Talking with Your Doctor...What Matters to You?

"What Matters to You?" is an international initiative to encourage healthcare professionals and patients to have conversations about what is most important to the patient regarding their health and then to act on it. The following brief video describes the benefits to healthcare professionals.

Click here for a previous post on the patient's role in shared decision making and the importance of telling your physician what matters to you. And click here, if you have trouble talking with your doctor.

Shared Decision Making—The Patient's Role

What are your preferences, needs, and values when it comes to your health? When confronted with an important medical decision do you and your doctor discuss how the various diagnostic and treatment options—including doing nothing—may effect the physical, emotional and social aspects of your life? 

If Dr. Michael J. Barry and Physician Assistant Susan Edgman-Levitan had their way doctors would be asking their patients "What Matters to you?" as often as they do "What's the matter?"

Their article—Shared Decision Making—The Pinnacle of Patient-Centered Care which appears in the March 1st issue of the New England Journal of Medicine—points to the need for clinicians to "relinquish their role as the single paternalistic authority and train to become more effective coaches or partners...."

Patients, too, need to be educated about their role and given the tools and emotional support they need to fully participate in the process—without fear of criticism or judgment. Dr. Barry and Ms. Edgman-Levitan believe that by adopting the principles of shared decision making, "clinicians can help patients understand the importance of their values and preferences in making the decisions that are best for them."

This is especially relevant when a "patient arrives at a crossroads of [acceptable] medical options" each of which is associated with benefits and risks that may have profound and lasting effects. The authors cite as good examples: "... therapy for early stage breast cancer or prostate cancer, lipid-lowering medication for the primary prevention of coronary heart disease, and genetic and cancer screening tests...."

Dr. Barry is President of the Informed Medical Decisions Foundation and Ms. Edgman-Levitan is a Board member. The organization, which was founded in 1988, works to advance shared decision making through research, policy, clinical models and patient decision aids. The Foundation's website offers a wealth of information, tools, and resources, including videos of patients and providers discussing their experiences with shared decision making.

Here's a brief introduction:

Choosing Wisely™

Your doctor recently ordered a medical test or course of treatment for you because (choose all that apply):

Photo Credit: Ambro

1. She is practicing evidence-based medicine, i.e., the test or treatment has been proven effective in diagnosing/treating your condition
2. She is afraid she will be sued for malpractice if she misses something
3. She hasn't spent enough time with you
4. She is participating in quality measure reporting
5. All of the above

Answer: It depends...


According to an article by Brenda E. Sirovich, MD, MS, Steven Woloshin, MD, MS, and Lisa M. Schwartz, MD, MS, published last year in Archives of Internal Medicine, 42 percent of U.S. primary care physicians believe that patients in their own practices are receiving too much care; only 6 percent said they were receiving too little. Factors cited for aggressive testing and treatment included: fear of malpractice (76 percent); clinical performance measures (52 percent), and inadequate time spent with patients (40 percent). Sixty two percent said diagnostic testing would be reduced if not for financial incentives to specialists (39 percent for primary care physicians).

The cost of these unnecessary, and sometimes harmful, tests and treatments are estimated to be a third of the $2.6 trillion Americans spend on healthcare each year.

Last week, a new campaign that Dr. Donald Berwick—former Administrator of Centers for Medicare and Medicaid and longtime champion of patient safety—called "a game changer" was launched by nine prominent physician groups. The groups have each identified five specific tests or procedures that are commonly used but not always necessary. 

Choosing Wisely™ Five Things Physicians and Patients Should Question which is led by the American Board of Internal Medicine Foundation with Consumer Reports, includes such recommendations as:

• Don't order sinus computer tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis (American Academy of Allergy, Asthma & Immunology)
• For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals (American Gastroenterological Association)
• Don't do imaging for low back pain within the first six weeks, unless red flags are present (American Academy of Family Physicians)
• Don't perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present (American College of Cardiology)
• Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology (American College of Physicians)

Full lists with rationales can be found on the Choosing Wisely™ website. Several more physician specialty groups are preparing lists that will be released in the fall of 2012.

While many in healthcare have praised the initiative, others worry that the recommendations may be adopted too broadly, restricting choice and putting patients at risk.

A press release for the campaign describes the lists as evidence-based recommendations that are meant to encourage discussion among physicians and patients and to guide decisions about the most appropriate care based on individual situations.

So the next time your doctor recommends a test or treatment, ask questions, talk through the options and together make the best decision for you.

