Last night’s BlogTalkRadio show was alot of fun. I found an article about patient complaints but the neat thing about it was that it discussed complaints doctors had about patients.

Here’s a summary of each group’s complaints - in future posts I will discuss each of these:

Doctor Complaints                                            Patient Complaints

 Enjoy the show:

 How much wonderful info comes from About.com!

Patient Education - Can You Know Too Much?

Patient Education Should Enhance The Doctor-Patient Relationship

Being An Informed Patient Is Not A Substitute For Trusting Your Doctor. Can You Know Too Much? 

Patient education is vital to good health care 

Patient education is an important aspect of managing chronic illness. Patients are often encouraged to learn all they can about their disease, to become informed, and take a positive approach to managing their condition. 

 Patient education does not replace a proper diagnosis

I’ll tell you that the title of this turned me off but I forced myself to read it and then found it captivating…take a gander and see what you think. Thanks to Scott Wanless and the Business Intelligence Network. I’ve removed much of the business related info though. I think it’s interesting.

Increasing patient satisfaction is a critical goal for healthcare organizations of all types, especially in these times of increased competition, scrutiny and demand for services. Business intelligence based on satisfaction analytics can help you compete.

Our family doctor cements my loyalty as a patient every time I go to see him. He accomplishes this with one simple action combined with two sophisticated uses of patient intelligence. The simple action is to put notes into my care record that indicate what satisfies me. Currently, two of the notes in my record read: “Likes patient population statistics” and “Likes ideas that came from patients.” He has, for example, used both of these statements in a recent visit to diagnose and treat a sleep disorder I was experiencing. During our conversation, he asked one of the nurse practitioners to share statistics on the percentage of the clinic’s population who are experiencing the same type of sleep disorder, and then drill into the percentages for men vs. women and for men of my age group. This type of insight takes deep intelligence to be gathered, stored, processed and shared among the providers. This is business intelligence.

Taking this use of information one step further, our doctor then walked through a one-page sequence of events for my treatment. This included consult with a pulmonologist, an overnight study at a local hospital, education from a home health and medical equipment specialist, and finally follow-ups with both the pulmonologist and with him as my primary care physician. At each stage of this treatment, I was given information on what to expect and why, as well as homework I needed to do in preparation for the specific stage. He sealed the deal with me by telling me that this sequence of events originated with an idea from one patient, and has grown through refinements made in using it with a variety of patients over the past few years. This too is business intelligence.

What is Patient Satisfaction?
At first blush, patient satisfaction sounds like its cousin customer satisfaction. There are, however, significant differences between the two. Topping the list are the licensing and professional restrictions placed on healthcare providers, who must first consider what the patient needs before what the patient wants. In most businesses, trying to sell people what they need versus selling them what they want is an efficient way to go out of business because the competition will gladly reverse this order. I am free to buy just about anything I want in a grocery or hardware store without any regard to whether or not I need it. But I cannot just get an MRI scan or a prescription I saw advertised just because I want one.

In addition to these restrictions are the financial rules from payers, purchasers and the patients themselves. As a provider in a fee-for-service situation, another x-ray may be called for medically, and help the practice financially, but could very well be denied by the patient’s insurance plan. In a capitation situation, this additional x-ray comes out of the provider’s bottom line. Once again, need trumps want.

Patient satisfaction is the subject of numerous books, articles and studies. In Crossing the Quality Chasm, the Institute of Medicine identifies patient-centeredness as one of the six ingredients of quality healthcare. The book uses terms to describe this focus such as empathy, responsiveness to needs/preferences, involvement, respect, information, communication, education, emotional support, physical comfort, value, transparency and heeding expectations. Irwin Press (co-founder of Press-Ganey) discusses the importance of patient experiences and perceptions, and the need to go beyond technical quality to encompass service quality in his book Patient Satisfaction: Defining, Measuring and Improving the Experience of Care. Furthermore, the Gallup Organization has extended the concept of patient satisfaction to become patient engagement. In other words, involving the patient in their care and in the delivery of their care increases satisfaction, loyalty, cooperation and respect.

