Physician burnout: is there any one cause?

burnoutshotHealth care has received a rude wake-up call. With one of the highest rates of depression among professions – more than 45% across all specialties – physicians are burning out at a rapid rate. According to dermatology specialist and physician burnout coach Dr. Elizabeth Hughes, studies show that an average of 54% of physicians across all specialties have experienced burnout. As recently as 2005, it was 31%.

“Burnout,” says Hughes, “is the most significant challenge facing health care in the 21st century.” Left untreated, burnout can lead to dissatisfied and underserved patients. Worse, it can lead to medical errors, increased risk of litigation, patient mortality, and physician suicide.

“We are facing some powerful changes in medicine,” says internist and addiction specialist Dr. Michael Schiesser, “changes that are just bringing out the possibility of burnout that has been there all along.” Among the most obvious are the current administrative demands upon physicians alongside the downward pressure on compensation.

While surface causes of physician burnout are often readily seen, burnout remains difficult for physicians to admit. Theirs is an inherently and uniquely difficult work. Much scrutinized, they must treat illness and anxiety on a daily basis. It is a profession in which the stakes, and the level of expertise required to meet them, are high. Education and training is costly, hours long, and a personal life challenging to maintain.

To manage the demands of a medical career fosters the very individual traits that can lead to burnout: idealism, empathy, and a type-A personality. These traits very often form a kind of fire wall between the physician and his ability to recognize the signs of burnout and to seek the necessary help to prevent or treat it.

That reticence to be vulnerable and admit to ourselves that we are spiraling downward, says Hughes, leads to a deteriorating quality of life, including work overload, loss of control, lack of reward and community, feeling like a cog in the wheel, a diminished sense of personal accomplishment, and the sacrifice of family, hobbies, friendships, and other non-medical life goals.

Sadly, a habit of not having these life-invigorating resources to rely upon becomes ingrained and results in alienation from what was once a promising career choice. “Burnout leads to disengagement,” notes Hughes. “I see it as a real mismatch between the skills and expertise that physicians spent years honing and how they actually spend their time. This leads to frustration that physicians can’t do the jobs they’ve been trained to do.”

Though the cost for not doing so is great, physicians are notoriously hesitant to ask for help and sometimes with good cause. Burnout is often viewed as the physician’s fault, as if the reason a health care worker is burned out is because he or she is failing and not that the system is failing the physician. And physicians, as a group, can be their own worst critics.

“We want to see ourselves as always capable, not vulnerable, and that we don’t make mistakes” says Dr. Darcy Constans, a family physician at Seattle’s Polyclinic and a Leading WellTM team member at Physicians Insurance. “Because we are ultimately the ones responsible for everything, we must also be responsible for our own burnout.”

And yet, physicians experiencing burnout are not the most subjective observers of their medical issues. Says Dr. Mick Oreskovich, a Seattle psychiatrist and leading national researcher on burnout, “Those suffering from burnout or depression often have pretty delusional thinking. They are going to work thinking that they’re still doing a good job. They are often the last person in the room to know how depressed they are.”

Schiesser says that society nevertheless expects physicians to be flawless and on call to meet patient needs when, in fact, “physicians (also) have personal circumstances that need help and attention.”

Hughes calls for nothing less than a “culture of wellness” within the health care profession, because “when physicians aren’t well, the patients can’t be well either.” She quotes author Michael Scott, who said, “Put on your own oxygen mask before helping those around you.”

How ironic that the very traits that can make someone a quality doctor can also lead them to a predisposition for burnout. The key to helping patients be happy and healthy is to maintain the qualities that keep you connected to them and their care, while quite consciously fending off the pressures that prevent sharp focus and high touch healing from taking place.

Watch for Part 4 of our burnout series —  Physician burnout: solutions.

Meanwhile, read the rest of the burnout series:
– Part 1: Physician burnout: recognizing the signs
– Part 2: Physician burnout: impact on you, your team, and your patients

Physician burnout: impact on you, your team, and your patients

The Physician Burnout Series: Part 2 of 4

Stop burnout it before it stops youFive years into practicing family medicine, Dr. Marlene Costa (not her real name) had no control over the hours she worked or when she was on call. The organization that employed her increased its requirements for documentation, expecting her to write separate care plans for each chronic condition diagnosed. With some patients having three or four conditions, the paperwork became repetitive and overwhelming. Though Costa agreed it was important to have a plan of care, documentation was turning into a matter of checking the boxes. Not only was the process inefficient, it also frustrated her because her organization’s demands denied her the power to decide what was meaningful and effective in patient care.

A growing lack of control over her professional life and its encroachment on her personal life caused Costa to fall into the sinkhole of burnout.

“Medicine was my calling, my passion,” Costa said. “It was what I was meant to do—and it was killing me. I felt like everything I had spent my entire life working for was evaporating in front of me. I felt stuck. My work was making me so depressed and anxious that I wasn’t functional anymore, but I had no way out because I had hundreds of thousands of dollars in student loans to pay. When you look at the numbers out there of depression and suicide among physicians, having gone through that depression and the shame it brings, it doesn’t surprise me.”

For Costa, climbing out of the hole of burnout meant taking a year off and then reestablishing herself with a new group of physicians that values teamwork and allows her more autonomy. She is happy again in her profession, and thankful.

