1. Building a Better Care Relationship with Effective Doctor-Patient Communication By Michael L. Millenson Communication Comes to the Fore In 2001, the Institute of Medicine listed “patient-centered care” as one of six aims of the U.S. healthcare system. Since then, measurement of how effectively clinicians com- municate with Medicare patients has become part of “report cards” shared with the public and community through the H-CAHPS survey (Hospital Consumer Assessment of Healthcare Providers and Systems). Similar report cards are planned using a clinician and medical group survey (known as CG-CAHPS). Meanwhile, patient-centeredness measures are linked to reimburse- ment for Medicare’s accountable care organizations, in the patient- centered medical home, and in other new payment models from private and public payers. While there are multiple ques- tions, what lies at the heart of all these surveys are the conversations i n the era of accountable care orga- nizations, patient-centered medical homes, and online report cards, The wording of the Care Card and the doctor-patient interaction involved in using it are carefully that take place between physician and patient. The average physician conducts effective communication between designed to help patients more more than 150,000 interviews doctors and patients can have a efficiently and effectively express during a practice lifetime, making significant impact on reimbursement, what they want to accomplish and the patient interview potentially patient relationships, and community help doctors consistently collaborate “the most powerful, sensitive, and reputation. with them in doing so. The formal versatile instrument available.”1 It The Better Health ConversationsSM name for this type of effort is does not always fulfill that potential: program was developed as an “agenda setting.” one oft-quoted study showed that evidence-based, consumer- and In a pilot program at three diverse physicians interrupt the patient’s ini- physician-friendly means of medical groups, the program prompted tial description of his or her problem integrating better communication a positive response from both patients after just 18-23 seconds.2 into the office visit routine to improve and veteran physicians who might Done right, however, effective care and satisfaction. The program’s not have been aware that their own communication skills build a better centerpiece is the Care CardSM, communication practices could be relationship that has a powerful which patients bring with them into improved. As one physician participant impact on doctors and patients the doctor’s office, share, and then acknowledged, “It changed my way of alike. Better communication enables take home. starting conversations with patients.” physicians to improve patients’ 12 Group Practice Journal may 2012May2012_mech.indd 12 5/14/12 12:08 PM
2. understanding of their illnesses, which was then shared with focus and office staff and a Frequently improve patient adherence to treat- groups conducted with AMGA Asked Questions page ment regimens, use time efficiently, member executives and doctors. ■■ Waiting Room Display, alert- avoid professional burnout, and There are already health literacy ing patients to the program and increase professional fulfillment.3 programs for patients, encourag- engaging them Studies show “unequivocal and ing them to ask several specific ■■ CareCard for the patient to fill significant relationships” between questions, and training programs out and share with the physician various aspects of communica- for physicians to improve commu- tion and such health outcomes as nication skills. What distinguished The Care Card is central to psychological and functional status, Better Health Conversations was our the program. It directly addresses symptom recovery, and recovery decision to make improving com- patients at the point of care, asking from emotional problems.4,5 munication a responsibility shared them to write down health concerns On the other hand, physicians by clinicians and patients. That joint before seeing the physician and then who communicate poorly not only approach, the focus on one specific take the card into the exam room miss out on a chance to help their area (agenda setting), and the warm to share with the doctor. There are patients, but also run an increased and friendly “look/feel” of all the three separate lines for the first risk of being sued.6 program materials set it apart. three concerns, followed by lines for The spread of consumer-oriented Two caveats came through loud “Additional Concerns.” However, medical websites, third-party payer and clear from AMGA members: the concerns were deliberately not incentives related to patient satisfac- “What’s in it for me?” had to be numbered so as not to require (or tion, and changed societal expecta- immediately apparent to doctors, and suggest) prioritization; joint agree- tions have made effective com- the program had to fit seamlessly ment on prioritization is at the munication even more important. into a very busy office workflow. heart of the clinical conversation. Yet the nuts-and-bolts components Three diverse groups volunteered The request