Common satisfaction measures were summed up in a recent study by DrScore and included:

• Accessibility – both physical access and financial access to care.
• Communication skills – of the doctors, nurses, PAs, NPs and others involved in direct patient care.
• Personality and demeanor – of the same group.
• Quality of medical-care processes – as provided directly to the patient.
• Care continuity – regarding the handoffs made provider-to-provider, as well as across time.
• Quality of healthcare facilities – in terms of having the appropriate equipment, supplies and peripheral resources available.
• Efficiency of office staff – in handling scheduling, billing, etc.

As you can see from these lists, the focus of patient satisfaction relies on providers going beyond the mechanical delivery of medical care to the delivery of a true health service.

Driving Forces for Increasing Patient Satisfaction
The list of benefits of paying attention to patient satisfaction is long and extends to virtually every corner of the healthcare organization whether hospital, physician practice, home health, long-term care and so forth. This makes sense, since the range of factors making up satisfaction is quite wide.

With greater patient satisfaction comes:

Clinical Benefits

• Greater patient trust and acceptance with treatment plans.
• Increasing buy-in for treatment plans more quickly, making best use of scarce physician time.
• Increasing trust, which allows physician to discover more factors that may affect the care needs of the patient.
• Enhancing patient involvement in their own care through preventative measures, corrective measures and so forth.

Operational Benefits

• Driving efficiency into the organization by focusing on what works well with patients, and eliminating what does not work well.
• Cross-over trust is enhanced. For instance, a good experience in scheduling appointments can cross over into a better experience with the care provider. In addition, a good experience with the patient’s PCP can cross over into a more positive experience with specialists that the PCP has referred.
• Increased internal support for other quality improvement efforts, such as timeliness improvement, care process improvement, etc.

References:
White B. Measuring Patient Satisfaction: How to Do It and Why to Bother. Family Practice Management; January 1999, Vol. 6, No. 1, pages 40-4.

Another post from About.com

Top 10 Reasons to Fire Your Doctor

 What a great article from About.com - even though it’s primarily about arthritis, the concepts are exactly the same for every patient-physician encounter. Read about it.

The Patient-Physician Encounter

From Carol & Richard Eustice 

The good physician treats the disease; the great physician treats the patient who has the disease ~ William Osler (Canadian Physician, 1849-1919) 

The Patient-Physician Encounter 

What do patients want from a medical encounter with a physician?

In the thoughts of one physician (Delbanco,1992): 

• Patients want to be able to trust the competence and efficacy of their caregivers.
• Patients want to be able to negotiate the health care system effectively and to be treated with dignity and respect.
• Patients want to understand how their sickness or treatment will affect their lives, and they often fear that their doctors are not telling them everything they want to know.
• Patients want to discuss the effect their illness will have on their family, friends, and finances.
• Patients worry about the future.
• Patients worry about and want to learn how to care for themselves away from the clinical setting.
• Patients want physicians to focus on their: 
                    pain
                    physical discomfort
                    functional disabilities  

The Relationship Between Patient And Physician 

The relationship between patient and physician has been analyzed since the early 1900’s. Prior to when medicine was more science than art, physicians worked to refine their bedside manner, as cures were often impossible and treatment had limited effect.

In the middle of the century when science and technology emerged, interpersonal aspects of health care were overshadowed. There is currently a renewed interest in medicine as a social process. A physician can do as much harm to a patient with the slip of a word as with the slip of a knife. 

Instrumental And Expressive Components 

The patient-physician encounter crosses two dimensions:

• expressive
• performing diagnostic tests
• physical examinations
• prescribing treatments

What Are The Effects Of An Effective Patient-Physician Relationship?

What are the effects of an effective patient-physician relationship? When the PATIENT-PHYSICIAN RELATIONSHIP includes:

These factors can provide for PATIENT SATISFACTION WITH CARE which leads to better ADHERENCE TO TREATMENT.

 This is about heart disease from About.com but the info is still pertinent

Getting What You Need From the Health Care System

There’s nothing more frustrating, or more dangerous, than having to solve your own medical problems. No matter how many hours you spend searching the Internet, listening to the accumulated wisdom of your Great Aunt Hilda, or engaging in games of Twenty Questions with taciturn medical personnel, you can never be sure you’ve got the right answer. 

