‘Looks older than stated age’

Pity the young, pretty blonde doctor who’s constantly mistaken for being less accomplished than she truly is.

“Sexism is alive and well in medicine,” Dr. Elizabeth Horn lamented in a guest post this week at Kevin, MD, wherein she describes donning glasses and flat heels in an attempt to make people take her more seriously.

As someone who used to be mistaken for a college student well into my mid-20s, I certainly feel her pain. But let’s be fair: Doctors judge patients all the time on the basis of how old they appear to be.

It’s a longstanding practice in medicine to note in the chart whether adult patients appear to be older, younger or consistent with their stated age. Doctors defend it as a necessary piece of information that helps them discern the patient’s health status and the presence of any chronic diseases.

According to theory, patients who look older than their stated age are more likely to have poorer health, while those who look more youthful than their years are in better health. But does it have any basis in reality? Well, only slightly.

An interesting study was published a few years ago that examined this question. The researchers found that patients had to look at least 10 years older than their actual age for this to be a somewhat reliable indication of poor health. Beyond this, it didn’t have much value in helping doctors sort out their healthy patients at a glance. In fact, it turned out to have virtually no value in assessing the health of patients who looked their age.

Other studies – and there are only a few that have explored this issue – have come up with conflicting results but no clear consensus, other than the conclusion that judging someone’s apparent age is a subjective undertaking.

When there’s such limited evidence-based support for the usefulness of noting the patient’s apparent age, then why does the habit persist?

I’ve scoured the literature and can’t find a good answer. My best guess is that doctors are trained to constantly be on the lookout for risk factors – which patient is a heart attack waiting to happen, which one can’t safely be allowed to take a narcotic, which one is habitually non-adherent – and assessing apparent age vs. actual age is one more tool they think will help, a tool they may have learned during their training and continued to use without ever questioning its validity.

Appearances can be deceiving, however. A patient who looks their age or younger can still be sick. Someone who looks older can still be relatively hale and hearty.

And beware the eye-of-the-beholder effect. One of the studies that looked at this issue found that younger health care professionals consistently tended to overestimate the age of older adults. When you’re 30, everyone over the age of 60 looks like they’re 80, I guess.

Whether you’re a young physician fighting for the respect your training commands or a patient fighting against assumptions in the exam room, the message is the same: You can’t judge a book by its cover.

Emotions by rote: when empathy is scripted

Something bothered me last week while blogging about teaching medical students to deliver bad news to patients.

Although training and practice can help develop and reinforce effective, empathetic communication skills in medical students as well as doctors, I kept having the nagging thought that this wasn’t the whole story. Is delivering bad news merely about following the six steps of the SPIKES protocol? Would I want a conversation involving bad news to be packaged as a carefully learned formula? Don’t patients sense the difference between rote platitudes and genuine caring?

Then… eureka! an article appearing in the New York Times the same day captured it exactly.

Dr. Timothy Gilligan, co-director of the Center for Excellence in Healthcare Communication at the Cleveland Clinic, and Dr. Mikkael Severes, director of the leukemia program at the Cleveland Clinic, nailed it: Doctor-patient communication isn’t something you can readily force or script or reduce to “10 Easy Techniques For Demonstrating Empathy.” Although good communication is an essential skill for any health care practitioner, it should be real, not faked.

From their article:

No communications course will magically transform lifelong introverts to hand-holders and huggers. At the same time, we must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care. Having physicians sound like customer service representatives is not the goal.

For those doctors who are emotionally challenged, communications courses can provide the basics of relating to other human beings in ways that, at the very least, won’t be offensive. But for the rest of us, we should take care to ensure the techniques and words we learn in such courses don’t end up creating a barrier to authentic human contact that, like the white coats we wear, make it even harder to truly touch another person.

As one of those “lifelong introverts”, I take exception to the implication that introverted clinicians need fixing so they can give more hugs. Introversion and good communication are not mutually exclusive, and introverted doctors may in fact be better than many extroverts at listening to their patients.

But Drs. Gilligan and Severes raise important questions about the degree to which empathy can be taught and the unintended consequences of trying to program clinicians into better communicators.

