Patients must speak up at the doctor’s office

While reading the New York Times I stumbled upon an article by Pauline Chen addressing issues with doctor patient communication.

In the article, Dr. Chen describes a highly educated, articulate patient who was unwilling to speak up and discuss care related issues with her doctor.  The reasons given for not wanting to speak up included not wanting to anger the physician and not giving the perception of questioning judgement.

I immediately began to reflect on one of my recent blog posts on patient compliance and outcomes.  During the course of researching that particular blog topic, I found much published that suggested that patient-doctor partnerships in care were key to positive outcomes. Certainly, if a well educated, academic patient like the one described in the New York Times is reluctant to discuss care related issues with her provider, what about the rest of the world’s patients?  Maybe this is the largest barrier to achieving more positive outcomes and better compliance.

First and foremost, providing high quality care means doing what is right for our patients.  We all learn in medical school and residency the “gold standard” diagnostic test and the first line therapy for many disorders.  However, there are often several options that are within the scope of standard of care. The option that we may choose for a patient may have a significant impact on therapy success (even when treatment options have data to support equivalent outcomes).  Moreover, how we go about choosing which option to utilize in a particular patient has a lot to do with how successful the therapy may be.  Involving patients in this type of choice and providing the patient with decision tool aids is critical to this process.

A recent review by Dr Michael Barry, published in the Journal of Ambulatory Care Management in 2012, explored this very issue.  The concept of shared decision making is defined as “a patient working together with clinicians to select appropriate treatments or management options.”

Shared decision making is an obvious approach when patients are facing major procedural decisions such as whether or not to have an ICD implanted.  In order to use this approach there must be more than one acceptable option with acceptable outcomes.  However, these options often have different types of side effects and patterns of therapeutic effects.  In addition shared decision making can be used when trying to decide about whether or not to use a particular screening test that may have far reaching implications (such as mammograms in younger women–often yielding false positive results and necessitating follow up breast biopsies).  As clinicians we must present the outcomes data for a particular test or intervention and help our patients decide (together, as a team) what is best for them and their overall situation.

With these concepts in mind tools to aid in decision making have been designed specifically for certain diagnoses.  Decision making tools can be utilized to aid patients in making difficult treatment or testing decisions.  The International Patient Decision Aids Standards (IPDAS) provides quality standards for decision aids.  These decision making tools are designed for particular disease states and are created to provide information about options to patients.  They are not designed to promote one option over another nor are they designed to replace a consultation with a physician.  According to the IPDAS, “they are specifically designed  to prepare patients to make informed, value-based decisions with their practitioner.”  These tools are created to facilitate the shared decision making process.  They do not replace the communication process with the physician–they are created to enhance it.

So, it is obvious that shared decision making requires communication.  We must find a way to remove barriers to communication.  As physicians, we must work to avoid giving our patients the perception that they are “questioning  judgement” or “bothering the busy doctor” when they ask questions during a routine office visit.  In fact, at every office visit, we should introduce a time for questions.  In my EP practice, before the patient leaves the room, I try to ask if there are any issues they would like to discuss and try to have them assess their progress.

By involving them in discussions at every visit, I hope that I am able to open the door for future patient-initiated discussion.  We know from numerous studies that patient engagement is key to successful outcomes.  Now we must make sure that our patients, regardless of education or socioeconomic status feel free to ask questions, challenge treatment plan decisions and discuss options for care.  We must strive to remove barriers to communication and facilitate shared decision making.  When patients are not afraid to speak up in the doctor’s office, care is exponentially improved.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • Peter Elias

    I agree with the thrust of your very nice post, but there is one thing glaringly absent. Any discussion of TIME or a reimbursement system that recognizes the value of (and time needed for) the sorts of discussions involved in SDM.

    I gather that you are a procedural cardiologist. I don’t know the specifics of your practice or revenue flow, but I suspect that your perception would be different if your income stream depended solely on office visits, and the various wRVU driven bullets that must be documented. Perhaps not, but…

    I am an enthusiastic supporter of patient centered care and shared decision making and attempt as best I can to allow this to happen. But it is a challenge. The PSA discussion with a 55 year old well male or the mammogram discussion with a 45 year old well woman or the bisphosphonate discussion with a patient with a T score of -2.3 are each 10-15 minutes on a good day. Not so easy to do well in a 30 minute annual visit.

  • Nurse Holt

    I will tell you what would help.  STOP marking up the billing sheet for every question that I ask. I recently had an ENT doctor do this and you can best be sure that I am having BCBS investigate for fraudulent billing.  It is a true shame that I have to recommend labs and medications I would like to try to my PCP.  STOP trying to see so many patients in a day and then a doctor will have time to have a frank discussion. 

    • itsonlypalliative

      I am a biller & coder by trade. I have had the same thing happen! And have followed you and had the provider investigated by fighting the charges. It also falls on the billers and coders as well for allowing the coding that the doctor provides them as ‘the word’ and not auditing the files. GOOD FOR YOU!

  • Joan Marie Verba

    What would really help is if doctors would refrain from losing their tempers when questioned. I’ve had more than one doctor do that, and, in fact, one doctor got angry with me when I expressed my satisfaction that he had recommended a treatment that avoided surgery (he was a surgeon).

  • Doug Capra

    One of the key factors impeding communication is time — most usually the doctor’s time. What you’re really talking about is trust. People won’t open up unless trust has been established. It takes time to establish trust. It doesn’t just happen with most people. If a patient knows his/her PCP well, that may be the deciding factor — depending upon the demeanor and personality of the provider. It in today’s medical world, most often the doctor is in a rush. This isn’t announced, but unless the doctor behaves in a way that places time secondary to communication, the patient will most likely open up. People know when others don’t really want to communicate. So…until we can solve that “time” problem, that may affect all the other factors involved in this problem. I’m not saying time is the only factor, but it is an important, maybe driving element.

  • Maura69

    It is amazing to me that with all the knowledge that we have obtained through school and past experiences that some of use do have an anxiety attack with our doctors. I have had numerous major surgeries in the past among them brain surgery, (subarachnoid tear & leak), 17 surgeries on my right leg, (15 knee and 2 hip). So when I proceeded to ask my doctor why after 8 months of therapy, 3 times a week, with 6-8 miles a time on the bike, leg crunches, (80-100#) and rowing w/60# resistance, I have no stamina, my legs are like rubber and I am unable to walk a distance of more than a block, he informs me with a question, “Have I ever been 65 years old”? This is the answer that I received alluding to the fact that I am not young anymore. Needless to say I have a very bad back, (major accident years ago) which does complicate matters, nevertheless this response was not appropriate.
    I was a premed student and then became a surgical RN so, although I am not an MD, I still have some knowledge and felt that his answer was completely inappropriate. My question, why, even though we know better, do we still put doctors on a pedestal? It is because we have been brought up that way: To respect, to admire this profession as the best there is. As a child, most of us wanted to be doctors or nurses because just the thought of helping someone was magnificent and a worthy profession. I am not saying that it is not, all I am saying is please don’t simplify matters and demean the patients knowledge or fears. The fear may be very real and so to maybe the problem. Take an extra minute and you may learn something valuable.

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