Category Archives: doctor-patient relationship

In the waiting room

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Talking about long waits for patients to see the doctor is like touching the proverbial third rail: sure to spark frustration and anger from patients and defensiveness from the medical community.

They were at it again this week at Kevin, MD, where guest blogger Barbara Bronson Gray wrote about long waits and and delivered the ultimate judgment on this aspect of the patient experience: “Expecting me to wait a long time in the doctor’s office tells me two things. First, I don’t feel respected. The physician is, after all, my consultant. And secondly, I wonder how committed the practice is to my comfort and reducing my anxiety when they seem to be putting more emphasis on their needs than on mine.”

Touché.

As you might guess, it provoked a storm of reaction. “If you want Cadillac service, pay for it by joining a concierge practice,” one person snarked.

Other commenters, most of them apparently doctors, pointed out how hard it is to stay on schedule when patients have multiple and sometimes unpredictable issues that need to be addressed. “It often is not as simple as ‘they don’t care’ or ‘they haven’t prioritized your time,” one physician wrote. “It is a complicated combination of complexity of care, patient expectations to have care provided at one time (without a second visit/co-pay), primary care offices running at high capacity because of a workforce shortage, etc.”

I’m not sure doctors and patients are ever going to see eye to eye on this issue. But there’s no denying that wait times are a major source of frustration for many patients, which begs the question: Is reducing the wait time truly an impossible task, or is it simply not a priority for most medical practices?

And a corollary question: How long should patients reasonably be expected to wait? Is 20 minutes acceptable? What about an hour? What about two hours?

There’s been a considerable amount of study on wait times, what contributes to them and how to reduce them. To be sure, the problem sometimes rests with patients who don’t show up on time, aren’t organized during the visit or wait until the final moments of the encounter to bring up an important issue. But medical practices are kidding themselves if they don’t think they’re contributing to the problem as well.

A few years ago the American Academy of Family Practice hosted a national demonstration project on the patient-centered medical home model that included intensive evaluation of patients’ experiences. Among the issues studied were wait times, which resulted in the uncovering of some interesting data.

Patients were given a clipboard and pen when they arrived at the doctor’s office and asked to record the time at each point during the visit: when they arrived at the office, when they were ushered into the exam room, when the doctor arrived in the exam room, and so forth. There turned out to be multiple bottlenecks, ranging from cumbersome paperwork that patients had to fill out to staff inefficiencies in patient flow and setting up exam rooms between appointments. At some offices the first appointment of the day was scheduled for the same time the staff showed up to work, inevitably resulting in delays. In other cases, the practice didn’t have an appointment schedule that was flexible enough to allow for emergencies or for the patient who needed a longer visit. Sometimes doctors simply weren’t very punctual.

The best time that a practice in the national demonstration project was able to achieve? Thirty minutes, from start to finish (although this practice did not have any ancillary services, such as lab or X-ray, on site).

Dr. Melissa Gerdes describes how it was done:

They were able to achieve a 30-minute cycle time by working closely in teams. They even designed their office space to put all team members, from front-office staff to physicians, in close proximity, which encouraged ongoing communication throughout the day. They started on time. They staffed appropriately and scheduled realistically for the work capacity of the day. And they made being on time a priority.

Consider the example of several health systems that have adopted so-called lean processes that, among other things, cut down on the amount of time patients spend waiting. At a children’s hospital in Wisconsin, the time in the exam room between when the patient arrived and when the doctor came in was reduced from 38 minutes to 11 minutes.

If there’s a common thread here, it’s that the organizations that reduced their wait times were successful because they made it a priority.

What’s a reasonable amount of time for patients to wait? The national average, according to a recent report by Vitals, a physician review site, is 21 minutes. It varies regionally, from a low of 19 minutes in the Midwest to a high of 22 minutes in the South.

What’s unreasonable, then? Here’s a frustrating story from someone in the Boston area who brought a family member to an appointment, struggled with heavy traffic, couldn’t find a place to park, dropped off his relative so she could arrive at her appointment on time – then got lost trying to find the right clinic.

He recounts:

On finally reaching the right clinic, I found my family member patient still in the waiting room. She had not been told by the front desk the doctor was running behind. However, we learned from other patients who had been waiting for up to an hour and a half that she was running behind and that it is possible to give the front desk staff a cell phone number and to leave to get some lunch. We were not offered this option, but when we went to the front desk to ask, we were allowed to do this. On coming back, we still had to wait, and were finally called in at 1 p.m. (for an appointment time that was for 11 a.m.!).