Reactions to their article were almost as fascinating as the article itself. A sample:

- “Patients usually come to us because they hurt. They’re suffering, and most of their suffering isn’t from tumors or low platelet counts; it’s from their own normal emotions in response to being sick: depression, anger, confusion, loneliness, anxiety, and so on. We might be able to fix their lesions, but we can address their emotions only by listening to them, and that’s a more sublime skill than repeating, ‘Go on’ or ‘How does that make you feel?’”

- “Providing education and skill sets to improve communication will only go so far. Addressing issues around emotional intelligence is the core of the problem.”

- “As a physician, I find It amazing that anybody could write about problematic interactions between doctors and patients without noting the 2,000 pound gorilla in the room: what our healthcare system pays doctors for. The less time doctors spend with each patient, the more patients they are able to see and the more money they can make. If you pay doctors the same whether they talk to patients for five minutes or 45 minutes, guess which they are most likely to do.”

- “Most of these technically brilliant but interpersonally stunted doctors are either married, have friends, and successful careers, meaning that they must have some social skills. I’m not sure the issue has anything to do with being introverted or geeky. I think it might have a lot to do with arrogance and not seeing the patient as a person.”

I’ve heard some health care workers say scripts help them stay focused, especially in difficult situations. Others find scripts restrictive, even a bit silly, and would rather allow the conversation to flow naturally.

What do you suppose patients and families prefer – empathy that’s clumsily expressed but sincere, or all the right words with no feeling behind them?

The language of health care

Awhile back, I wandered into an Internet discussion about the use of the word “non-compliant” to describe patients who didn’t follow the doctor’s instructions or take their medications as directed.

Don’t use that word anymore; the correct and less judgmental term is “non-adherent,” one person wrote.

A home health nurse shot back: She’d been using the term “non-compliant” for years, there was nothing wrong with it and she wasn’t about to change, thankyouverymuch.

Health care has a language of its own. Not just the technical words, although there are plenty of them. No, this language consists of ordinary words used in ways that convey certain shades of meaning. Sometimes patients are confused by it, sometimes they’re offended, and sometimes it subtly reinforces the paternalism and power imbalance that have historically existed between health care professionals and their patients.

Were your test results “negative”? Breathe a sigh of relief, because negative results in most cases are positive news for the patient. If the doctor notes that your symptoms are “unimpressive,” it’s not meant to be denigrating, it just means you’re having symptoms that aren’t severe or pronounced. That abbreviation in your chart that says “s.o.b.” doesn’t indicate what you think it does; it just denotes that you’re having shortness of breath.

As you venture farther into this terrain, it gets trickier. Why, for instance, do patients “deny” having chest pain or whatever other symptoms they don’t have? (One of my newsroom colleagues says that whenever she hears this term, she pictures a conversation that goes something like this: “You have chest pain!” “No, I don’t!” “Yes, you do!”)

What is an “incompetent” cervix, and what kind of value judgment does this term imply?

Does it matter what words we use? Are they just a neutral collection of letters and syllables with no deeper meaning? Or is the language of health care more than this?

As patients become more engaged in their care and the doctor-patient relationship becomes more of a partnership and less of a dictatorship, the language has correspondingly come under greater scrutiny. In this brave new world, do doctors issue “orders,” or do they provide “instructions”? Do they talk about collaboration or do they make all the decisions?

The whole debate over the use of the word “compliant” illustrates the extent to which the sands have been shifting. Although the term is still frequently used, critics point to its connotations: obedient, submissive, acquiescent, yielding, docile. In short, not the words many people would like to see associated with the doctor-patient relationship. The term is increasingly being replaced by “adherent,” which sounds vaguely like it might have something to do with duct tape but at least doesn’t appear to carry some of the same emotional baggage as its predecessor.

It might seem like political correctness run amok. But words often do matter, and they can influence our thinking in ways we might not realize. For instance, it’s common to record the reason for the patient’s visit to the doctor as the “chief complaint” - a rather psychologically loaded term, since the patient might not literally be complaining and might in fact be reluctant to complain in the truest sense of the word. Does the use of this word create subtle attitudes about patients and perhaps consign them to an unwanted role?

What about the common practice of referring to the patient’s current history of ailments, issues and chronic conditions as a “problem list”? Does this invite doctors and nurses to view patients as a collection of problems in need of fixing? Does the focus on “problems” make them overlook other aspects of the patient’s health in which he or she is doing well?

What does it mean when the patient “didn’t tolerate the procedure”, and whose fault does this imply?