to the patient to fill out of clinical communication, such as to help refine the materials and the card is phrased as a way to help information sharing and relationship conduct a four-week pilot in the “us” provide better care; that is, it building, are inevitably stressful and summer of 2011: Crystal Run implicitly gives permission to the challenging for both patient and Healthcare of Warwick, New York, patient to become a partner. physician.7 That’s why both sides serving a suburban and rural popula- The reverse side of the card need new tools that will allow them tion; Holzer Clinic in Gallipolis, includes space for note taking by to move forward together. Ohio, serving a rural population; the patient or for notes written by and University of Utah Health Care, the physician. However, the card is Improving on Improvement Tools Salt Lake City, serving primarily an deliberately given back to the patient Health Quality Advisors LLC, urban and suburban population. by the doctor so it does not become a a consulting firm on quality of care formal part of the medical record and and patient empowerment, began by Developing Program Materials possibly subject to privacy regulations. assembling an expert advisory board While the Better Health to develop an intervention that would Conversations materials are anchored Launching the Pilot be effective in the group practice in the medical literature, they have We knew good materials alone environment. We included patient a consumer-oriented look and an were insufficient. Building a better advocates along with physicians and engaging style of writing that signals doctor-patient relationship starts academic researchers. We also worked patient and doctor alike that this is with other relationships. Critical to closely with the American Medical not typical “educational” materials. launching the pilot was buy-in by Group Association in conjunction The different components include: medical group leaders, who selected with the pharmaceutical company a physician champion at each group. Daiichi Sankyo, Inc. to ensure that ■■ A Program Guide for the Group They were: Jonathan Nasser, M.D., the intervention would be effective Practice that welcomes provid- an internist board-certified in “in the trenches.” ers, describes the program, and pediatrics and internal medicine, at In addition, we set out to learn contains references and other Crystal Run; Adam Breinig, D.O., a from what had been done before by information family practice physician, at Holzer; reviewing the medical literature on ■■ Agenda Setting: A Practical and John Houchins, M.D., a family physician-patient communication Guide, supplementing hands-on practice physician, at Utah. All three and assessing similar initiatives coaching at the program launch champions received background offered by others. We also learned information on communication and along the way: the expert advisory ■■ Folderwith Welcome Letter, in- on physician training. board provided continual feedback, cluding an overview for physicians Training took place face-to-face 14 Group Practice Journal may 2012May2012_mech.indd 14 5/14/12 12:08 PM
3. for about an hour at a lunch or unfounded. The most frequent gram was helpful to them in theirbreakfast meeting onsite with the number of concerns listed on the overall interaction with patients.physicians in each group recruited to Care Card was one (36.5 percent). Sixty-five percent felt “the Caretry out the program. After a remote Just 12 percent of patients listed Card was helpful to me in mypresentation by advisory board more than three concerns. interaction with patients” and 50experts Howard Beckman, M.D., and ■ Patient satisfaction with how percent agreed “I was more satisfiedRichard Frankel, Ph.D., about the physicians addressed concerns was with my interactions with patients.”science of doctor-patient communica- very high. About 98 percent of For a short pilot with a very modesttion, Health Quality Advisors’ team patients were “completely” or “very behavioral intervention, that sort ofmembers on site provided informa- satisfied” with the visit. positive impact is striking.tion about the goals and structure ■ The consistency of satisfaction ■ About two-thirds of physiciansof the program. Most important of suggested a program effect. Even favored continued use of the Careall was an interactive role-playing when patient expectations were Card or were neutral. Fifty-sevenexercise in which physicians had the increased by telling them their percent were positive and 14opportunity to use the Care Card in doctor was interested in what they percent neutral. Some of thoseclinical scenarios developed by Health wrote on the Care Card, those reacting negatively may have beenQuality Advisors. Switching between new and higher expectations were influenced by a technical glitch—the doctor and patient roles provided met. Had they not been, satisfac- the cards were printed on glossya personal experience of how the tion could have taken a dip. paper that was tough to write on.Care Card could work in an actualclinical encounter and gave physicians ■ The Care Card appears to have This positive reaction standsthe opportunity to ask practical (and been a relationship facilitator. out even more when one considersprobing) questions. Patients seemed to have felt more that practicing physicians tend to The Health Quality Advisors comfortable sharing concerns. One believe they already communicateteam and the physician champion physician champion said the Care well; it typically takes videotapingalso spoke with front office staff Card got patients talking about and formal follow-up to suggestat each group about their role in problems they wouldn’t ordinarily otherwise. Two physician championshelping explain to patients what was talk about—truly a better health said they did not fully appreciatebeing asked of them and helping conversation. Others reported some the impact of the Care Card onmake the program a smooth-flowing returning patients asked about the their own practice habits until theypart of the office routine. A regularly Care Card after the pilot ended. stopped using them and saw howscheduled phone call among the they had served as a “prompt” forphysician champions and the Health Perhaps in part because of the agenda setting.Quality Advisors team also provided patient reaction, participating physi-support and feedback. cians were mostly positive. Conclusion Better communication buildsThe Results ■ Nearly 80 percent of physicians better relationships that have posi- A satisfaction survey attached to agreed the program improved tive clinical effects, positive effectsthe Care Card was returned by 1,465 agenda setting, both by prepar- on patient satisfaction, and positivepatients during the pilot. A physician ing patients and reminding them effects on clinician worklife satisfac-satisfaction survey was returned by of the importance of setting an tion. We believe the Better Health14 out of 19 participants and at least agenda jointly. When asked to Conversations pilot to enhance60 percent at each medical group. respond to the statement, “My physician-patient communicationsWe also tracked anecdotal reports. patients were better prepared to succeeded for several reasons:While this was not a research study, discuss their concerns,” 11 of 14we submitted the survey results for physicians agreed somewhat or ■ The program focused on ananalysis by an academic consultant. strongly, two disagreed somewhat important problem for medical In sum, signs of the good things or strongly, and one was neutral. groups and physicians. As a result,the medical literature predicted— When asked whether the Care it received strong support from thealbeit difficult to see clearly in a very Card “was a useful reminder to me leadership and individual physi-short pilot—started to appear while about agenda setting,” 11 physi- cian champions.the feared negative consequences did cians agreed somewhat or strongly, ■ The program addressed an indi-not. For example: three disagreed somewhat or vidual component of physician- strongly, and none was neutral. patient communication where it■ Fears of opening a “Pandora’s ■ Physicians generally felt the pro- could make a difference in a man- box” of patient concerns proved16 Group Practice Journal may 2012
4. ner that resonated with doctors and patients alike.■ The program was innovative, col- laborative, and flexible. Feedback from participants and Health Quality Advisors’ program partners was solicited and acted upon. As a next step, we are using thefeedback received from the pilot torefine the content of materials andthe way those materials are used toimprove their effectiveness. In today’shealthcare environment, with anincreasing need to integrate betterphysician-patient communication intothe routine processes of outpatientcare at medical groups, a collaborationbetween doctors and patients is moreimportant than ever. Better HealthConversations seems to providean evidence-based, consumer- andphysician-friendly means of helpingthat collaboration happen.References1. G.L. Engel. 1988. How Much Longer Must Medicine’s Science Be Bound by a Seventeenth Century World View? In: K.L. White, ed. The Task of Medicine: Dialog at Wickenburg. Menlo Park, CA Henry J. Kaiser Family Foundation, 133-177.2. M.K. Marvel, R.M. Epstein, K. Flow- ers, and H.B. Beckman. 1999. Soliciting the patient’s agenda: have we improved? JAMA, 281(3): 283-287.3. Anthony L. Back et. al. 2005. Approaching Difficult Communications Tasks in Oncol- ogy. Cancer Journal for Clinicians, 55(3): 164-177.4. M.A. Stewart. 1995. Effective physician- patient communication and health outcomes: a review. Canadian Medical Association Journal, 152(9): 1423-1433.5. Rainer S. Beck, Rebecca Daughtridge, and Philip D. Sloane. 2002. Physician-patient communication in the primary care office: a systematic review. The Journal of the American Board of Family Practice, 15(1): 25-38.6. Gerald B. Hickson et. al. 2002. Patient Complaints and Malpractice Risk. JAMA, 287(22): 2951-2957.7. S.J. Lee, A.L. Back, S.D. Block, and S.K. Stewart. 2002. Enhancing physician-pa- tient communication. Hematology/American Society of Hematology Education Program, 464-483.Michael L. Millenson is president ofHealth Quality Advisors LLC in High-land Park, Illinois and the MervinShalowitz, M.D., Visiting Scholar atKellogg School of Management.