Is this disrespectful of the patient’s time? It would be hard to disagree that at some point, lengthy wait times cross the line from minor inconvenience into major headache – more so if the wait time is poorly managed by organizations that come across as tone-deaf to how patients feel about long waits. Zero wait time may not be a realistic goal but many wait times clearly could be shorter and better handled than they are.

Undermining the patient

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The way some people tell it, most patients are ignorant, unmotivated consumers of health care who’d rather seek the opinion of a doughnut vendor in the hospital lobby than do the actual research it takes to find a qualified doctor.

Harsh words? They come from Dr. Jon Cohen, a vascular surgeon and chief medical officer at Quest Diagnostics, who spoke last week at the annual TEDMED conference in Washington, D.C.

Among some of the excerpts from his talk: The average American spends more time deciding which TV to buy than choosing a physician. Consumers are more likely to judge the quality of their health care on the basis of service – whether the parking was convenient and how long they spent in the waiting room – than on the basis of the actual care they received and whether it was clinically appropriate and effective.

Finally, most people just aren’t motivated enough to be good consumers of health care, Dr. Cohen concluded. “Consumer-driven health care doesn’t work because people don’t want health care.”

Ouch.

There’s some truth to this. But in saying it, Dr. Cohen has unwittingly exposed the gulf that often lies between patients and health care professionals – namely, that they approach the patient experience from entirely different perspectives and an entirely different fund of knowledge. And it’s a mistake to write off the patient’s behavior as uninformed or unmotivated or unconsumer-like without considering the validity of the health care experience from their point of view.

The TEDMED folks unfortunately haven’t yet posted a video of Dr. Cohen’s speech, so I’m relying here on secondhand reports of what he said. I’m going to give him the benefit of the doubt by assuming he meant to give his audience some food for thought rather than bashing on consumers.

But the whole tenor of his talk raises some pretty interesting questions: If it’s so hard to get Americans to think like well-informed, thoughtful health care consumers, whose fault is it (if, indeed, “fault” is the word we want to use)? If people aren’t better health care consumers, is it because they don’t want to be, or is it because they’re being held back by how the current system functions? If patients make decisions on the basis of different values and beliefs than clinicians, does this invariably make them wrong?

A glimpse of the online reaction that emerged this weekend in response to the TEDMED conference suggests people feel rather strongly about the issue. A commenter at the Wall Street Journal called it “a typical paternalistic surgeon perspective. Everybody is dumber than they are, and nobody can make a decision as well as they do.”

“Let’s get real here,” opined someone else. “If the consumer had transparency into key drivers like, quality, cost, access and could have a ‘real’ discussion with care providers then maybe the average consumer could become a good health care consumer… The insurance companies, pharma companies and the provider communities need to check their ego at the door and actual[ly] SERVE their patients as CONSUMERS.”

Bunk, argued another commenter. Patients don’t behave like consumers because their health insurance cushions them from the cost of their care and they have no financial incentive to shop around for quality or cost-effectiveness.

The mHealth Insight blog has another point of view: “I don’t think we should be blaming the key stakeholders (patients) for the way they make choices but focusing on the failure of healthcare providers to bring transparency to the services they offer.”

For what it’s worth, I suspect a lot of people want to become more informed as patients and health care consumers. No, wait, make that: I know a lot of people want to become better patients and health care consumers. But the system doesn’t make it easy for them, and I think Dr. Cohen is dead wrong in his assertion that “intense desire trumps all barriers” to becoming good health care consumers.

Whenever the topic turns to patient empowerment, it seems to stumble into a double bind: Patients are told they should be more engaged and involved in their care, yet they’re given few tools for doing so. They’re lectured for not doing more yet the expectations are often set woefully low on the assumption they’re not smart enough to get it anyway (the assertion that most people don’t really want to be good health consumers being a case in point). One minute they’re exhorted; the next, they’re undermined.

Could patients do more to educate and advocate for themselves? Of course they can, and should. Sheer desire isn’t always enough, however, to overcome systemic barriers and the weight of a health care culture that’s still of two minds whether to accept that patients are indeed capable of becoming more involved partners in their care. If patients are falling short at being good health care consumers, it would seem there’s plenty of blame to spread around.

Photo: Wikimedia Commons

When families clash during the doctor visit

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Family togetherness is usually a good thing but sometimes it’s a source of conflict, and new research suggests doctors can be slow to recognize when families disagree about the best course of care.

A small-scale study involving patients with advanced lung cancer, their oncologists and caregivers found that the doctors didn’t always notice differences of opinion between patients and families.

In interviews conducted separately with the participants, the researchers found that most of the time, patients and families did agree on important care decisions such as extra tests or options for hospice care. And most of the time, the doctors correctly perceived there were no conflicts between the patient and caregiver.

