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Comments from the scientific community regarding Medical Care.

Thursday, February 12, 2015

Patients stand up and speak up!
by Sosena Kebede, MD, MPH
A NY times Op-ed published on 1/5/15 under the title of “Doctor, shut up and listen,” discussed one of the most serious and pervasive problems in healthcare—doctors who don’t listen to their patients. The solution proposed by the author, Nirmal Joshi, was to train physicians in communication skills. Although necessary, this proposed change alone will likely not be sufficient to bring about better communication because of the following factors: time, presence, rewards, and patient satisfaction.
Time: On average a physician spends about 15 minutes per patient in the outpatient setting and less than that in the in-patient setting. There is no empirical evidence about the optimal length of time required for physicians and their patients to develop effective therapeutic relationships. Yet, most physicians fully recognize that for a significant number of their patients who have several health concerns, health literacy problems, or language barriers, 15 minutes is barely enough time to adequately diagnose a patient, much less develop a therapeutic relationship.
Presence: Popular doctor-themed TV shows paint a romanticized picture of a busy, multi-tasking doctor. In truth there is nothing romantic about that reality. Multi-tasking during patient care (even simple interruption by a page or a phone call) can reduce the quality of care we give or may even be dangerous. A Time-in-motion study by Tipping and colleagues, which was done at a tertiary care center in 2010, found that even though hospitalists spent only 17% of their total time in direct patient care, several additional activities generally occurred simultaneously during patient care. Physicians whose mental bandwidth is occupied by multiple items cannot possibly be fully present with their patients even for those short 10-15 minutes of face-time.
Rewards: The fee-for-service payment model is not the only reward system that perpetuates this problem. Even among salaried physicians who are paid a flat fee regardless of how many patients they see per day, rewards are set up to promote detailed and expeditious documentation, efficient discharges, and reduced length of stay, among other things. Even salaried physicians are not rewarded for spending time with patients or for the quality of their interactions. This is especially true for procedure-based specialties where the physician-patient “interaction” may essentially be limited to time the patient is under sedation.
Satisfaction: Despite complaints from patients and doctors about short visits, patients often report high levels of satisfaction with the care they receive. A recent study we did at the Johns Hopkins Hospital found that even though patients’ understanding of aspects of their hospital care was suboptimal, their level of satisfaction with the care they received was fairly high (Kebede et al., JAMA-IM August 2014). Effective communication has been documented to improve satisfaction. Our study showed that despite the suggestion that communication is out poor, our patients were satisfied. This raises the question, are patients letting their docs off easy with less than optimal communication? Or are they satisfied with the manner in which the communication was delivered even if it did not result in improving their essential knowledge base of their care? Or are patients satisfied merely when their outcomes are improved regardless of the quality of the process? More studies will be needed to answer these questions.
The Robert Wood Johnson Foundation has recently launched an endeavor to promote A Culture of Health in America.  This endeavor acknowledges that as a society we need to create a demand for a culture of health to take root in our day-to-day life. The culture surrounding patient-physician interaction should be part of this culture. Patients should stand up and demand that physicians’ time and rewards be fully aligned with creating a meaningful and effective therapeutic relationship that has been shown to improve health outcomes.
Sosena Kebede is a medical doctor and public health practitioner with 15 years of combined experience, in patient centered clinical care, quality improvement research projects and in providing technical guidance and consultation to global health programs, and health systems strengthening endeavors. Her current primary appointment is at the Johns Hopkins University School of Medicine, but she also holds joint faculty appointments at the Johns Hopkins Bloomberg School of Public Health in the departments of Health Policy and Management as well as in the department of International Health. She is a faculty member and a consultant for the Armstrong Institute for Patient Safety and Quality.