One of the biggest complaints I continue to hear from patients and clients is the issue of lack of communication with their healthcare provider, most notably physicians and mid-level providers. Communication issues seem to be related to a few categories including: inattention to the patient (various reasons), lack of empathy and/or big picture of the patient, lack of time, unacceptance of alternative health approaches by the patient, and generational views of the healthcare provider by the patient.
When discussing issues of inattentive providers with patients and clients, I often take the time to look at both sides of the coin. As a patient, when my provider is stuck talking to the computer screen instead of me, I get very irritated. As a provider, having worked in a CMS/Insurance industry, I often get overwhelmed with the amount of documentation specifics required both by the agency that employs me and the insurance company that reimburses my fees. Some inattention of the providers is due to the everchanging (and often temperamental) electronic record system demands a great deal of time both inside the office visit and outside. Providers are often forced to do repetitive, time-consuming clicks and data entry in order to move forward in an electronic chart. The electronic record system often crashes or has technical issues adding to the time and focus away from the patient. And, admittedly, inattention by a provider can also be related to those days when some type of drama fills the work or home environments. Just like all employees, drama/stress at home or the work place can put providers into an auto-pilot mode where we go through the motions to simply get through the day.
Other issues revolve around the patient’s perception of a provider’s lack of empathy or inability to see the big picture of the patient. Examples that I have heard include a provider’s inability to be more “human” to the news of some type of loss to the patient. Sometimes when the loss of a loved one happens, the patient may be presenting with a physical complaint, but what they really need is to tell the story of the loss and to be allowed to grieve. I have yet to see this accomplished in less than 15minutes. Failing to see or look for the bigger picture often comes from being symptom focused. For example, when discussing vaginal dryness from menopause, providers may fail to look into the sexual health and wellness of the patient and her partner. So maybe she is having painful sex due to vaginal dryness, but the relationship overall is unsatisfactory to her and she may be struggling with self-esteem and hormonal changes. The answer isn’t only adding lubrication or estrogen cream, but also engaging in a dialogue about sex and the health of the relationship. Unfortunately, for a busy provider, this is often deemed non-essential communication and takes away from the next patient.
If I had a penny for every time I hear about provider-patient time issues, I’d be very comfortable in my life… This is a wide-ranging complaint from not being able to get in to see a provider for months, to going to an appointment and waiting 1+ hour(s) to see the provider, to the provider was in the room for less than 5 minutes, or the provider had their own agenda and never provided time for questions about a new treatment. As a patient, I have had all of this occur, and quite frankly, its caused me to change providers. As a provider and having been so behind that all I can do is basics in a visit has caused me so much distress that I quit that type of practice. One of the greatest gifts I can provide is the ability to have conversations with patients and give them the time needed to feel heard.
Between 1997 and 2005, “results of previous studies suggest that it would take at least 7.4 to 10.6 hours per workday to deliver recommended care to a typical panel of primary care patient (Chen, L.M., Farwell, W.R., and Jha, A.K., 2009). In a 2012 study found in the Annuals of Family Medicine, the average patient panel that most primary care physicians had was 2,300 patients. The study further goes on to indicate that in order to do all the necessary work (i.e., preventative care and screenings, addressing acute issues, chronic disease management) for this size of patient panel, one provider would need to spend approximately 21 hours/day to get all the aspects covered completely (Altschuler, Margolius, Bodenheimer, and Grumbach, 2012). Then you factor in a schedule that is supposed to be 15min office visits, with an average length of time spent in the visit by the provider in 2011 was 13-16 minutes (Brodwin, and Radovanovic, 2016).
The average time spent on face-to-face office visits has decreased since them. Remember, providers are paid by insurance/Medicare for every patient they see according to why they see the patient, and what procedures they perform for the patient, and (this is key) not by the amount of time they spend with the patient. So. while you may only see the provider for 8 minutes, they will bill the insurance for 15min or more depending upon the complexity of your health. Additionally, while four patients per hour sounds very reasonable, the current reality in a primary care office is more like 6-8 patients per hour with double or triple booking for the same 15min time slot. Often times, I would hear my medical assistant trying to spur me on to keep up with a hectic schedule by telling me, “Mr. Jones is a ‘SIMPLE’ medication refill visit.” The reality is there is no such thing as a simple fast visit. In a time with not enough providers and many patients who only go into the healthcare provider’s office once every few years, the easy medication refill visit becomes more involved due to questions, emergence of issues during the visit, or education/discussion with the patient.