It’s not supposed to be like that. When you’re sick and need help, you’re supposed to be able to rely on a doctor - a doctor who is knowledgeable, who really cares what happens to you, and who will leave no stone unturned in seeing that you get exactly what you need.  Unfortunately, having such a "model" doctor is becoming rare. Patients are on their own much more often, and to a much greater extent, than they used to be - and it’s getting worse all the time.  

If you’ve read Part 1 of this series, you’re acquainted with our contention that patients are feeling abandoned by the health care system because they really have been abandoned; and that (because widespread covert rationing is systematically destroying the doctor-patient relationship,) the abandonment of patients is happening by design rather than by chance. But even if you don’t buy DrRich’s explanation of the problem, the problem still remains. When you’re sick and find yourself engaged in a hostile health care system, you need somebody in your corner who knows what she’s doing, and who cares about you.  And that somebody is supposed to be your doctor.

Choosing the right doctor for yourself, and nurturing a good relationship with him, is probably the most critical step you can take in becoming an effective patient. With the right doctor at your side, the path to good health care becomes clear and wide. Without that doctor, you’re lost and alone in the enchanted forest.  Accordingly, this article discusses two aspects of dealing with your doctor: Choosing the Right Doctor, and The Care and Feeding of your Doctor-Patient Relationship.

Rule # 1. We ought to begin with the first rule of choosing a doctor, to wit: You hired him; you can fire him.

Choosing a doctor is different than, say, choosing a car. When you buy a new car, you can shop around to your heart’s content, but once you plunk down your money and bring that baby home, you’re pretty much stuck with it. If it’s not everything you hoped it would be, you can’t just get rid of it - why, it lost 50% of its original value the minute you drove it off the lot. Besides, it’s not life and death, it’s just a car. So if your new car turns out to be a disappointment, you’ll usually shrug your shoulders and resolve to live with it for a few years, at least until you can justify buying another one. 

It’s different with doctors. For one thing, it’s harder to shop around before you make your move. For another, starting with a new doctor doesn’t require an up-front investment of tens of thousands of dollars. Early on, all you’ve invested is some time and inconvenience. And finally, choosing the right doctor potentially is a matter of life and death.

Many patients have the same attitude when they’re dissatisfied with their doctors that they would have if they were dissatisfied with a car - "Oh, well, guess I’ll just have to live with it." This is the wrong attitude, since, indeed, in this case you may not live with it. Doctors are serious business.  Choosing a doctor is an important decision, but it’s not an irreversible one. It’s not uncommon for discerning patients to run through two or three doctors before finding the right match. And there’s nothing wrong with doing it that way. So if you’ve tried a new doctor and you’re not satisfied with him, get another one. Remember: You hired him; you can fire him.

The most important factor in choosing a doctor: Communication.  If you can’t communicate well with your doctor, you’re in trouble. This is the person, after all, who will need to understand your wishes and values regarding your health care. She is the one who will need to explain to you, so that you can understand it, the nature of your medical problems - the causes, the testing that may be needed, the potential treatments, the pros and cons of the various therapeutic options, and why she’s recommending one option over the others. She’s also the one who has to convince your insurance carrier that the course of action you and she have decided upon is the right one, that it’s medically necessary, and that they - the insurance carrier - ought to pay for it. Communication has always been important in medicine. Now it’s vital.

Is your doctor really listening to what you are saying? Does he show he understands your concerns by responding meaningfully to them? When he explains medical issues to you, does he make them understandable? Does he have more than one way of explaining a difficult concept? Is he patient with you, waiting for you to grasp what he’s saying, or does he try to embarrass you into saying you understand, with shakes of his head or rolling of his eyes? Do you like him, and more importantly, does he seem to like you? (This may become very important when it’s time for him to go to bat for you.) 

The inability to communicate effectively with your doctor is sufficient reason to move on to someone else. Without communication, you’ve got nothing.

The second most important factor: Does your doctor know what she’s doing?

