[tweetmeme source=”Healthmessaging” only_single=false]My favorite blog, besides Mind the Gap, is KevinMD.com. It’s not just because they let me do a guest post now and then. I like it because it is a great place to interact with lots of other readers, particularly physicians.
Last week, KevinMD picked upon my post here on empathy or should I say the lack of it. True to form, I received some engaging comments. One comment in particular caught my attention. The contributor for some reason equated “being empathetic” with “giving in” to patient requests presumably during routine office visits. Here’s a direct quote:
Give the patients what they want! Antibiotics are OK for colds. The patients want them. So what if narcotic-addicted patients get more pain medication. That’s what they want. Why make a big deal about a patient’s weight or a patient’s smoking habits? It will upset them.
It then struck me that I hear variations on this theme quite often from physicians. I interpret this to mean that some physicians are afraid that saying no to a patient request may negatively impact their patient satisfaction scores. I can see why one would be concerned about this issue so I did a little research to see where the truth lay.
First of all, patient requests are not uncommon. For example, a sample of 200 patients (closed panel HMO) generated 256 requests for service, e.g., medications, tests, and specialty referrals. Treating physicians complied with most frequently with patient requests for medications (75.6%) and tests (71.4%) more frequently than expectations for referrals (40.8%). So what was the impact of these physicians “saying no” figuratively and literally on patient satisfaction and patient trust? Nothing. Patient satisfaction and trust in their physician remained high regardless of whether patient expectations were met or not.
When patients make requests, I really wonder what they are asking for. Do they really want/need that antidepressant which they ask for u name or do they just want their physician to listen to them; yes even empathize with them? After all, the number one complaint of patients is that their doctors don’t listen to them. Do patients make requests because they worry that their doctor is too busy to notice a problem like anxiety or depression? I suspect that negotiating patient requests is not a big concern in physician practices characterized by strong patient-physician relationships and high quality physician-patient communications. I could be wrong…
What do you think?
Sources:
Koropchak CM, Tulsky JA. Behind Closed Doors – Management of Patient Expectations in Primary Care Practices. Archives of Internal Medicine. 2007;167:445-452.
Vega CP. The Satisfied Patient – Overprescribed and Costly. Medscape Family Medicine. 2010:3-6.
I AGREE. Docotr now tote a laptop into the exam room and type notes while pretending to pay attention to a patients problem. Efficiency experts praise them for getting their work done in a timely manner. Completing the PQRI needs become more important than listening without divided attention to the problems of the CURRENT patient. We recently did the satisfaction survey as part of our PCMH survey and while the drug seekers aren’t happy with us , our patients are very happy. EMR is completed after the patient visits.
Kerry,
In your work with PCMH practices, how would you characterize physician-patient communication before becoming a medical home and after becoming a medical home. I understand that many of the changes associated with primary care re-design take time..but I was curious if you have noticed any trends.
Kerry:
Excellent point. I don’t understand why the fact that the doc is using a computer makes it acceptable for him/her to sit in front of the patient and do secretarial work.
One of many sad things about the PCMH is that it is really administration-centered (look at the writings of Dr. L. Gordon Moore and others); patient satisfaction and improved health are largely ignored.
Actually assessing patient satisfaction is part of the PCMH survey process and has to be gathered. Choosing to change the processes and place a premium on the approach is up to the provider. Tracking through registry data of overall health and patient specific wellness is also part of the process. Many EMRs do not support this function so we may be largely missing an opportunity to change the process at the practice level while expending large amounts of money. Some commercial plans have seen the value of compensating PCMH physicians and have moved to seperate contract tiers for them……..wonder when the government will smarten up and do the same
What really strikes me is the lack of understanding of what empathy really is. In most basic terms, it’s the understanding of how the other person thinks and feels about a situation. If it is conceptualized as a process, not an endpoint, it plays a vital role in negotiation – which in simple terms – is a dialogue between people intended to reach an understanding or agreement. If you think about the key words ‘understanding’, ‘dialogue’, and ‘agreement’ – doesn’t this sound like what patient-centered healthcare should be?
Consider the juxtaposition of these two titles on the same page:
“Physician Behavior Change Comes Slowly If At All”
and
“Looking for a Way to Engage Patients in Behavior Change? Try Storytelling.”
Hmmm. . .
Lol…hope springs eternal…luckily there is a solution that does not require physicians to take the lead in behavior change…
Stephen,
You raise some great questions. You are right about the #1 complaint “Doctors don’t listen”. I have done an informal survey of patients and doctors for my newest book in process. The desire to be listened to came in many forms and about many aspects of their care.
With appointments lasting 5-7 minutes, the ability to communicate well and develop a healthy relationship between doctor and patient has been seriously compromised leading to many types of shortcuts by both parties. Both feel rushed and that affects what patients say / request, the doctor’s ability to really listen and doesn’t allow time for either party to truly understand each other.
How doctors are measured be it satisfaction surveys, measures being used by insurance companies, or incentives in place that affect their pay only add to what effects how appointments are conducted and decisions are made. It’s a very complex issue. The system is seriously broken. Putting millions of more patients into it without identifying and fixing the root causes of the problems will only make things worse.
The problem is we have required surveys and this directive and that directive and what abbreviations can be used and DRGs and ACO and Observation stays ,CPOE. and al we have forgot is to leave time for physicans to provide care. Perhaps we should find a way to put care back into our encounters
Kerry: Agree with you completely, and that’s why I don’t like the PCMH as currently designed. The administrative requirements are huge, and, as originally designed, it’s based on the doctor having a larger patient panel, shorter appointments, and delegating more patient care to other members of “the team.” Is that really what we want?
I guess it depends on what version of the medical home we are discussing. The change in process is difficult and requires work on part of the practice . We are working with a consultant who has eased the pain of the admin requirements for us greatly. The original versaions of the medical home were patient,process focused and the “team” approach wasn’t part of the concept. The version calling for more delegation is the version that needs to die but I seriously doubt its the evrsion that phsyicians designed or recommend. I suspect the wonks and widget folks advocate the “team” approach and not Doctors
I’ll admit, I’m not familiar with PCMHs and PQRIs. However, from a patient’s perspective, I would respect my doctor much more if I made an inappropriate request and he or she denied my request and explained why than if he or she simply acquiesced to my request just to please me.
Lisa,
Turns out that the scenario you describe happens quite often in Pediatrics where Pediatricians assume, based upon comments from “Mom” about bacterial infections, etc. that “Mom” is asking for a prescription for the patient. A prescription is then ordered for an antibiotic because the doctor thought that’s what “Mom” wanted when in fact she didn’t.