But in seven cases in which a patient reported conflict with a family caregiver, the doctor picked up on only two of them. Of the 17 cases in which a caregiver reported conflict, five of them were recognized by the doctor. And in the 15 instances in which both the patient and caregiver separately reported some kind of conflict, only two of them were recognized by the doctor.

This was a very small study but the implications are intriguing.

Do the findings mean doctors are often obtuse about what’s going on between patients and caregivers? Sometimes they are, perhaps. “This is not something that oncologists regularly explore with patients,” Laura Siminoff, of the Virginia Commonwealth University School of Medicine and one of the researchers, told Reuters News.

But it’s equally likely that patients and families often hide their disagreements when they’re in the presence of the doctor. Maybe patients are uncomfortable bringing it up, especially if a family member is in the exam room with them, or maybe they don’t want to bother the doctor with something they perceive as trivial, Siminoff suggested.

There’s a bigger question here, though: Does family involvement help or hinder patient care?

Experts in patient advocacy are unanimous in believing patients fare better when they have a family member or caregiver who’s committed to helping them manage their health and who can advocate for care that’s in their best interests. There’s been considerably less focus on how to deal with families who disagree or don’t function well together.

American Medical News recently explored this topic and what it means for the clinician who’s sometimes caught in the middle:

Even as the push toward the patient-centered medical home stresses the invaluable role that families can play in improving compliance and health outcomes, the presence of a relative raises a host of complicated issues for physicians to navigate.

“Now you’ve got potentially two patients in the room,” says Jason Karlawish, MD, professor of medicine and medical ethics at the University of Pennsylvania School of Medicine. “You even have a kind of third patient, which is the relationship between the family member and the patient. If you ignore that, you ignore it at your own peril.”

Some examples of how the dynamics can get complicated: The patient might not want the family member in the room but is too polite or too intimidated to say so. Family members might have an agenda that conflicts with that of the patient. Relatives who are distrustful might second-guess or undermine the doctor’s assessment and recommendations.

The visit doesn’t have to get adversarial to be difficult, noted the physicians interviewed by American Medical News. Sometimes well-meaning family members simply take over the discussion, talking on behalf of a patient who’s perfectly competent to speak for himself or herself. Or they might appeal to the doctor to take sides in a family dispute over health behaviors, such as a spouse who doesn’t want to stop smoking or an aging parent who doesn’t want to take a medication.

The biggest mistake that can be made, according to Dr. Yul Ejnes, an internist in Cranston, R.I., is “to forget that the patient is the boss.”

Conflict can be magnified a thousandfold in high-stakes situations, such as when end-of-life decisions need to be made. The study involving the lung cancer patients and their caregivers and oncologists didn’t look at whether disagreements – and the doctor’s lack of awareness of them – had an impact on care, but Reuters Health spoke to experts who said the discord often raises the family’s stress level and can complicate the process of making treatment decisions.

Dr. Anthony Back, an oncologist at the Seattle Cancer Care Alliance, said it’s important for oncologists to notice the cues and to call in a social worker or therapist to help resolve family differences. “Sometimes those things are beyond the purview of the oncologist,” he said. “But when (patients and caregivers) have some major issues, they need to figure it out and we have other resources for them.”

Doctor, heal thyself

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Do doctors who are carrying a few extra pounds shy away from advising overweight patients to lose weight? Are they less likely to counsel patients about making lifestyle changes – eating broccoli, being physically active – if they don’t follow the same advice in their own lives?

An interesting new survey presented last month at a meeting of the American Heart Association suggests that physician health plays a role in how they talk to their patients about a healthful lifestyle – and that when doctors don’t practice what they preach, it might be to the detriment of their patients’ health.

The survey was carried out among 1,000 primary care doctors. Among the findings: 27 percent said they exercised at least five days a week and 39 percent reported eating the recommended five servings of fruits and vegetables per day. Only 4 percent said they were smokers.

The survey comes on the heels of a study earlier this year, published in the Obesity journal, that found doctors who were overweight or obese were less likely to talk to their patients about weight loss than doctors with a normal body mass index. A similar study that appeared in 2010 in Preventive Cardiology reached the same conclusion: Doctors who exercised regularly and were at a healthy weight were the most comfortable discussing lifestyle behaviors with patients.

American Medical News spoke recently about this issue with Dr. Jo Marie Reilly, a family physician and associate professor at the Keck School of Medicine at the University of Southern California. Her take: “Practicing what we preach is important. Physicians are just more aware and better able to counsel patients if they take care of themselves.”