I’m not sure whether these terms ought to be replaced, or what we could replace them with. There’s no vocabulary police in health care, after all, and no real consensus on what the best words should be. In any case, it’s a moving target. The debate over “compliant” vs. “adherent” isn’t going to go away any time soon, and within a few more years the favored term could drop out of favor in exchange for something better.

Occasionally, however, attention to language results in real change. At one time, patients who were in pain were said to “complain of pain.” It’s a phrase that can be freighted with emotion and value judgment, however, and health care providers began to realize that many patients with treatable pain weren’t speaking up because they didn’t want to appear to be complaining. With heightened awareness of this issue, providers began using the term “reporting pain” instead. This more neutral language is now so widespread that it has become rare, at least in the professional literature, to find references anymore to patients “complaining of pain.”

And occasionally patients themselves put the medical community on notice that some language is unacceptable. Karen Parles, executive director of the Lung Cancer Online Foundation, fired off a letter a few years ago to oncology specialists about the commonly used phrase “the patient failed chemotherapy.” She wrote:

Have the patients really “failed” when chemotherapy drugs do not work? Of course they haven’t. So why use a phrase that implies blame?

… This unfortunate convention is used in the medical literature, at professional conferences, and not surprisingly, in the clinic. It is common for oncologists to tell patients that they “failed drug X.” By telling patients they failed to respond to treatment, doctors may increase the guilt that many patients already struggle with as a result of their cancer diagnoses. For others, like me, it becomes an annoying refrain. At minimum, it puts emotional distance between doctor and patient and undermines the doctor-patient relationship. Just imagine under the same circumstances if the patient said to the doctor, “You failed to give me the right drug to treat my cancer.” The question isn’t who failed, but what failed.

Dr. Bruce Chabner, the editor-in-chief of The Oncologist, responded with an apology and a thank-you to Parles for pointing out “the all-important use and impact of our words.”

“I assure her that I have expunged ‘that phrase’ from my vernacular… and I urge my colleagues to do likewise,” he said.

This post originally appeared on Nov. 4, 2009.

Making friends with the patient portal

I’ll disclose this up front: I’m a big fan of the concept of allowing patients online access to their medical information through a patient portal. Family members who live in the metro area have been using portals for a few years, and now this feature is available locally too.

Patient portals are promoted as a tool to help patients become more involved and engaged in their care. It’s still a little early to know whether this actually is the outcome; portals just haven’t been around long enough to build up a strong body of evidence in their favor.

At the very least, though, they make it easier for people to find out their lab results, double-check their prescription medication list, etc., by simply logging into their personal account. No need to make phone calls or leave messages. No waiting for results to arrive by snail mail. And seriously, is there anything more annoying than to be told only that your lab results or X-ray were “normal”? Show me the numbers, please.

Not that there aren’t naysayers. Many folks haven’t been very impressed by their experience with patient portals – for example, health communication guru Steve Wilkins, who recently was introduced to the portal offered by his doctor’s practice and was underwhelmed. He can send messages to the staff and request appointments and prescription refills but apparently not much else. “Asking is certainly different than doing in my book,” he reflected. “How the heck is this supposed to make me feel engaged?”

I’ve heard other complaints that some portals are very restrictive in how patients are allowed to use them, thereby limiting the benefits.

A couple of thoughts: First, patient portals won’t instantly remove all the obstacles in doctor-patient communication. They’re a tool, and their success will partly depend on people’s willingness and ability to use them as intended. I think there’s going to be a learning curve before the benefits become apparent. In the meantime, everyone needs to be somewhat patient and not demand results like, right now.

Second, simply offering a patient portal doesn’t automatically mean it has value, as Wilkins points out. Practices that only allow a handful of non-interactive features on their portal will probably be disappointed when few patients sign up or actively use the portal… but they really shouldn’t be surprised.

My prediction is that engagement will be highest when the portal 1) has multiple features that appeal to patients and create a useful tool for health care self-management; and 2) is actively promoted by medical practices as something their patients ought to try.

Patient portals might sound like nothing more than a new technological spin on the exchange of information that has always taken place between doctors and patients. But the reality is that they’re helping shift the fulcrum of engagement toward the patient. Our medical information was always available to us but it was often presumed that it didn’t have to be shared unless we asked to see it. Now the presumption is that of course our information will be shared without first having to ask for it. See the difference?