Sometimes its hard to know for sure how knowledgeable your doctor is. But at a minimum you should check to see if your doctor is board-certified in her specialty.  At least two sources can help. The Directory of Physicians in the United States and the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists list doctors who are board-certified. These books are available in most public libraries, and your doctor should appear in them.

Does your doctor seem smart to you? When you ask a question about one of you health problems, are the answers quick, logical, and cogent? Do the answers jibe with what you know to be true? Are her answers given confidently, or is she dissembling? Keep in mind that it’s often fine for a doctor to answer, "I don’t know," as long as she promises to find out the answer, and then follows through on that promise.

For specialists you will be seeing only once or twice, or who you are going to for some complex or esoteric medical procedure, their experience, knowledge and ability are often much more important than how well they communicate. If I’m having a heart valve surgery, I care much less about how warm and fuzzy the surgeon makes me feel during the pre-op interview, and much more about how many similar procedures she’s performed, and what have been her surgical results.

The third most important factor:  Is your doctor respected by his peers?

Doctors watch each other perform in the trenches, and in general, are pretty good at sizing each other up. If you can get a recommendation on a doctor from another doctor you know you can trust, that’s likely to be a good starting point.  If you know some doctors, ask them what they think. Would they send their own patients to your doctor? Or, better yet, do they send their own family members to him? Do they use him as their own doctor?  And, if your doctor is invited to participate in the training of medical students or medical residents at the local university, that’s a reasonably good sign that he’s held in high regard by his peers.

Other factors to consider. 

• Where is your prospective doctor located? Is her office convenient to you?
• Which hospitals does she have admitting privileges to? Are these hospitals convenient to you, and do the specialists there (since the specialists in those hospitals are the ones she will be referring you to) have a good reputation?
• What are her practice arrangements? Who covers for her when she is away?
• Is her age, gender or race important to you?
• What is her office staff like? Are they reasonably competent, friendly, and helpful, or is their main job to keep you out?
• What are her office hours and office policies?
• What insurance plans does she participate in? This may be especially important if you are likely to be changing jobs (and thus changing insurance carriers.)

Where to look.

Start with your family and friends - people whose opinions you trust. Find out who their doctors are, and whether they are happy with them. Find out why they like them.  Also, talk to medical specialists, and especially to nurses and (if you know any), physicians’ assistants.  See which doctors they respect and admire, and why.

Another place you might consider looking is www.bestdoctors.com.  This is a listing of American physicians chosen through a survey of other American physicians.  For a doctor to make the list, a large number of physicians have to assert that they would want that doctor to take care of them or their family members if they were sick. Best Doctors is a business, however, and currently requires a $35 subscription fee.  A problem with Best Doctors is that it is sometimes weighted toward academic physicians, and there are potential drawbacks to academics - doctors often sing the praises of academics not because they are especially good doctors, but because they have published a lot, or are in positions of power. Some of the most famous university doctors are not especially good clinicians. The bottom line is that while you may find Best Doctors useful, it should by no means become your chief searching tool.  The large majority of excellent doctors in the U.S. are not listed there at all. If you strictly limit your search in this way you may be cheating yourself.

Once you have made your list of doctors, check for them in the Directory of Physicians in the United States or the Official American Board of Medical Specialties Directory of Board Certified Medical Specialists in your public library to make sure they are board certified.  Finally, call the office of one or two of the doctors still remaining on your list. See what you have to do to get an appointment.  See whether the office personnel seem friendly and efficient, or whether they’re obstreperous and obstructive.  Remember that you may need to deal with these people fairly often, and that before you ever get in to see the doctor, you’ve got to get past them. And remember that the doctor’s front office is a reflection of his own personality.  If his receptionists and nurses are difficult to deal with, you’ve got to assume that the doctor likes it that way. 

 The remaining step is to pick one of the "finalists" on your list, and make yourself an appointment.  If after meeting with the doctor you decide this isn’t going to work out, remember Rule # 1.

If you’ve read Part 1 of this series, you know that the traditional doctor-patient relationship is in deep trouble.  The problem, of course, is that the health care system simply can’t afford the traditional doctor-patient relationship anymore. There’s no way that HMOs, hospitals, insurance carriers, or federal regulators can allow doctors to continue directing the spending of health care dollars as if the only important consideration is the welfare their patients. In thousands of ways doctors are being coerced into giving the needs of each of these other parties a higher priority than the needs of their patients. So in becoming an effective patient, you’ve got to take the weakened state of the doctor-patient relationship into account.