There’s certainly something to be said for being a good role model, and that includes health care organizations as well as individuals. It doesn’t send the right kind of message when the hospital cafeteria menu is loaded with high-fat, high-calorie food, or when patients can glimpse the staff at the medical clinic clustered in the loading dock for a smoke break.

The doctors in the Obesity journal study seemed to sense that “do as I say, not as I do” can create problems in caring for patients. Physicians of normal body mass index who participated in the survey had higher confidence in their ability to offer lifestyle counseling. They also were more likely to think that patients wouldn’t trust weight-loss advice coming from an overweight doctor.

One conclusion that might be drawn is that patients with less-than-ideal lifestyle behaviors tend to get a free pass from doctors whose own behavior doesn’t match the ideal and who are thus reluctant to bring up the subject in the exam room. In other words, they don’t want to appear hypocritical, even if remaining silent isn’t in the patient’s best interests.

But there’s another way to look at this. Perhaps doctors who struggle in their own lives with weight, nutrition and activity are more sensitized to how patients might feel about lifestyle advice, and more apt to be accepting when patients fall short.

Although the studies didn’t examine how patients perceived normal-weight vs. overweight doctors, it raises the question: Do patients truly resent it when an overweight doctor tells them to lose weight? Some of them surely do, but others might feel an overweight doctor is better able to identify with and understand the difficulty of making lifestyle changes.

One also has to wonder where to draw the line. Should a physician who has depression (and, sadly, the incidence of depression is higher among doctors than the population at large) counsel patients about their mental health? If the doctor drinks, is it hypocritical to talk to patients about problem alcohol use? Is it OK for a doctor to refuse a flu shot? To be seen in public eating a burger and fries? By these measures, everyone in the medical profession has probably been a hypocrite at one time or another. It doesn’t necessarily make them bad doctors; it makes them human beings susceptible to the same struggles that confront every other mortal.

What seems to matter is how the conversation is framed, suggests Dr. Reilly. Even when doctors aren’t perfect, they can still help patients by talking about their own struggles with weight or other issues. And they can take the time to have the discussion about lifestyle habits if that’s what patients need, she told American Medical News. “It’s really important that we take that time to counsel patients about how their health habits influence their lives at every visit, and that we look at that as important as any medication,” she said.

Defining patient engagement

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Everyone in health care is talking these days about patient engagement, but a funny thing happened on the way to the discussion: There doesn’t seem to be a widely agreed-on definition of what this actually means.

When the National eHealth Collaborative recently released the findings from an online survey conducted in February, the responses were all over the map.

Some thought patient engagement meant the ability to email the doctor, make an appointment online or have online access to the medical record. Others thought it meant access to educational information about health. Some thought it meant a willingness and comfort with asking questions or challenging the doctor’s recommendations.

Virtually everyone who responded to the survey said it was either “important” or “very important” for patients to be engaged in their care.

But how can patients be expected to do this when no one is sure what patient engagement is supposed to look like?

If the survey accomplished anything, it was to shed some light on the lack of widespread consensus and to identify the beginnings of some common points of agreement.

Of the 185 people who took part in the survey (admittedly a very small sample size for drawing any meaningful conclusions), the description on which they agreed the most was “Patient uses educational material and online resources to learn about better health or their own health conditions.” This was closely followed by “Patient uses tools and resources to manage his or her medical record and other health data.”

I was interested to note that “Patient feels comfortable challenging doctor when something doesn’t seem right or when explanations are not clear” ranked third among the responses picked by the survey participants. Does patient engagement mean it’s OK for the patient to disagree with the clinician, then? Plenty of folks would say that engaged patients are the ones who go along with whatever the doctor recommends (and sure enough, 22.7 percent of the survey respondents said “Patient follows their doctor’s orders after a visit” was a sign of an engaged patient).

Since this was a survey carried out by the National eHealth Collaborative, it isn’t surprising that health information technology was seen as a critical piece of patient engagement. But is this the most important ingredient? Can someone who doesn’t even own a computer still be an engaged patient?

What about concepts such as active participation by patients in their health care? Or commitment to learning more about their health at whatever level they’re comfortable with? Or self-management and shared decisionmaking?

More negatively, does patient engagement mean patients will start dictating the terms of their care, even when what they want is medically inappropriate?

And who gets to define patient engagement, anyway? Does this rest with patients alone? With providers? With both of them together?

Here’s how Donna Cryer, CEO of CryerHealth, defines it in a post she wrote last year for the Prepared Patient Forum at the Center for Advancing Health:

Properly done, patient engagement in action looks like shared responsibility between patients (and their families if applicable), health care practitioners (the entire team: surgeons, physicians, nurses) and healthcare administrators (providers of the infrastructure and payment models) to co-develop pathways to optimal individual, community and population health. Patient engagement brought to life means involving patients and caregivers in every step of the process, providing training or financial support if necessary to their participation.