Dumbing it down

When the handouts from the hospital downplay, gloss over or don’t even mention the potential for bad things to happen, a patient can be excused for feeling totally blindsided to find out a complication is serious enough to require surgery.

How do I know? Because it happened to me. And to say I felt misled by the vague, sugar-coated generalities contained in the patient literature is an understatement.

The focus on health literacy is both welcome and necessary. Far too much about health care is arcane, difficult to understand and not explained well to patients, especially those who have difficulty reading or for whom English is not their primary language. But there’s another side to this issue: the risk that in the drive to simplify health information for patients, we’re going too far.

I’m not the first person to ask this question. I’ve heard the same concern from health care professionals who worry that the basic facts, while important to convey, aren’t always enough to truly arm patients with what they need to know.

Dumbing it down has consequences. At best, it can confuse patients about what their symptoms or side effects might mean and what, if anything, they should do about it. At worst, it can put them in harm’s way.

More than this, it has the overall effect of lowering the bar for what’s expected of the patient. “Don’t dumb down diabetes!” declares blogger Allison Blass at Lemonade Life. She describes a recent focus group meeting during which she shared the data methods she uses to help manage her insulin for her type 1 diabetes, only to be told, “You seem very tech-savvy but what about the average diabetic?” Her response:

Understanding diabetes is a daily battle. This disease doesn’t make a bit of sense most of the time and I will be the first person to admit that I don’t always do what I am supposed to do. But I don’t understand how providing someone with less information about their health is supposed to help them? And I don’t understand why it is such an extraordinary thing to encourage people to read, ask questions, be educated and know all they can about their disease.

One aspect of this is the rather patronizing don’t-you-worry tone that often pervades the handouts and written information for patients. This faux reassurance, with its dumbing down of patients’ emotions, can be very misleading. It can give patients the impression that their symptoms are no big deal, and it can leave them unaware or unsure of when something is serious enough to need medical attention. It also puts patients at a serious disadvantage in communicating with the doctor and ensuring that a complication or side effect is being appropriately addressed. Rare complications are, by definition, rare, but they do happen, and patients are ill served by information that condescends to them rather than enables them to recognize when to take action.

In the bigger picture, dumbing it down can blur or erase many of the nuances that need to be part of the public discussion. A prime example: the attitude that screening for disease has preventive value and is invariably beneficial. On some level, and in some circumstances, this is entirely true. But screening and prevention are not the same thing. Moreover, screening has limitations; it’s not 100 percent accurate, it doesn’t necessarily change the course or outcome of a disease, and sometimes it results in patients undergoing unnecessary treatment.

Understanding this could help Americans have more realistic beliefs about what screening can – and can’t – accomplish, and might help them make health care decisions that are more informed. This level of understanding won’t happen, however, if the discussion stays mired in generalities sheerly for the sake of keeping it simple.

To be fair, most health care professionals, at least the ones with whom I’m acquainted, prefer it when patients participate in their care and make an effort to be educated. But many of them also struggle with where to draw the line. If you tell patients too much, will they be overwhelmed? Will information about potential complications or side effects scare patients away from necessary treatment? Or will people just tune it out?

Not everyone wants, or is able, to handle the same amount of information. It’s a genuine challenge – maybe even impossible – for health care professionals to find out and keep track of each patient’s preference for knowledge.

This shouldn’t have to mean, however, that we automatically default to the lowest common denominator. Keeping it simple isn’t always the right answer, nor is it always in the patient’s best interests. It’s a lesson some of us have learned the hard way.

This entry was originally published Nov. 3, 2010.

Flipping the clinic

Advocates of patient-centered care talk of “flipping the clinic” to create an environment in which everything, from the sign-in process to how patient-provider conversations are conducted, is designed with the patient experience foremost in mind.

So here’s a really radical thought. What would happen if we took this one step farther and flipped the flip? What if patients also became more mindful of the provider experience and, by extension, more supportive and understanding of their doctor, their nurse and others involved in their care? What might we gain as a result?