“In the context of a medical consultation, people feel uniquely vulnerable. Asserting their views might require disagreeing. Patients [often] fear [disagreement] will lead to negative consequences that might impact their care in the future” (Weir, 2012). Recently, a new patient was establishing care with me. Her explanation for the change was her previous provider “fired” her from their practice because she admitted to seeing an acupuncturist and taking Oriental herbs. I was flabbergasted to think that a peer could actually be that closed-minded, until I heard from another patient from a different provider doing something similar. The research is out and available that Complementary and Alternative Medicine (CAM) and health practices are valid and useful. My argument is 3000+ years of Asian medicine can’t be wrong or there would not be a whole continent of people still living. As a provider, a patient that actively engages in their health and wellness and obtains some relief in addition to what I provide is the best kind of patient. Remember, it is ok to disagree with the healthcare provider and to have a discussion about why there is disagreement. You, the patient, are the head of the treatment team and plan. If you don’t agree or buy into the plan, then you won’t be compliant and see relief/results.
Finally, I have it very interesting to see how different generations perceive their healthcare provider. The elderly, into most of the baby boomer generation, view their healthcare provider with an amount of reverence and obedience. I often hear statements such as, “Doctor knows best!” “I didn’t question him/her, I just took my prescription and filled it.” “I don’t want them to be angry with me!” As we move to the younger boomers and into those in their 40-60’s, there is more questioning of the healthcare provider’s decision and recommendations. The Internet has allowed us to begin self-diagnosing, and the TV tells us what medicine to ask/demand from our providers. As the age groups get younger, communication itself is different with the help of the electronic health records and patient portals. I now do a lot of communication via email, text, and phone call (more so with the 30-50 year olds). The younger generations seem more prone to provider shop and use drop-in clinics for basics instead of establishing with a provider long-term. The healthcare provider is becoming more of a fast-health restaurant then the “GOD-like” deity in the span of 50 or so years.
The purpose of this article is to aide in breaking the communication barriers. Below is a listing of recommendations to help. “Communication can falter for a variety of reasons. Patients who are ill (or afraid they might be ill) may suffer from heightened anxiety, which chips away at their self-confidence. Language barriers can drive a wedge between patients and their doctors. Less obvious structural barriers may also impede the conversation. For instance, when patients belong to a health-care system in which they see a different provider every time, they may never develop a comfortable rapport with a single physician” (Weir, 2012).
In an article in Mental Health Fitness (n.d.), there are 13 tips for talking with a physician about depression. However, this information is valid for any kind of issue.
Tip #1: Recognize that, although you may feel uncomfortable, you are sharing a legitimate medical concern in order to get the help you need.
Tip #2: Choose which physician to confide in. Whether it is your primary care provider, OB/GYN, or other specialist. Make sure you have a provider that you feel comfortable to discuss tough subjects.
Tip #3: Set goals for the conversation. “Before the discussion, think about the outcome you’re seeking. Remember that diagnosing and treating [issues can take] time and expertise, so if your goal is to make your symptoms disappear immediately, you’re likely to be disappointed. Instead, set a few reasonable goals for the conversation, such as a) putting your concerns on the table and b) working with your doctor to determine a plan to address those concerns.”
Tip #4: Do a little homework. I find WebMD or other medical sites often leads patients to a live or death conclusion of their symptoms. If you have a chronic illness, become educated about it. This will aide the conversation to move at your pace and will allow you to ask treatment questions with a baseline of knowledge behind them. You may even have a new piece of information the provider doesn’t!
Tip #5: Don’t expect the doctor to read your mind. If you have a concern about a symptom or illness, ask! If you don’t tell me you are experiencing panic attacks waiting on biopsy results, I can’t address the cause of the panic or help ease the symptoms.
Tip #6: Make it a top priority, not an afterthought. “In a busy medical practice, your time with the doctor is limited. Many patients see their PCP for a brief visit once a year or less. The temptation is to stuff a number of issues into one meeting…. Consider preparing a brief list”… Often times a list allows providers to paint a bigger picture or fill in questions about an illness without us asking. And it may help us prioritize the visit.