An infographic put together recently by Steve Wilkins of the Mind the Gap blog offers further insight into some of the challenges of defining patient engagement. Simply giving patients access to information doesn’t mean they’ll know how to use it, he writes. And measuring engagement by the patient’s willingness to ask questions and challenge the doctor fails to account for the time constraints in the exam room or the lack of confidence many patients feel in speaking up.

The role of the patient is being redefined in ways that are more far-reaching than perhaps any other time in history. Traditional power structures are being upset, and this can be unsettling to patients and providers alike. Although it may be tough to reach a consensus on what the core principles of patient engagement should be, it’s important to the process – and yes, engagement means patients should be part of it.

Getting emotional about mistakes in care

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When patient safety is compromised, clinicians often react with guilt, frustration, embarrassment and sometimes anger. Even when the incident is minor, or when the patient wasn’t harmed at all, it’s common for people’s emotions to get involved and for them to sometimes have trouble coping, a new study has found.

The research was carried out in Canada and appears in the latest issue of the Journal of the American Board of Family Medicine.

Although there’s increasing recognition that caregivers often become the “second victims” after a patient is harmed, few studies have attempted to systematically examine how they feel and how they respond, especially in the medical office setting. Using a confidential questionnaire attached to incident reporting forms for a regional community practice medical safety program, the Canadian researchers collected data from physicians, nurses, managers and office staff at 19 family medicine practices in Alberta.

Here’s what they found:

- Across the board, frustration was the most common emotional response to a patient safety incident. It was reported by 48.3 percent of the respondents. About one in three also reported feeling embarrassed, 12 percent said they were angry and 10 percent felt guilty.

- Whether the safety incident was minor or serious didn’t seem to matter. Most caregivers and office staff reported some kind of emotional reaction when something went wrong or when there was a close call.

- The emotional impact was greater when the patient was harmed or when there was a possibility the harm was more than temporary.

- About 63 percent of the respondents reported using a coping strategy to deal with their feelings after an incident. Their most frequent response was to talk to someone else about it. But more than one out of three said they did nothing, and only 17 percent said they told the patient.

- Of note, the physicians in this study were more likely than the rest of the clinic staff to have an emotional reaction to an incident, and were also less likely to use a coping strategy in the aftermath.

Although this was a small study, one of its strengths is that it was based on real-life incidents and how people responded to them, rather than asking for their response to a hypothetical situation. It also captured the smaller-scale mistakes and miscues that can happen in daily office practice – losing or misfiling a patient’s lab report, for instance – where most patients receive the majority of ongoing care.

Most of the patient safety incidents involved in this study were in fact relatively minor, which might account for why frustration, rather than guilt or blame, was the dominant emotional reaction. Other studies have found that anxiety, shame, self-doubt and self-blame are often part of the doctor’s response to a medical mistake – but these studies generally focused on how doctors felt about the worst or most memorable mistakes of their career, rather than the daily ups and downs of primary care.

It’s a side of office medicine that most patients don’t see. Many might not even realize it exists. But whether patients are aware of it or not, it has an impact on care, the study’s authors wrote.

When clinic employees, and doctors in particular, don’t have good coping strategies for dealing with mistakes, they’re at greater risk of burnout and depression, the authors wrote. it also can become a missed opportunity for personal and organizational learning.

“All members of the health care team report experiencing emotions related to patient safety incidents in their practice,” the researchers wrote. “Incidents with minor or no harm still invoked emotional responses from the providers. It is important to understand the impact that patient safety incidents have on the medical clinic as a whole.”

The decline of empathy

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It’s probably safe to say that most medical students start their training with a high desire to be empathetic toward their patients.

But these ideals often don’t survive the grueling process of becoming a doctor, a recent study published in the American Journal of Pharmaceutical Education has found.

Researchers at Midwestern University in Chicago and Thomas Jefferson University in Philadelphia wanted to know whether exposing first-year medical and pharmacy students to a theatrical exercise depicting the challenges of aging would improve their ability to empathize.

It did. The study involved 370 students at the Chicago College of Pharmacy and the Chicago College of Osteopathic Medicine at Midwestern University. They were asked to complete a test measuring their empathy levels before and immediately after the skit, and they scored significantly better afterwards. Unfortunately, though, the effects weren’t long-lasting. When the empathy test was administered again (one week later for the pharmacy students, 26 days later for the medical students), most of the scores had returned to their original baseline.