It’s a novel idea raised  by Natasha Gajewski, a patient advocate and innovator who recently blogged about attending a Flip the Clinic symposium hosted by the Robert Wood Johnson Foundation and hearing some of the success stories about patients who were empowered to become full participants in their care. Seeing how rewarding it was for clinicians to help make this happen, Gajewski reflects:

… [J]oy and satisfaction are apparently in short supply amongst care providers, particularly those on the front lines. So I find it curious we focus so much attention on salvaging the wellbeing of the patient, when studies and the emerging crisis in primary care suggest that more attention needs to be given to improving the wellbeing of clinicians.

Then she asks the million-dollar question: “Could patients cure clinician burnout and other problems in our healthcare system?”

In one of those moments of synchronicity, I came across Gajewski’s online posting at the same time I was reading Dr. Danielle Ofri’s new book, “What Doctors Feel,” about the undeniable – and sometimes overwhelming – role of emotion in the practice of medicine. Then, to clinch it, New York Times contributor Dr. Pauline Chen wrote this week about the growing problem of clinician burnout and how to lessen it.

It would be hard to find a health care provider in the U.S. these days who isn’t under tremendous stress at least part of the time. Although stress is inherent in the health care professions, it’s being ratcheted up and up and up by constant change, increasing demands on people’s time and energy, and resources that are becoming ever more strained.

While most Americans are probably aware of this, one has to wonder how well the average person understands the connection between frazzled, exhausted, unhappy clinicians and unsatisfactory patient experiences.

Dr. Chen lays it out for us:

Research over the last few years has revealed that unrelenting job pressures cause two-thirds of fully trained doctors to experience the emotional, mental and physical exhaustion characteristic of burnout. Health care workers who are burned out are at higher risk for substance abuse, lying, cheating and even suicide. They tend to make more errors and lose their sense of empathy for others. And they are more prone to leave clinical practice.

Do patients care? More than a few people might react the same way as one of Dr. Chen’s online readers who called it professional narcissism: “Enough about how physicians and other medical professionals’ lives are so difficult. We all have jobs that are hard to do.”

But I would hope this is a minority view. At its core, health care is about relationships between human beings. It’s hard for the parties to truly engage with each other when one of them is physically and mentally overloaded, frustrated and on the verge of burnout.

This isn’t to say that provider satisfaction should be the sole responsibility of patients. Patients often have enough to handle without also worrying about managing the morale of their health care team.

But patients do have a stake in this, whether they realize it or not. So, to go back to Gajewski’s question: Is there something we can do about it?

Health care’s new paternalism?

Is the patient’s blood pressure at 120 over 80 or below and controlled with one or more medications if necessary? Check.

Normal body mass index? Check.

Recommended screenings carried out according to the recommended schedule? Check, check, check.

But here’s the real question: Are all of these goals important to the patient, or does he/she see them as frustrating, burdensome and perhaps impossible to achieve?

The push toward better health care has organizations and clinicians focusing a tremendous amount of energy these days on patient outcomes. Few policymakers seem to have asked, however, where patients fit into this and how they feel about having their health goals – appropriate weight, appropriate blood pressure, glucose and cholesterol levels, appropriate prescription medications and so on – essentially dictated to them.

Is it going too far to call it a new form of health care paternalism?

If you listen closely, you can hear the beginnings of some pushback from people like Dr. Victor Montori of the Mayo Clinic, who last week talked to the Star Tribune of Minneapolis about hitting the pause button on all the checklists and having a heart-to-heart conversation with patients about what they really want.

An excerpt from the newspaper’s interview with Dr. Montori:

He argues that doctors must take into account the patients’ “values and preferences.” If one drug can bring their blood sugar down a notch, but doesn’t make them feel better, is it worth taking? “It’s making sure we don’t make any decisions about them without them,” he said. It’s a strategy that stops demanding perfection from patients and focuses on the treatments that are most important to them. “So they only get what they need and what they want.”

This is squarely at odds with the current approach of setting goals and measures and expecting all the players to reach these targets in order to achieve quality care.

There’s much at stake. By fiscal year 2015, fully 30 percent of Medicare payments to hospitals will be based on outcomes. Medical practices are dealing with similar pressure to reach specific goals in patient care.

This isn’t to say health care shouldn’t be held accountable for results. Outcomes do matter. But when an organization’s fiscal health and people’s livelihoods are on the line, it’s not hard to see why there would be a rising tide of all-around frustration when patients can’t – or won’t – meet the prescribed goals.

Meetings of the Rice Memorial Hospital board here in Willmar are normally rather subdued, but one of the most animated discussions I’ve seen in months erupted this week over the issue of patient adherence.

