Thursday, December 21, 2006

clinical innovations, patient relationships at point of care, Twenty Clinical Innovations to Build Patient-Doctor Trust, Eighth in a Series:

Building Trust in Patient-Doctor Relations at the Point of Care, Eighth in a Series

From my perspective as a doctor,“innovation” is about seizing opportunities to do things better, differently, more cost-effectively, and more conveniently for patients. It is also about doctors controlling their own destiny from the “bottom-up,” from the point at which care is delivered rather than waiting for the government or other powerful health care payers to act. It is about doctors controlling their own destiny, rather than having others control that destiny.

My book Innovation-Driven Health Care contains this quote, with which I agree, from Donald Copeland, MD, a family physician in Cornelius, North Carolina:

“When I read about new types of innovative practices they all write about
same day access, better communication with patients, computerized medical
records, "medical homes," "team practices," use of non-physicians for routine care, but none write about the need to strengthen the doctor-patient relationship.

There is no other profession as personal as the medical profession. If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them. they will lose their patients and will be nothing more than over-educated hired technicians.”

There are many organizations dedicated to bringing innovation to the frontlines of care. Among these are:

•The Institute of Healthcare Improvement in Cambridge, Massachusetts. The Institute’s conferences and training sessions include web-based training to reduce waiting times, increase practice efficiency, implement quality improvement, assure reliable services, reduce hazards of prescribing, dispensing, and administering drugs; and creating “innovation communities” to reduce hospital mortality, improve flow through acute care units, emergency rooms, and perinatal units, and reduce surgical complications and hospital infections.

•The International Council for Quality Care in Boca Rotan, Florida. The Council works with hospitals with acquired physician practices. Its mission is to improve effectiveness, efficiency, and quality of these practices. The Council says it has a 30 year old database that allows it to identify 300 variables of practice success. It has benchmarked the ingredients of competitive superior practices and helps physicians introduce systems, subsystems, and processes to raise clinical quality, gain patient trust, and enjoy balanced personal lifestyles.

•The American Academy of Family Physicians in Kansas City, and the American College of Physicians in Philadelphia. These two organizations, representing family physicians and internists, which comprise most of the primary care physicians in America, advocate primary care practices as patient-centered "medical homes.” These homes should be based on patients’ continuous relationships with personal physicians to make care more effective, more efficient, and more equitable. The Academy and the College do not believe this can be done through physicians’ efforts alone. Improved care will require government to pay for more coordinated care, offer incentives to acquire electronic and personal health record systems, and reward physicians by paying for performance. Medicare recently made a step towards rewards primary care physicians by increasing whatit will pay physiciansin 2007 for counseling patients on preventive care.

The following text is from the American Academy of Family Practice’s 2006 web site. It is entitled “Tips on Building Doctor/Patient Relations,” and gives solid advice on the human dimensions of practice.

Demonstrate to your patients that you understand their situations and feelings by showing empathy during patient interviews. Empathetic communication is one of your most valued modalities and goes along way to ensure a trusting relationship between you and your patients. The following steps will strengthen your patient communication skills:

1. Seek to minimize distractions and interruptions when visiting with your patients. For example, try putting your beeper on a silent mode during your visit. Close a door if outside noise is a distraction. (However, ask your patient’s permission first.) Remember, too, that patients can offer you a great deal of insight into their condition just from what they tell you. So limit the number of times you ask questions or otherwise interrupt when your patients are presenting their chief complaints

2. Engage in active listening. Concentrate on what the patient is communicating verbally and nonverbally. Take into account both facts and emotions.

3. Be deliberate about the nonverbal cues you send. Lean forward, maintain eye contact, nod appropriately and don’t cross your arms.

4. Offer concrete feedback. When you summarize what you’ve heard, frame your responses by saying, and “Let me see if I have this right…” Seek to identify or clarify the patient’s feelings by saying “Tell me how you’re feeling about this” or “I have the sense that…”

5. Allow the patient to correct or add to your responses until he or she confirms your understanding – “Did I miss anything?” According to several sources, the effective use of empathy promotes diagnostic accuracy, therapeutic adherence and patient satisfaction.

• Enhance your counseling and listening skills by using a simple five-step process. Gather information about the context of the patient’s visit by asking: 1) what is going on in your life? 2) How do you feel about that (or how does it affect you)? 3) What about the situation troubles you most? And 4) how are you handling that? Then show understanding and empathy by observing: 5) “That must be very difficult for you.” This technique is identified by the acronym BATHE (which stands for background, affect, trouble, handling and empathy).

• Remember to ask about any alternative treatments that the patient may be using. More and more patients are turning to complementary and alternative medicine (CAM) providers for help with their symptoms. Knowing this information will help you make an accurate assessment and develop a treatment plan for the patient. Do you need more information about this growing trend? Some schools include information about CAM in their curriculums, but many do not. The National Center for Complementary and Alternative Medicine, part of the National Institute of Health, has a Web site at that includes fact sheets, consensus reports, complementary and alternative medicine databases and more.

• Talk with your patients about lifestyle issues. Many students and physicians alike are hesitant to bring up unhealthy behaviors with their patients. Remember these tips to guide you in this process:

1. Expect resistance to change. Solicit feedback from your patients on their thoughts about changing their behavior and use these conversations to gauge how important changing is to them. (Understand and appreciate the fact that many people derive pleasure from unhealthy habits, such as smoking.)

2. Avoid merely listing the negative effects of your patients’ actions; instead highlight the positive effects a new lifestyle could bring.

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