Tip #7: State your concerns as plainly as you can… “The more direct and specific you can be, the easier it will be for your doctor to respond effectively.” I recently had a patient tell me about concerns she had with a heart medication side effect prescribed by her cardiologist. After some digging, I discovered she had yet to plainly address her concerns with the provider. This is where it is necessary to have open communication with providers. I could have simply made some medication changes to appease her, but I would have been interfering in the treatment plan made by the cardiologist. Instead I redirected her to her cardiologist and provided additional resources she could utilize.
Tip #8: Understand that there are a number of diagnoses to consider. “Once you’ve shared your concerns, realize that your doctor has the important and challenging job of arriving at a diagnosis.” What may initially sound like depression may in fact be the result of other causes such as a vitamin deficiency.
Tip #9: Manage your expectations. “What do you expect will result from your discussion? Do you expect to leave with a prescription to fill? A referral to a specialist?” Understand that a list of 20 issues/symptoms may need to be broken into 2+ visits to address.
Tip #10: Take ownership of the follow-up. This is about doing your part as the patient. If you’ve been asked to change or modify lifestyle habits or start a new medication, then your job is to follow through. If you don’t give your best efforts in compliance of what you and your provider have agreed upon, then you own some responsibility if the treatment fails.
Tip #11: Make sure your providers are communicating with each other. This is a huge issue in the medical field. This issue is not only because of the logistics in getting information to other providers, but ensuring the other provider actually reads the information. If you find your providers are not communicating, you may have to be the runner of documents between offices to ensure a pending appointment includes all the necessary information. Assuming that information has been shared with a primary care provider is just that… an assumption. Rarely do other providers notify the PCP’s of changes in status or treatment. “Just as you may need to take the lead in coordinating your follow-up, you may need to take steps to keep everyone participating in your care connected. It is common for the PCP to prescribe medications while therapy is provided by a psychologist, social worker or other specialist. To help facilitate communication between your providers, first make sure that you have signed a release form (sometimes called a HIPAA form because it is the product of the Health Insurance Portability and Accountability Act of 1996) so that your physician and therapist can exchange information while protecting your privacy. It is also helpful to have your therapist[/provider] share his/her diagnostic assessment along with notes about the objectives of your [treatment with other members of your healthcare team]”.
Tip #12: Be a persistent advocate for yourself. You are your best advocate!
Tip #13: Be patient. Finding the right solution can take time.
“Regardless of where you receive care, be patient with yourself and with your care providers. Each case is unique, and it takes time to arrive at an effective individualized treatment plan. Finding the right approach to managing your symptoms may mean trying more than one medication or combination of medications as well as counseling and a mix of self-care strategies. Once you’ve begun the dialog, continue to speak up about what’s working and what isn’t. Remember: it’s a team effort, and you are the most important member of the team.”
Tip #14: If you need more time to discuss a sensitive issue, make sure you arrange for extra time when you make the appointment. Providers often understand increased time blocks for a patient visit indicates the need for more interaction and dialogue regarding some issue.
Ultimately, at SNVHS, I strive to ensure my patients and clients are heard, feel unrushed, and given my undivided attention. Should this be something that is missing from your healthcare, give me a call!
Altschuler, J., Margolius, D. Bodenheimer, T., and Grumbach, K. (2012, Sept/Oct). Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation. Annuals of Family Medicine @ http://www.annfammed.org/content/10/5/396.full
Brodwin, E. and Radovanovic, D. (2016, Apr. 6). Here’s how many minutes the average doctor actually spends with each patient. Business Insider @ https://www.businessinsider.com/how-long-is-average-doctors-visit-2016-4
Chen, L.M., Farwell, W.R., and Jha, A.K. (2009, Nov.). Primary Care Visit Duration and Quality. Does Good Care Take Longer? JAMA Internal Network. Arch Intern Med. 2009;169(20):1866-1872. doi:10.1001/archinternmed.2009.341
Mental Health Fitness. (n.d.). Bringing it up: 13 tips for talking with your physician about depression @ http://mentalhealth.fitness/bringing-it-up-13-tips-for-talking-with-your-physician-about-depression/
Weir, K. (2012, Nov.). Improving Patient-Physician Communication. American Psychology Association @ http://www.apa.org/monitor/2012/11/patient-physician.aspx