The doctors in the room spoke of the challenge of persuading their patients to adhere to the standard, and the frustration of being penalized when they don’t.

The hospital leaders in the room spoke of the unenviable task of being asked to meet goals that may hinge on patient decisions and behaviors beyond the hospital’s control.

The implications go deeper than this, though. What about hospitals who care for high numbers of elderly, frail and medically complex patients who may not have outcomes as favorable as that of a younger, healthy population? What about the 90-year-old who has been living with congestive heart failure for a decade and has decided it’s time to stop with aggressive management of the condition?

Should hospitals and medical practices become more selective about the patients they’re willing to take and start turning away those deemed to be too sick or too complicated or less likely to be compliant? Most Americans would agree it’s unethical (or at least unfair) to cherry-pick the “best” patients, but there’s no denying this looms as one of the unintended consequences of outcome-based payment. Left unanswered in all of this is who, exactly, will care for the sickest and most vulnerable when the reimbursement model is rigged against them.

Finally, there’s the issue of patient autonomy. The patient’s right to make his or her own medical decisions is one of the core tenets in American health care. This basic value seems to mesh uneasily, however, with performance-based payment. What happens to patients who don’t want to take a particular medication because the regimen is too burdensome or the side effects are intolerable? What about the patient who simply wants to feel better and function better rather than meeting specific target numbers?

To make things even more complicated, all of this is taking place simultaneously with a growing emphasis on patient-centered health care and shared decisionmaking.

It’s far from clear how this is supposed to fit together, or the extent to which the average consumer is aware of the push-pull between giving patients more say in their care, while at the same time deciding on their behalf what the measure of their health should be.

Don’t look for this to be resolved anytime soon. No one ever said health care was simple.

Do we need another patient survey?

Many patients – well, some of us, anyway – appreciate being asked for feedback about their experiences with the health care system.

After all, it wasn’t long ago that patients’ opinions were rarely sought. Now they’re being queried about everything from whether their hospital room was clean to how quickly the nursing staff responded to their pain.

When analyzed in ways that are accurate and meaningful, patient surveys can provide health care organizations with a reality check on what their patients really think about the care they’re receiving. Is there consistently negative feedback about inattentive staff or awful parking? Maybe it’s a sign that these need to be addressed. Consistently good feedback, on the other hand, is a strong indication of an organization that gets a lot of things right about the patient experience.

It may be time to ask, however, whether patient surveys have crossed the line into overkill.

The American Hospital Association recently said “enough already” to a plan by the Centers for Medicare and Medicaid Services to add two new types of patient surveys, one for hospital outpatient surgery departments and the other for ambulatory surgery centers.

In a four-page letter, the hospital association asked CMS to reconsider, saying the Consumer Assessment of Healthcare Providers and Systems program already includes multiple and overlapping surveys. Adding even more will likely lead to confusion among patients, the AHA contended. It’s possible, for example, that ambulatory surgical patients could receive as many as three similar surveys for the same episode of care, the AHA said.

There’s also the administrative burden of administering all these surveys and compiling and analyzing the results, the hospital association pointed out.

The AHA’s suggestion: Instead of developing separate new surveys for outpatient and ambulatory surgery patients, why not just add some supplemental questions to existing survey tools and be done with it?

If you listen closely to health care providers, you can sense the creeping onset of survey fatigue.

“Hospitals and doctors, unaccustomed to being rated and ranked like resort hotels and American Idol contestants, are suffering from performance anxiety and feeling an intense desire to be left alone,” observes Dr. Robert Wachter in a recent blog post that asks an important question: Do surveys and rankings really help improve care?

The answer seems to be both yes and no.

Poor survey results can penalize providers for factors that may be outside their control – for instance, hospitals that have large numbers of patients living in poverty, Dr. Wachter writes. Moreover, surveys sometimes apply inaccurate yardsticks or measure the wrong thing altogether, hence severely limiting their usefulness.

On the other hand, a disappointing ranking might be the motivation a health care organization needs to get serious about improving its performance. And consistently good ratings don’t tend to happen by accident; usually they signal organizations that are higher-performing.

