The medical exam wasn’t designed to engage patients

Primary care physicians are the point of first contact that people like you and I have with a hospital or health systems.   We are 13 times more likely to visit a primary care physician in any given year than we are to need a hospital stay.

Primary care physicians are very important.   Yes they are they the first line of care for many people.   The primary care physician’s office is also the  “make or break” point for “engaging the patient.”

What people experience have experienced in primary care physicians’ offices  in the past tends to “shapes and frames” their expectations of future health care experiences.    Patient complaints about doctors that don’t listen, long waits, etc. are as much a reflection  of our collective life-long experience as they are the reality of any one physician.   So it is with the tendency of patients  to stay disengaged from their health care.   That’s what we as patients are taught from childhood.

What’s the point?

The point is that the medical exam – the most frequent point of contact between patients and the health care – was never designed to engage patients.  This is the same “medical exam process” taught in medical schools to this day.

The medical exam is a highly structured affair.  It doesn’t just happen.   It consists of 6 steps or processes that physicians move the exam through with the single goal of diagnosis and treating the medical problem

The medical exam wasnt designed to engage patients

The most important “take away” from this graphic is that patients – people – are invited to freely speak only during the 2nd step – the patient’s opening statement.  This is where people tell the doctor the reason for their visit.   Even then…patients are often interrupted before finishing their story.

From this point of the medical exam on, the patient’s role – aka the sick role – is to answer yes or no to their physician’s questions.

How can physicians, hospitals or health systems ever hope to truly engage patients in their own health  care when the heart of the heart of the health care system – the medical interview – is so un-engaging?

The key to patient engagement: High quality patient-centered communication

Patient-centered communications by definition is tailored to the patient – their beliefs, fears, concerns and past experiences.   It invites patient input and participation.   It engages us in important conversations with our physician that would not otherwise occur.   When practiced over time, patient-centered communications will enable physicians to accomplish more…in shorter visits…while creating exceptional patient experiences.

Hospitals, health plans, and ACOs looking to engage patients should begin by looking to ways to help their physicians adopt more patient-centered communication skills.   Simply providing them with EMR systems and care coordinators is not enough.   Going forward, those physician groups and hospitals most successful at engaging patients will be the ones that are the most patient-centered where it counts – physician-patient communications during the medical exam.

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

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  • Dave Miller

    After reading this, I’m forced to ask

  • John Henry

    The exam–the doctor examining the patient, not the patient talking–is about what the doctor needs, namely information on signs and physical findings. Unlike the chief complaint, where the patient is in the lead, the doctor is supposed to be taking charge in the exam. The patient is supposed to be cooperative at this point. “Engagement” should amount to “can you do this, and does it hurt to to that” and to make an effort to cooperate and to honestly reply to the doctor’s requests. A successful encounter depends on both the doctor allowing the patient to speak when the time is appropriate, and also the patient being willing to follow and cooperate with the detailed inquiries of history and the physical examination. The patient does not have to be passive, but they are not in charge either. And not every moment is the right time to “freely speak.”
    Open communication is essential, but appropriate expectations and behavior by all parties is also, including patients.

  • Amy tezza

    I have never asked a patient to be quiet during the exam; however there are times when I need to concentrate on the exam. Yes; you need to be quiet then. And sometimes I need to think; there isn’t time built in for that either. 
    This whole article seems a bit ridiculous. 

  • Dike Drummond MD

    I agree completely that a medical exam as it is typically taught to medical students – at a time when all their awareness is focused on diagnosing and treating the pathophysiology contained in this particular patient – is not something that engages the patient. The opportunity to engage the patient in something more that a symptom checklist is missed for one simple fact.

    The “provider” has an agenda that takes priority over the patient’s agenda
    Make the right diagnosis (so you don’t get sued)
    Order the right treatment (so you don’t get sued)
    Get the answers required to document adequately for the CPT code charged (so you get paid)

    The only thing that would create a more Patient Focused experience is if the Provider places some value on their Relationship with the PERSON sitting there. More often than not that same Provider is suffering from Compassion Fatigue from not getting their needs met. Burned out Doc = no patient engagement/empathy/compassion and the medicolegal and documentation agenda take priority.

    We can’t just sit here and expect to “should” providers into a patient engaging visit when all these forces are working in the background.

    My two cents,

    Dike Drummond MD

    • Anonymous

      I’m sure you didn’t literally mean this, but as written it almost sounds like it’s the fear of lawsuits that motivates the doctor to make the “right diagnosis and right treatment”. If there is tort reform, that fear factor will be loosened up somewhat, hopefully not at the expense of the patient.

      • Dike Drummond MD

         Hey Emily … what I am relaying to you is the words I hear coming from my clients … who are stressed out practicing physicians. The more burned out you get … the farther you recede from any concept of “patient centered care”. Listening goes out the window first … then Compassion fatigue sets in … followed by cynicism, sarcasm and feeling like every patient interaction as a lawsuit waiting to happen. In that state — patient engagement is not on the doctor’s list of priorities … on a conscious or subconscious level.

        That’s why it is so important to make provider’s health a priority in the healthcare system. It is only when the doctors are healthy and getting their needs met … that they can engage their patients cleanly … as equals/partners/human beings … and really connect and serve.

        This is a HUGE challenge given that 1/3 of all docs worldwide regardless of specialty are suffering from symptomatic burnout every day. (not me just saying that … it is a research proven fact in multiple studies over decades)

        Make sense?

        Dike Drummond MD

        • Anonymous

          It does make sense.  Unfortunately.

  • Steven Reznick

    Most good clinicians allow the patient to speak freely during the history portion of the exam and during the post exam discussion of the physicians findings, thoughts and suggestions

  • Anonymous

    Not included in the above time line:

    3 minutes for EMR data entry, 2 minutes for formulary review and electronic transmission of prescriptions, 30 seconds for meaningful use chores . . . 

    Where is the room for engagement by physician or patient?

  • Jim Jaffe

    like more than a few others here, I’m puzzled by precisely what the alleged problem is here.  there are so many parts of our healthcare system that are broken, it seems odd to target one that is, at worst, imperfect.  we patients go to docs with problems we don’t understand that worry us.  our hope is to exit with a bit of understanding and comfort, both physical and psychological.  many of us find that a visit structured by the physician, who we select because she’s had much more experience with such interactions than we’ve had, works just fine.

  • Steve Wilkins

    Great comments here.  It still begs the question however of “where” among the many touch points where patients/people come into contact with the health care system is engagement supposed to occur? 

    Patients are in their primary care physicians office 13 times more than in a hospital.  Yet to read the comments…the office visit is not the time or place for engagement.

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