This doesn’t necessarily mean these students were completely lacking in empathy. But it points to the difficulty of instilling and maintaining this quality in the future health care workforce as they progress through their training.

Previous studies have reinforced this. The one that’s probably cited the most often appeared in 2008 in the Academic Medicine journal and examines what the authors describe as “hardening of the heart” during medical training. It tracked four classes of students at the University of Arkansas for Medical Sciences and documented notable declines in empathy scores, especially after the first and third years of medical school.

Similar findings have been reported among students in dental school and in postgraduate medical education.

Given the intensity of medical training, it seems inevitable that students would undergo some hardening of the heart, if for no other reason than to cope with the sheer burden. The academic demands are rigorous. The reality of providing care for actual patients, which starts in their third year, can be overwhelming and disillusioning for many students, especially when patients die or don’t fare well. Training environments that place medical students at rock-bottom in the pecking order are exhausting at best and abusive at worst. Add in the ever-present anxiety about grades and educational loans, and it’s no wonder that empathy begins to take a back seat.

Here’s a peek at the emotional state of a second-year medical student at Johns Hopkins who is about to transition into hospital training:

Suddenly the theoretical becomes practical, the “nice-to-knows” become “must-knows,” and simple clinical scenarios become ethical dilemmas. The vicissitudes become quite intense: one moment you feel ready to save a life as you stand triumphant over a mannequin, then suddenly you’re hovering in the pediatrics emergency department hearing the gurgle of a seizing child and feel completely helpless to handle such situations.

But it all begs the question: Is empathy something you can teach to medical students, or is it innate? If it’s teachable, can the curriculum be strengthened to foster and develop empathy? If it’s innate, should the admission process put more emphasis on selecting students who have this quality?

The 2008 study in Academic Medicine uncovered some interesting nuances. Overall, students who chose specialties in fields with a high amount of patient contact and continuity of care – family medicine, internal medicine, pediatrics, obstetrics-gynecology, psychiatry – had higher scores on the empathy scale than those in other specialties such as surgery or radiology. Male students in the core specialties actually scored higher than the population norm at the beginning of their training. On the other hand, the largest decline in empathy scores took place among male students in non-core specialties. Meanwhile, female medical students started at the norm and scores then declined for females choosing non-core specialties.

Of note, few if any of these students entered medical school with a deficiency in their empathetic abilities. But something about the training process may have diminished their capacity to feel empathy for others. To date there haven’t been many studies to determine whether this is temporary or whether it persists throughout their career. The study in the pharmacy education journal suggests that even when students are exposed to academic exercises specifically designed to increase their empathy, the effects may be short-lived.

Despite a lot of study, especially in the past decade or so, there remain many questions about how best to foster empathy in students who will be spending the rest of their working years in patient care. It matters because patients are more likely to comply, more likely to receive an accurate diagnosis and more likely to be satisfied with the clinician-patient relationship when empathy is present, the pharmacy journal authors wrote. “Empathy is an important component of the healthcare provider-patient relationship that has been linked to optimal patient outcomes.”

Online doctor reviews: not ready for prime time yet

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It sounds like a useful idea: online ratings that help consumers sort through their choice of doctors and pick the one who’s the best match.

In real life, though, the concept doesn’t seem to have flourished as well as expected. An intriguing piece published this past weekend in the New York Times explores why this would be the case for what writer Ron Lieber calls “the highest-stakes choice of service provider that most people make.”

Litigation is one obvious concern. Patients don’t want to be sued for posting an online review that may be negative. In case you think this would never happen, think again: A Duluth, Minn., man was sued by a neurologist after making critical comments on three consumer rating sites about the doctor’s bedside manner. The case was thrown out by the St. Louis County District Court but the Minnesota Court of Appeals ruled this January that a jury should be allowed to decide.

Sometimes patients worry their anonymous comments will be recognized and that there’ll be retaliation in some form, Lieber wrote. He spoke to an Angie’s List customer who “said she would never talk negatively about her doctors on the site because there were only two decent hospital systems where she lived and she didn’t want to end up blackballed by doctors at either.”

The biggest issue I’ve seen, however, is that most of the online rating sites simply aren’t that robust. I’ve browsed through RateMDs, which purports to have more than a million consumer-written reviews of physicians in the United States and Canada. A search for Minnesota physicians revealed very few reviews for any doctors outside the Minneapolis-St. Paul area and most of the doctors had fewer than five reviews posted for them – not a particularly strong sample size and not very useful if you don’t live in the metro area.