How to reconcile these two opposites? Dr. Wachter writes:

Public reporting of quality measures not only improves the work of the measured, it improves the work of the measurer. Ultimately, a healthcare ecosystem in which reasonable measures help guide patient and purchaser choices will lead to improvements in both the quality of care and of the measures themselves. I believe we can look forward to an era of more accurate measures, measures that capture the right things (not just clinical quality but teamwork and communication skills, for example), and measures that are less burdensome to collect and analyze.

By all indications, we aren’t there yet.

Surveys that ask patients for feedback are just one piece in a larger picture that also tracks how providers are doing on key measures such as recommended immunizations and screenings, hospital-acquired infection rates and use of best practices in managing diabetes, congestive heart failure and more. Even patient surveys, however, don’t necessarily produce reliable information.

The American Hospital Association’s letter to CMS points to new research suggesting that how patients fill out surveys may be more related to patient characteristics than previously thought. The AHA cites an analysis by the Cleveland Clinic that found that when patients were sicker, patient satisfaction scores tended to decline. The researchers found the same thing among patients who were depressed.

Other studies have discovered that when patients feel strongly about the care they receive, they’re more likely to fill out and return a survey. Research also has found that even seemingly minor factors such as geographic region and time of the year can have an influence on the answers patients are likely to give on a patient satisfaction survey; Midwesterners seem more willing to give higher marks to hospitals than patients on the East Coast, and scores overall tend to decline slightly during the winter months.

It’s not clear what to make of all this information, nor how to use it effectively. Throw clinical measures into the picture and it becomes even more complex. Do we really need more patient surveys? Maybe what’s needed are better, more reliable measures and better ways of interpreting and understanding the data already being collected.

My weekend as an emergency patient and what I learned

If you want to see what health care is really like, there’s no better way than by becoming a patient yourself.

To paraphrase the wisdom of Dr. Seuss, “Oh, the things you’ll learn!”

The truth of this was recently hammered home for me during a weekend in the hospital that started with a Friday night trip to the emergency room, devolved into IV antibiotics, painkillers and surgery, and ended in a (minor) complication that luckily resolved on its own.

Who doesn’t benefit from undergoing a reality check every so often? It’s safe to say I encountered some old lessons that were reinforced and some “Aha!” moments that were new.

Here are a few of them, in no particular order of importance.

- Most of us pay no attention to our gallbladder until it unexpectedly stages a major rebellion. Then we notice very much indeed, especially when it becomes gangrenous.

- The word “patient-centered” can be rather nebulous. What does it mean, anyway, and how do you know patient-centered care when you see it? Here’s a clue: When the emergency room staff’s immediate response is to deal with your medical situation and worry later about seeing your health insurance card, that’s patient-centered.

- People in health care work really, really hard – days, evenings, nights, weekdays and weekends. It can be easy to judge their efforts by the amount of time they directly spend with you, the patient, but this is only the tip of the iceberg.

What you don’t see is the amount of time spent assessing the patient’s situation, reviewing lab results, communicating with the rest of the team, scheduling procedures, making decisions, following safe, evidence-based practices and documenting everything accurately in the medical record. When the behind-the-scenes action is done well, you likely are receiving better care and will have a better outcome, even though most of the work on your behalf will never be visible to you.

- When it’s your health at stake, it’s hard to be objective about costs. The effort has to start somewhere, though. Although physicians have a responsibility to avoid potentially harmful and expensive overtesting and overtreating, this is a two-way street. It needs to be OK for the doctor to say, “We’re not doing a CT scan because it’s unnecessary” and not meet with instant backlash from the patient. It needs to be OK for patients to let go of the I-want-you-to-do-everything security blanket and not fear they’re receiving substandard care. In health care, more does not automatically mean better.

However:

- Cost can’t be the sole consideration. Sometimes it’s OK to delay care and sometimes there’s a less expensive option. But sometimes the patient needs immediate care and sometimes the care needs to be aggressive. This, rather the goal of simply being as cheap as possible, is the real challenge in health care: providing the right care at the right time, not too much, not too little, not too soon and not too late.

- It’s good to ask questions but patient engagement is much more than this. It’s about listening, absorbing information, understanding how and why key decisions are being made, and seeing the big picture. It’s about communicating clearly and accurately. It’s about following directions. This is complex stuff, and a sudden hospitalization is not the best time to try to learn the language and behavior of patient engagement. Far better to start cultivating some of these skills when you’re well, rather than in the middle of an emergency.