References

Choosing Wisely by Christine K. Cassel, M.D. and James A. Guest, J.D. Journal of the American Medical Association, published online April 4, 2012.
Accessed at http://jama.ama-assn.org/content/early/2012/03/30/jama.2012.476.full

Doctor Panels Recommend Fewer Tests for Patients by Roni Caryn Rabin. The New York Times, April 4, 2012. Accessed at http://www.nytimes.com/2012/04/04/health/doctor-panels-urge-fewer-routine-tests.html

Physicians Wade Into Efforts To Curb Unnecessary Treatments by Julie Appleby. Kaiser Health News, April 4, 2012. Accessed at http://www.kaiserhealthnews.org/stories/2012/april/04/physicians-unnecessary-treatments.aspx

U.S. Physician Groups Identify Commonly Used Tests or Procedures They Say Are Often Not Necessary. Press release, April 4, 2012. Accessed at http://www.prnewswire.com/news-releases/us-physician-groups-identify-commonly-used-tests-or-procedures-they-say-are-often-not-necessary-146046345.html

Trouble Talking With Your Doctor? Try a Little Empathy

There is an often quoted physician maxim from a lecture given by Dr. Francis W. Peabody to students at Harvard in 1925: "...For the secret of the care of the patient is in the caring for the patient."

I came across the quote this morning in a blog discussion among physicians about how best to manage difficult patients. The physician went on to say that one of the strategies he uses is to try to understand what might be causing the negative behavior and to address the problem if he can. If that doesn't work, he says he tries to find something to like about the patient. It may take two or three visits, he advises, but it usually helps improve the relationship. 

Clearly, this doctor understands that his caring actions, not just his technical skills, can have an important effect on patient behavior, health outcomes and overall satisfaction.

His thoughtful comments got me thinking about the traditional patient-physician relationship and how strangely lopsided it has been in terms of knowledge, power, vulnerability, intimacy and detachment. No wonder we have trouble communicating with each other.

One of the lingering effects of paternalistic medicine—even as the physician-patient relationship evolves to more of a partnership—seems to be how little we as patients think about the physician's day before and after our appointment. If we're honest, many of us don't give him much thought during the appointment either, except in terms of his response to us.

Maybe it's time patients started caring more about their physicians. After all, one of the keys to successful communication is to be able to take the other person's point of view and to understand what he or she is feeling.

Two recent studies provide insights into physicians' concerns about practice-related barriers to developing a sense of connection and mutual understanding with patients.

In "What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice," Richard J. Baron, MD, details the volume and types of services provided by a practice employing five physicians supported by four medical assistants, five front desk staff, a billing manager, a health educator, and two-full-time clerical staff. 

Dr. Baron describes the daily challenge of preserving long-term trusted relationships with patients while also attending to:

• Administrative forms
• Correspondence from health plans
• Reports on home care and physical therapy
• Telephone calls
• E-mails
• Prescription refills
• Laboratory reports
• Imaging reports
• Consultation reports
  

Efforts have been underway for the past few years to redesign the practice of primary care. In the meantime, medical school graduates are choosing other specialties which doesn't bode well for the future of family medicine.

Electronic Medical Records Both Help and Hinder Communication 

Another study based on in-depth interviews with clinicians in twenty-six physician practices found that, in general, EMRs made accessing and sharing information easier, facilitated education during visits and allowed for more "quality" time with patients. 

Some physicians expressed concern that using a computer during a visit distracted them from the patient. Others worried that the vast amount of available information might lead physicians to ask fewer open-ended questions—e.g., about the effect of an illness on the patient's life—or to listen less.

The takeaway message from these studies and a growing body of medical literature on the topic is encouraging—physicians want to spend more quality time with patients and are looking for ways to foster better communication.

What You Can Do

If you are dissatisfied with the length or quality of time your doctor spends with you, it might help to consider all the competing demands for his time...and plan accordingly.

The best way to get the time you need is to respect the doctor's time and that means preparing for the visit like you would for any professional meeting:

• Decide what is most important for you to discuss, make a list and show it to your doctor at the start of the appointment
• Have a current list of prescription and over-the-counter medications and dosages handy 
• If test results will be discussed, followup to make sure they have been received by your doctor before your visit
  
• Share information that may be useful for the doctor to know
  
• Express your feelings and beliefs about your illness
• Be informed and actively participate in decisions about your care
• Make sure you understand what's wrong, what you need to do and why...repeat the information back to the doctor before you leave the office
• If there is something you don't understand, ask the doctor to explain it again
• Bring a close relative or trusted friend for moral support and/or to take notes 
• If you feel you need more time, schedule another appointment

Give caring a try...and if you still have trouble connecting, it may be time to find a new doctor.


References

Baron RJ. What's Keeping Us So Busy in Primary Care? A Snapshot from One Practice. New England Journal of Medicine V362:1632-1636, April 29, 2010.  Accessed at http://content.nejm.org/cgi/content/full/362/17/1632

O'Malley AS, Cohen GR, Grossman JM. Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less? Center for Studying Health System Change No. 131, April 2010. Accessed at http://hschange.com/CONTENT/1125