And what should the average doctor-shopper make of comments such as “Best pediatrician I have ever encountered!” or “not helpful, bizarre comments and behavior”? Without context, it’s difficult to judge, making the value of many of these reviews limited at best.

Certainly there are more objective rating sites online – for instance, HealthGrades, which provides information on both physician and hospital quality. But again, most physicians outside the metro area have only a small number of reviews, or none at all. (I also noticed the lists don’t seem to be updated when doctors retire or leave the community. How would someone who’s new to town and in search of a doctor be expected to know this?)

Nor are most of the online rating sites very helpful when it comes to judging physician quality on the basis of outcomes or best practices. Here in Minnesota, Minnesota Community Measurement seems to come the closest to reporting how medical practices stack up overall in outcomes and the use of evidence-based medicine. But either I’m a klutz or the site is overly cumbersome, because I’ve found it difficult and time-consuming to truly use effectively. And although it could probably guide consumers to a quality medical clinic, it doesn’t really help them choose an individual doctor, a decision that often comes down to personal values, preferences and communication styles.

Studies examining actual consumer use of online rating sites are rather thin on the ground. One survey, conducted in 2008 by the Center for Studying Health System Change, found that only about 10 percent of the 13,500 adults who were queried turned to an online rating site to help them find a new primary care doctor. The majority relied on old-fashioned word of mouth from family and friends.

What’s a consumer to do? Lieber writes:

Until a single one-stop shop exists for both reviews and data that are fair and useful, we are left with one another. The problem with asking friends for a doctor recommendation is that even if they are a lot like you, they may not have any idea whether the doctor is a good clinician or not.

Careful readers can probably find some sites with listings for certain doctors that in number and detail add up to a useful measure of many of their skills. But you may not know anything about whether the reviewers are people similar to you.

In light of all this, it’s curious to see policymakers continuing to forge ahead with all kinds of online data, from hospital performance to outcomes to patient satisfaction. Not that the trend isn’t welcome; we need more – not less – data and public reporting. Sharing the data is no guarantee, however, that consumers will be able to use it effectively, or indeed whether they’ll use it at all. It seems that in spite of all their promise, the online rating sites still aren’t quite ready for prime time.

Giving the patient bad news

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The patient, a young rodeo rider from rural Ohio, lies in a hospital bed, sick and in pain. The doctor has the results of his bone marrow biopsy and the news isn’t good: It’s Hodgkin’s lymphoma, a cancer of the lymph system which will require chemotherapy.

But that’s not all. In this excerpt from “The Country Doctor Revisited,” Lorence Gutterman describes what happens next:

I take in a deep breath, prepare myself for the next part. “But there’s another problem. You have AIDS.” I remain quiet but am unsatisfied that I’ve told him this without a family member or close friend in the room to comfort him after I leave. Carter turns away from me. I notice how thin his black hair is on the back of his head. In this moment, it’s not important how he got AIDS.

“Does Betsy know?” he asks.

“Not yet. Do you want to tell her or should I?”

“Ya tell her. God, I hope she’s okay.”

“She should be tested for AIDS.”

A slight nod and more silence. There are no right words to fill these spaces.

Sooner or later, virtually every doctor is forced to be the bearer of bad news. But although this is an important skill to have, few physicians receive formal training in how to convey difficult news to their patients.

The Journal of Cancer Education reported recently on a promising method of teaching this to medical students: videotaped practice sessions that allow students to role-play with standardized patients and receive feedback from the mock patients themselves.

Medical students who participated in the role-playing said afterwards that they felt more comfortable in their ability to deliver bad news. They especially benefited from the discussions with the standardized patients, many of whom were cancer survivors and familiar with the emotions – shock, denial, tears – that accompany difficult medical news.

The project was carried out at the University of South Florida College of Medicine. USF students who participate in an interdisciplinary oncology clerkship are required to complete two to three hours of training – first with other medical students and then with a patient actor – in how to convey bad medical news to patients. The mock interviews in the exam room are recorded and then analyzed to help the students identify their strengths and weaknesses and how they can improve.

The researchers wanted to know: What did students think of this teaching method? More to the point, did it help them increase their skills?

Overwhelmingly, students found it beneficial, the study’s authors reported. Although nearly all of them at some point during their medical education had seen bad news being delivered to a patient, only half had given the bad news themselves.

They found the feedback from the standardized patients especially valuable – more so than only receiving feedback from an instructor. The students also felt the role-playing exercise resulted in an overall increase in their knowledge of best practices for conveying bad news.

Giving bad news has always been one of the most difficult parts of medicine, and many physicians are highly uncomfortable with it or don’t do it very well. One study carried out in the United Kingdom, using audiotaped interviews with newly diagnosed cancer patients at a London teaching hospital, found that oncologists usually dominated the conversation, were more focused on the medical details than the patient’s emotions, and often failed to respond empathetically to the patient’s distress.

