1. Engaging Physicians and Patients in Patient-Centered Care
Dorothea Wild, MD, MPH, Dr. med.
Griffin Hospital
Image: MD and pt shaking hands

2. Overview
Explore barriers to physician engagement in patient-centered care
Evidence supporting effective patient-centered communication
Discuss strategies to engage physicians at all levels in patient-centered care:
Motivate
Activate
Monitor
Why is “weigh yourself every day” so hard? Engaging patients in managing their disease

3. Why is it so hard to bring the MDs around?
“I have many patients who would like nothing more than to spend 2-3 hours with me to go over every news report they have heard about a rare disease. I have patients who would like me to mediate the problems between their daughter and son-in-law, and those that just want to discuss politics and religion with me.”
“Why should a patient bother to consult a physician if the patient does not want professional care? (…) It is important to distinguish between a poor bedside manner and the expertise that develops from many years of training and experience. (…) Dr. Berwick is totally out of touch with clinical medicine and one wonders if he has ever been in medical practice.”
New York Times responses to Don Berwick article about patient-centered care
Somebody tearing their hair out, or running against wall, or setting off bombs

4. Physician Barriers… The Problem
Perceived contradiction between
evidence based care versus patient centeredness
Time constraints
Fear that engaging patients would lead to overwhelming demands on time
Lack of knowledge and skills
No incentives for communication/coordination
Impression that Institution/Medical staff does not value communication
Barriers

5. How to Motivate Physicians
Make it important
Make it evidence-based
Make it about their patients
Activate:
Show them where they are
Give them actionable things to do
Monitor:
Monitor the data
Give regular feedback

6. Good News: Communication Improves Outcomes
Good physician communication:
Increases patient adherence
Increases satisfaction
Decreases anxiety
Leads to more accurate recall
Improves management
Decreases inappropriate utilization of resources
Decreases litigation
Bartlett et al. J Chron Dis 1984;37: ; Stewart 2002

7. Patient-Centered Communication is More Scientific
“History-taking, the most clinically sophisticated procedure of medicine, is an extraordinary investigative technique: in few other forms of scientific research does the observed object talk.” Alvan Feinstein, Clinical Judgement 1967
“A successful dialogue between patient and physician is at the heart of working scientifically with patients.” George L. Engel, 1995
Image: scientist with microscope/beakers
Used with permission from Auguste Fortin III

8. It’s hard to be a patient…
Patients’ recall of their discharge info:
27.9% were able to list all their meds
37.2% were able to recount the purpose of all their meds
14.0% were able to state side effects
41.9% were able to state their diagnosis
Makaryus & Friedman Mayo Clin Proc 2005;80(8):

9. Motivate: Speak With the Voice of the Patient
Survey Patients while hospitalized, there is technology available to help (
Patient call backs 48 hours after discharge
Focus groups
Call fall-outs on HCHAPS scores to elicit more data
Image: Patient

10. Patient Call Backs How are you feeling since the discharge?
Are there any new or worsening symptoms?
Did you understand what you were treated for?
Did you get all your medication filled?
Do you have concerns or questions about your medication?
Do you know the doctor who was in charge of your care?
Did you get a follow-up appointment scheduled?
Image: Somebody on phone

11. HCAHPS Call-Backs
When you were asked “how often did your doctors explain things well, you said usually. What would it have taken for you to say always?”
Answer: “I was actually thinking about Dr. X, when I answered those questions. He seemed so aloof and very cold. He did a colonoscopy on me and when I woke up, he quickly told me I had a mass and went away. He did not stay back to explain to me what it means and what would be the next steps.”
Same Image: Somebody on phone

12. Activate: Show the Data
Analyze HCAHPs MD scores:
Attending
Nursing unit
HCAHPs question
BUT: Patients aren’t the only ones who observe MD communication!
Survey house staff/midlevel providers regarding attending teaching behavior and hidden curriculum
Survey nurses regarding physician behavior
Image: Data, lines going one way or the other

13. Survey Items from hidden Curriculum Survey
How often do faculty/residents/interns:
Encourage patients’ participation in their care
Take seriously patients’ concerns
Develop good rapport with patients
Explore emotional aspects of patients’ illnesses
Communicate interest in the patient as a person
Adapted from: Beckman, : Haidet P, Kelly PA, Chou C, et al. Characterizing the patient-centeredness of the hidden curriculum. Acad Med 2005;80:44-50
Image: Docs talking to patients

14. Survey Items from Nursing Survey
How often does this provider (resident/faculty):
Communicate concern in patients as unique persons
Encourage patients’ participation in their own care
Explore emotional aspects of patients’ illness
Provide patients with a clear understanding of their plan of care
Handle demanding interpersonal situations in a respectful and effective manner
Listen to you and considers what you have to say about patients’ care and concerns
Respond in a timely manner when notified
Image: Nurse talking to doc
Adapted from: Wooliscroft et al. Acad Med 1994;69:

15. Ask for concrete things to do: “Say: What Else?”
Physician Centered: MD: What brings you here today? Pt: I have headaches. MD: Where are the headaches? How long do they last? What do you do to relieve them?
Patient Centered: MD: What brings you here today? Pt: I have headaches. MD: What else? Pt: Well, I have trouble sleeping Pt: I am very worried about my son. He is using drugs.
Image: Pt and doc
Barrier et al. Mayo Clin Proc 2003;78:

16. OSCE (Objective Structured Clinical Exam): Tool to provide feedback
Resident script: It is morning and you are about to visit a patient in her room. (…) you received sign-out that this patient is coming in for pancreatitis, possibly alcoholic. Your goal for the next 6 minutes is:
establish a therapeutic relationship and
assess her understanding of her admission diagnosis.
Patient script: You are upset because you think that people are accusing you of being an alcoholic. You are convinced that your pain is from eating bad food.
Taped and viewed with chief hospitalist/external expert
Image: Doc with patient

17. During Rounds Model patient-centered behavior
Discuss evidence for patient-centered care during rounds
Instill the habit to end each encounter with “can you explain the plan for the day?”
Use the teach back method
“So, Mrs. X. What do you understand about what brought you in here?”
Image: Group of docs around patient

18. Monitor: Track Data
Track patient-centeredness as performance metric in resident and hospitalist files
Track HCHAPs score, How’s Your Care scores for groups and individual physicians
Periodically repeat hidden curriculum, nurses survey for improvement
Image: More tracking data

19. Monitor: Provide Feedback
Provide direct observation
Provide patient comments
Provide concrete behaviors to implement
Example: Sit down, ask a question, smile, and listen for 2 minutes without interrupting
Example: Patient said “all my friends smoke” – how could you respond in an empathetic way?
2 docs sitting down and talking

20. Why is “weigh yourself every day” so hard ?

21. Barriers to self-management
Multiple barriers to patient adherence
Financial and practical
Motivational
Cultural competency and health literacy
Health beliefs, external locus of control
Relationship with provider crucial to identifying and overcoming those barriers
Tools to activate patients and communicate in culturally and linguistically appropriate manner
Consistent monitoring and coaching
Image: Barriers

22. Expanding the partnership outside the hospital
Accountable care will require hospitals, SNF’s, VNA’s, and PCP’s to engage patients
Building partnerships across continuum of care
Putting patients and care
partners at the center of care
transitions
Holding each other accountable
Extending hands beyond hospital, team-based care