The effective patient’s strategy 

Simply assuming that your doctor is always going to be acting in your best interests - no matter how good a doctor he is, or how ethical - is a big mistake.  The effective patient understands this, but she understands something else, too. She understands that her doctor (if she’s chosen her doctor wisely) deeply wants to honor the traditional doctor-patient relationship, since honoring that relationship is his first duty as a professional. She understands that, despite all the coercive pressure to the contrary, her doctor will occasionally go up against an HMO for the benefit of a patient. He needs to do this as a matter of professional pride - just to be able to live with himself. (The HMOs understand this, too. Letting the doctors win one now and then - only, of course, after putting up a stiff resistance - costs them some money, but in the long run keeps the doctors mollified. It keeps the doctors working, and it keeps them quiet. It’s just one of the costs of doing business.) The effective patient also understands that, as much as he may want to, her doctor cannot go to the wall for every patient, or for every issue that comes up for a given patient. The process would be too grindingly difficult, and fatal to his career. She knows that her doctor must choose his battles carefully.

The effective patient understands all this, and nurtures her relationship with her doctor accordingly. She tailors the relationship in such a way that, when the chips are down, she is likely to be one of those her doctor will go to the wall for.  To be such an effective patient, consider following these three general strategies:

Strategy 1 - Be empathetic.  Show that you understand the constraints under which your doctor is laboring, and adjust your expectations accordingly. Don’t be too demanding, especially regarding the small stuff. Show that you respect your doctor’s skills, and that having his skills working for you is worth a few minor inconveniences. After all, you make clear, you know how hard it is to be a good doctor these days, and you’re thankful he’s there for you despite everything. 

Strategy 2 - Align your interests with those of your doctor. Remember: you and your doctor are in this together. He feels your pain, and you feel his. You both want the same things. You both want the patient (you) to get good health care; and you both want the doctor’s practice - and professional integrity - to thrive. So while you fully expect to get the care you need from your doctor, you will help him to deliver that care as efficiently and as cheaply as posible.

You will not bother him needlessly, or thoughtlessly. You will make the most efficient use of your time with him. You will learn how his office operates, and cooperate with his office staff in minimizing interruptions and special requests. (For instance, inquire as to the best time to call the office with questions, or to speak with the doctor.) The main idea is: you are interested in making the doctor’s job as easy for him as possible, while still having your own vital needs served. 

Strategy 3 - Become engaged in your own good health. Nothing makes doctors crazier than patients who completely neglect their own health, then expect their doctors to pull out all the stops for them when they get into medical difficulties. The fact is, your doctor simply cannot afford to vigorously advocate for every problem for every patient. This being the case, which patient is your doctor more likely to fight for when they get sick - the obese smoker who has made no visible effort to take care of himself, or the diabetic who has carefully tried to follow her difficult diet and drug regimens?  

Maybe it isn’t fair, but it’s nonetheless true. If a doctor is considering stepping out of line and jeopardizing his own security to fight for his patient’s best outcome, you can be sure he’s more likely to reserve that action for a patient who’s fighting right at his side for the very same thing. 

You greatly increase the likelihood that your doctor will go to the wall for you if you are fully engaged in maintaining your own good health. You need to stop smoking, lose weight, exercise, take an interest in disease prevention, and during your visits to your doctor, demonstrate how involved you are with your own health care. Make yourself into the kind of patient that doctors find it rewarding and fulfilling to fight for.

Summary

By understanding how and why the doctor-patient relationship is under fierce attack, you can "manage" your own doctor-patient relationship to make yourself a more effective patient. 
Any doctor worth her salt will respond favorably to patients who seem to understand the duress she faces each day in the practice of medicine, who try to help her keep her head above water while she provides health care, and who take an active role in maintaining their own health. Patients like that are worth their weight in gold, and doctors try hard to provide them with the best health care they can possibly manage.

