Engaging Physicians
and Patients in
Patient-Centered Care
Dorothea Wild, MD, MPH, Dr. med.
Griffin Hospital
Overview
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Explore barriers to physician engagement in patientcentered 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
Why is it so hard to bring the MDs
around?
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“I have many patients who would like nothing more than to spend 23 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
Physician Barriers…
The Problem
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Perceived contradiction between
evidence based care versus patient centeredness
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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
How to Motivate Physicians
Motivate:
 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
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;37:755-764; Stewart 2002
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
Used with permission from Auguste Fortin III
It’s hard to be a patient…
Patients’ recall of their discharge info:
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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):991-994
Motivate:
Speak With the
Voice of the Patient
Survey Patients while hospitalized, there is
technology available to help
(www.howsyourcare.org)
Patient call backs 48 hours after discharge
Focus groups
Call fall-outs on HCHAPS scores to elicit
more data
Patient Call Backs
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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?
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.”
Activate: Show the Data
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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
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 patientcenteredness of the hidden curriculum. Acad Med 2005;80:44-50
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
Adapted from: Wooliscroft et al. Acad Med 1994;69:216-224
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
MD: What else?
Pt: I am very worried about my
son. He is using drugs.
Barrier et al. Mayo Clin Proc 2003;78:211-214
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:
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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
During Rounds
• Model patient-centered behavior
• Discuss evidence for patient-centered care
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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?”
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
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?
Why is “weigh yourself
every day” so hard ?
Barriers to self-management
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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
Expanding the partnership outside
the hospital
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Accountable care will require hospitals, SNF’s, VNA’s, and PCP’s to
engage patients
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Building partnerships across continuum of care
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Putting patients and care
partners at the center of care
transitions
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Holding each other accountable