Another study, at Wayne State University in Michigan, evaluated medical residents on their skills in delivering bad news and found “a general lack of competence,” especially in their ability to converse in a way that was patient-centered.

Both of these studies were conducted in the 1990s, when the concept of patient-centeredness wasn’t particularly widespread. The curriculum at most medical schools has greatly expanded since then, incorporating more training to help medical students communicate better with patients and demonstrate more empathy.

It’s one thing, however, for students to practice and get feedback from their instructors and quite another to practice and get feedback from someone who’s actually been a patient, even if only a standardized patient.

The authors of the Journal of Cancer Education study concluded that although role-playing isn’t a substitute for a real-life encounter with a patient, it provides “a safe learning environment for the student. As a result, the students will have a solid background from which to begin developing good communication skills in the oncology setting.”

Patient satisfaction: Deadly to your health?

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Do patients truly benefit when health care providers pay attention to the patient experience?

A rather startling new study suggests otherwise. In fact, researchers found that the patients who were the most satisfied with their care also had higher prescription drug expenditures, were more likely to be hospitalized and more likely to die.

How can this be?

Predictably, many in health care are saying “I told you so.” The increasing emphasis on patient satisfaction as a measure of quality care has never sat well with some clinicians – for instance, the anonymous doctor who offered this online reaction to the study’s findings: “Now that the ‘patient satisfaction’ industry has taken root, we will continue to waste billions and billions of dollars on this each year, money that could have gone towards providing genuine health care.”

It’s a valid question to ask. Intuitively, you’d think that when patients are happier with the care they receive, they’re more likely to have a good relationship with providers, more likely to be engaged in their care, ask questions, follow directions and have better outcomes. But whether this is actually the case hasn’t really been tested rigorously enough to prove it; it’s gut instinct, not science.

Let’s back up for a minute and see what the study says. It was published this week in the Archives of Internal Medicine and involved data on cost, health care utilization and patient satisfaction scores for 51,946 adult U.S. patients.

Among the key findings:

- Patients who reported the highest satisfaction with their care were more likely to be hospitalized than patients who were less satisfied.

- Higher patient satisfaction was associated with higher prescription drug costs and higher overall use of health care services, but lower use of emergency rooms.

- Patients who were the most satisfied had a 26 percent higher mortality risk, even after the study’s authors excluded patients who had three or more chronic conditions and who had self-rated their health as poor.

The authors offer several possible explanations for their findings. Patients often expect – and demand – unnecessary drugs and tests, and they’re more satisfied when doctors cave in and give them what they want, even if this amounts to inappropriate or possibly harmful care, the researchers suggested.

Or maybe patients who received more care also were more reliant on their doctors and hence reported higher satisfaction, although the study’s authors note this doesn’t really explain the apparent connection between higher utilization and more patient satisfaction.

I’m not sure what to make of all this. But with all due respect to folks like uberblogger Dr. Kevin Pho, whose headline this week proclaimed, “How patient satisfaction can kill,” I don’t think this study offers proof that efforts by the health care industry to be more customer-centered are bad for patient care.

Patient satisfaction and clinical outcomes are not the same thing. Although there may be a link between the two, this is a far cry from establishing cause and effect.

Perhaps the real issue is that patient satisfaction, at least in some people’s eyes, has somehow become conflated with giving patients whatever they want. Would patients themselves define it this way? I’m not sure they would; they’re often more likely to use words such as “caring,” “compassionate,” “respectful,” “understanding” and “listens to me” when they describe what makes them satisfied.

Perhaps clinicians are judging on the basis of a different scale. Patients can be surprisingly tolerant of a less than stellar outcome – in other words, more satisfied – as long as they feel they’ve been treated like a human being. Clinicians, on the other hand, might be more apt to see a negative outcome as a failure, period.

Maybe we’re simply not very good yet at measuring patient satisfaction, or we’re using indicators that aren’t particularly meaningful. (Who’s selected to fill out those patient satisfaction surveys anyway? I have never, ever been asked to fill one out.)

If health care leaders focus on patient satisfaction to the exclusion of all else, then yes, it has the potential to be detrimental and even harmful. And clinicians who order drugs and procedures in the belief this is what’s needed to make patients happy (and keep their own satisfaction scores high) are not doing any favors for patient care.

But let’s not allow this study to persuade us to throw out the baby with the bathwater. The collective gut feeling of patients like me is that, on some level, caring about patient satisfaction truly does matter.