- Who wants to be the patient who arrives at the emergency room and is forced to say, “I don’t have one” in response to the question, “Who’s your regular doctor?” You can probably get by, but your hospital visit will likely go more smoothly if you have a primary care doctor who knows you – or, at the very least, if you have a usual source of care.

- Being sick and hospitalized is disruptive, to families as well as to patients. It upsets the normal routine and adds unexpected stress. It can take several days, or several weeks, for everyone to regain their equilibrium. What patients and families don’t need is more frustration from a health care system that’s cumbersome, confusing to negotiate or slow to respond. Organizations that work to minimize this for patients are doing them a favor.

- Health care is organized around systems but it’s delivered by individuals and reinforced by organizational culture. Every one of those interactions counts, and every one of them helps define the line between having a good experience and having a bad experience. This is your shout-out, Rice Memorial Hospital and Affiliated Community Medical Centers, for knowing where that line should be. Bad experiences don’t happen by design but good experiences rarely happen by accident.

Additional reading: Choosing Wisely; Image Wisely; Costs of Care; Center for Advancing Health; minimally disruptive medicine.

You’ll like sharing your hospital room. Really.

American hospitals have spent millions of dollars scrapping old-fashioned patient wards and double rooms in favor of private hospital rooms for everyone.

But maybe this strategy is entirely wrongheaded, suggests Dr. Richard Gunderman, a professor at Indiana University, who last week lamented the decline of shared hospital rooms and the resulting loss of human contact between patients.

Yes, patients might resent having their sleep interrupted by a roommate who snores or watches TV all the time, Dr. Gunderman writes. But deep down, don’t most of them long to connect with others who are going through the same thing?

Hospitals these days “increasingly resemble high-security prisons” designed to keep patients from interacting with each other, he writes.

In our haste to control infections, we isolate them. In our zeal to preserve confidentiality,  we prevent patients from getting to know each other. They sometimes begin to feel as though they are being kept like specimens in hermetically sealed containers.

What patients really want, he concludes, is to connect with other people who know what it’s like from the perspective of the hospital bed. And even though they think having a room to themselves is preferable to giving up their privacy in a group ward, “perhaps… they don’t know what they are missing out on,” writes Dr. Gunderman.

In many cultures, hospital patients often share a room with one or perhaps many people and can mingle freely with them. But the notion of privacy is deep-seated in American culture. Contemporary Americans value the ability to live their lives without intrusion or outside interference, and this spills over into how we manage our shared social space. How we feel about privacy can especially be put to the test when we’re sick, vulnerable and hospitalized. Do we want company or would we rather be left alone?

Many Americans (Canadians too) frankly prefer the latter, as evidenced by the reaction to Dr. Gunderman’s essay.

Here’s the response from Heart Sisters blogger Carolyn Thomas, who says she could “scarcely believe what I’m reading here.”

“As a heart patient who has become a frequent flyer of the health care system, I can tell you flat out that I don’t ever go into hospital to make friends with other sick people. Ever!” she wrote. “While the disruption of ‘a roommate’s television viewing or snoring’ may seem minor to you, it’s a very big deal if you’re the sick person being held hostage amidst this kind of noise.”

“This article had to be penned by an extrovert,” someone else wrote. “I cannot imagine anything worse than being in a forced social situation with some stranger while both of us were sick enough to be in the hospital… This whole premise almost sent me to the ER.”

There are obvious inconveniences to sharing a hospital room. Maybe you’re stuck with a roommate whose family and friends crowd the room at all hours of the day and night when you’re trying to rest. You’re forced to share a bathroom. You might overhear conversations that aren’t meant for your ears. There’s always a chance of unwanted proximity to vomiting, bleeding and other distressing physical functions – or of experiencing the humiliation of being the one to vomit in front of a roomful of strangers.

The serious question here is whether private rooms result in better outcomes for patients or whether they’re merely nice to have.

Although the evidence is somewhat mixed, the bulk of research has found that single-bed hospital rooms are linked to better infection control, less stress for patients, fewer sleep interruptions, especially in intensive care units, and improved recovery times resulting in a shorter hospital stay. Case studies also have found private rooms more conducive to patient education, medical consultations and the ability of family to be with the patient.

Does it also count for something that when patients are asked for their opinion, the vast majority say they prefer a private hospital room?