to market forces.
            I’m sorry that You are sickened by

        • http://warmsocks.wordpress.com/ WarmSocks

          That makes sense. Thank you for clarifying your point.

    • Anonymous

      “The patient will get what they are willing to pay for”

      What is the difference in the care the insured patient “gets” from you verses the patient who pays cash up front?

      • Anonymous

        I believe that the system is such that in a mixed practice, cash patients and insured patients are both treated the same way — as an assembly line product because that’s what the practice is set up to do. I don’t get cash patients so I don’t know if I’d treat them differently. I get a lot of self-pay patients but that is merely a euphemism for indigent in my patient population.

  • Anonymous

    The first communication with the doctor is through the medical assistant/nurse who escorts the patient to the room. The doctor already has a differential diagnosis when he walks in the door.  Perhaps it would better to ask the patient if there is anything to add to the original statement given to the medical assistant/nurse instead of asking for a repeat.

    I once at in a suicidal stupor at a doctor’s visit but since my emotional state wasn’t the purpose of the visit…

    • Steve Wilkins

       Just as communication hand offs are the greatest source of miscommunications (and medical errors) in the hospital setting, I suspect the same phenomenon applies to the doctors office, between the information had off between MA or office nurse and physician.

      I wonder how many times patients fail to tell their doctor something thinking that the MA shared it with the doc already – only to discover the MA never mentioned it.    

      • http://twitter.com/JasonBoies Jason Boies

        My current family doc is absolutely great, however, not all of my medical experiences have been smooth.  About 11 years ago, I came in with severe throat problems at an after hours clinic. Doc spent about 2 minutes with me saying I had Strep Throat.  What he apparently didn’t hear was that I was also unusually tired all the time.  Long story short, I got a second opinion and was diagnosed with Mono.  I’ve never been back to that clinic, they totally dropped the ball as far as I can see.  Great piece here, Steve. It really resonated with me.


        Jason Boies

  • http://www.thehappymd.com/ Dike Drummond MD

    Hey Kevin,

    It all  comes down to creating a “therapeutic relationship” with the two poles being the doctor and the patient.
    There’s the patient
    There’s the doctor
    Then there is the Relationship, which in a medical setting works best if it is a solid partnership … both parties headed in the same direction.

    The challenge comes when each side has a hidden agenda or incomplete understanding of the other side. Then, as in ANY relationship, it does not turn out well.

    Medicine is already set up for the relationship to have a power imbalance … the doctor giving “orders” and “doctor knows best”. What you are talking about is restoring balance to this vital relationship.
    I agree with your sentiment AND the biggest stumbling block is this will take more time with the patient … and time is what the docs have the least of.

    My two cents,

    Dike Drummond MD

  • http://twitter.com/USMCShrink Kevin Nasky, DO

    Primary care doctors aren’t really trained to provide non-pharmacological treatment of mood and anxiety disorders. Even if they were, they aren’t reimbursed (properly) for it, so there’s no way they’re going to do it. The rare primary care doc who is CBT trained isn’t going to spend 50 minutes doing CBT with one patient, when he/she could have treated 4-5 patients in that same time.

    • Anonymous

      Primary care doctors aren’t really trained to do a lot of things.  Would you fail to discuss a cancerous mole on my elbow because you don’t do chemotherapy?

  • http://twitter.com/WatsonHealth Watson Health

    Nice post. If physicians are rude to patients or have sloppy hand-offs, those patients are likely to be less engaged, so measuring patient engagement, if done well, will still prompt a closer look at processes to uncover issues such as these… your point is well taken though.  Thanks for the post!

  • http://www.facebook.com/profile.php?id=1342115186 Jody Hoch

    Please, docs ask your patients screening questions for depression!! I am sure mine would have been caught and put under control much earlier than it was as it took a long time for me to  figure it out on my own, and frankly only because of an ad on tv for a depression med. It cost me over a year more of misery when a simple screening would have connected the dots.
    My primary care doc used to have a simple questionnaire that I had to fill out before every visit. When she changed to another practice, no more questionnaire.
    Such a simple, but effective tool.

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