Revealing Statistics

The following statistics illustrate how widespread noncompliance really is among Americans: Only 55 percent of tuberculosis patients, 48 percent of diabetics, 46 percent of asthmatics, and 42 percent of glaucoma patients use their medicines correctly.

(Sources: The Food and Drug Administration and The National Council on Patient Information and Education)

 Dr. Terrie Wurzbacher is a retired Naval Officer and an Emergency Physician. She spent 29 1/2 years in the Navy and devoted much of her time trying to teach interns and medical students the fine "art" of communicating with patients. She does NOT claim to be an expert in that field but knows that once she realized that she was not getting the point across to her patients and began to concentrate on ways to help them understand, she was way ahead of most of her peers. There are great doctors out there and some of that greatness is based on technical skill. However, the majority of the great doctors are great because they make the patient a big part of the entire gameplan. Dr. Wurzbacher has always aspired to be that kind of doctor. She knows she's not great but hopes that patients will help their own doctors get to "great".

Perhaps a more important qualification for authoring materials about doctor-patient communication is that she's been a patient herself. Although she is very fortunate to have had excellent health, she has had to visit the doctor for several things and has had a sampling of pretty poor physicians and also wonderful ones. So, she does have the "credentials" to talk about doctor-patient communication.

Check out this article in USA Today! Thanks to my friend Joyce for alerting me about this.

The title is "Experts say lying patients at risk".

I’m so glad they published this article…and published it where lots of people will read it.

As embarrassed or unsure as you are about what a doctor’s reaction might be, it’s so vital that you tell the truth, the whole truth and nothing but the truth.

People tend to avoid subjects such as sex, depression (or other psych problems), herbal medicines, taking old medications (such as previously prescribed antibiotics), drinking habits, other conditions.

If you don’t tell the doctor about everything, you risk getting medications that will adversely interact with what you are taking. Many herbal medicines have dangerous interactions too.

Do not make the mistake of compartmentalizing your doctors. You may think that a specialist is taking care of a problem completely unrelated to anything else you have. But everything in your body (and everything you put into your body) is interconnected. So, tell them about everything. Oh, and don’t withhold information because you think that telling the doctor about everything is wasting his time. That is not the case when it comes to understanding what is happening in your body.

This is the reason I am such an advocate of carrying a list of your medical problems AND a list of your medications!

Read this article and pay attention, please.

Terrie

What on earth do I mean by that? What is perception? All I know is that perception is reality. How many times have we heard that? And how often do we think of that when we’re in the medical environment? Probably not as often as we should…..

I was having lunch with a good friend and his wife (whom I’ve gotten to know fairly well in the past 2 years). She told me about her encounter with a new doctor recently for a sinus infection. She was adamant when she simply stated "I know enough about what’s going on in my body that by the time I go to the doctor, I just want them to give me the drugs I need." My internal reaction to that was very disconcerting. I understood what she was saying but my doctor-instinct was horrified - I know I’m telling alot about myself

I wanted to explain to her that sometimes she might not know exactly what was wrong with her because "after all, you’re not medical" but i restrained my tongue for once, knowing that what she believed was, in fact, reality to her - and therefore, she probably did know what she needed.

I recalled a very sad case where a mother did not want to take her twin daughters home from the ER because they did not seem "better" to her after their asthma treatment. The ER doctor (not me, thank goodness) told her that the girls were not wheezing so they "must" be better. So, reluctantly mom took them home. The outcome was not good - one of the girls ended up dying. I tell this not to be morbid but to emphasize to patients that they really do know their bodies better than anyone (and to remind the physicians to listen to the patients and pay attention). I learned such a valuable lesson that night, nearly 28 years ago - and I think that’s what held my tongue in abeyance with my friend’s wife.

The point is that doctors and patients have different perspectives and therefore the perception of each is most likely 180 degrees apart. Each of us has to ask for clarification or offer it if we want to be understood by the other - and if we’re not understood, we’re in deep trouble.

Doctors - throw away your judgments and open up your ears AND your minds.

Patients - stick up for yourself and make sure your doctor hears you and where you’re coming from. And then make sure you understand what he’s saying.

Perception really is reality

Til next time…..

Terrie