“I feel really lucky that I had the resources and wherewithal to take time away and figure it out—to change my situation. It would have been so easy for that to turn out differently,” she said.

The dehumanizing work environment Costa experienced is one of the primary causes of burnout, according to Dr. Charles Meredith, a board certified addiction and general psychiatry professional who was medical director of the Washington Physicians Health Program for a decade and recently went into private practice.

Correlations have been made between burnout and depression, substance abuse, emotional disengagement, and increased medical errors. Though errors may increase because of burnout, they may also be the cause of it to some degree. Errors that cause harm to a patient are devastating to the physician as well as the patient.

Albert Wu, MD, MPH, professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, has coined the term “second victim” to describe the effect of medical errors on physicians. In an interview for Patient Safety Network, he said, “Over the years, we gradually began to realize that most things are at least partly the responsibility of the system: things are built into the system that allow other things to go wrong. But even though individuals are often not responsible at all for things that go wrong, they still feel responsible.”1

Dr. Darcy Constans of Seattle’s Polyclinic agrees. According to the 36-year-old family physician, mistakes are not considered acceptable in the medical profession. “Physicians hold themselves to a ridiculously high standard—perfection.” Constans said. “Medicine is different than a lot of other careers. Take baseball for example: one home run out of 20 hits is doing really well. But if you’re a doctor, you feel you have to make 20 out of 20 or you’re really screwing up. When a physician makes a mistake, especially a big one, it’s devastating in a core way that may cause him or her to question whether or not he or she should be doing this.”

Experts agree that recovery from a medical error is dependent on the support a physician receives. The emotional aftermath is not something that can be swept under a rug.

“It’s different for each person in how it plays out, but physicians can have a deep sense of shame over any kind of mistake, as well as intense fear that they could do it again and hurt someone,” Constans said. “That isn’t something you can live with every day if you are practicing. You might be able to hang on for a couple months or even years, but not for an extended period of time. A lot of times people suffer significant depression and anxiety and then stop practicing, or leave clinical practice and find something else that doesn’t involve patients and feels safer.”

Of 10 colleagues who graduated from residency with Constans six years ago, two are not practicing any longer and many others have experienced severe sadness in their work, she said.

Dr. Ron Hofeldt, psychiatrist and Director of Physician Affairs for Physicians Insurance since 1994, has helped hundreds of physicians work through the ramifications of medical errors, both emotionally and in litigation. In recent years, he has partnered with Carolyn McManus, a teacher of Mindfulness-Based Stress Reduction at the Outpatient Rehabilitation Department at Swedish Medical Center in Seattle, to lead workshops on mindfulness meditation, a practice known to help doctors recover from and prevent burnout.

“Anecdotally, at the level of state and county medical societies and leadership, people are seeing a bit of a crisis in the medical field,” Hofeldt said. “Over the last five to eight years there are increasing rates of dissatisfaction among physicians in general, leading to attrition in the field. When I was in medical school, my professors would complain that they couldn’t get their children to go into medicine and it was the only field worth going into. Now I hear doctors say they would counsel children against going into medicine. They are looking for ways to get out of the profession.”

In response to the crisis of physician burnout, Physicians Insurance is multiplying the efforts of Hofeldt and McManus with a program called Leading WellTM, which consists of a team of 10 physicians who will offer consultation to organizations and groups in order to both lessen the burnout experienced by physicians and also enable those who are burned out to recover. Hofeldt is hopeful that the work of Leading Well and other groups will renew a passion for the field of medicine by giving current and future practitioners a new set of tools they can use to tackle the stresses of health care in the 21st century.

1 Robert Wachter, “In Conversation with…Albert Wu, MD, MPH,” PSNet, May 2011, accessed August 5, 2016, https://psnet.ahrq.gov/perspectives/perspective/101/in-conversation-with-albert-wu-md-mph.

Next: Watch for our upcoming blog article titled Physician Burnout: Is There Any One Cause? (Part 3 of a 4-part series on Physician Burnout)

Physician burnout: recognizing the signs

The Physician Burnout Series: Part 1 of 4

Recognizing burnout in yourself or others

Recognize the signs of burnout in yourself and others

Sarah: An oncology nurse for 30 years, Sarah has such great bedside manner she’s taught seminars on the subject. But following a recent annual review, statements like “lacking in compassion,” “not listening well,” and “staring blankly when confronted by grief” are bouncing around in her mind. She wanted to argue with her supervisor, to point out the commendations she has received in years past, but truthfully, she knows that the needs of her patients that used to arouse empathy in her now only seem to sap her energy. It’s enough for her to complete the physical work of nursing these days, and she wonders where her passion for people has gone.

Tom: Always the life of the party in medical school and residency, Tom could always be counted on to go clubbing and drink anyone under the table. Even now, after a decade in emergency medicine, colleagues who stopped partying hard to meet the demands of their profession notice that Tom’s energy seems to ramp up rather than diminish with age. Lately he’s not only been energetic, he’s also visibly agitated and unapproachable. Then, following a night shift, he drove his Porsche through a railing and off an embankment on his way home. When he was admitted to the ER, they found methamphetamine in his blood work.

Matt: Matt placed the central line during a code blue and did everything he could to save the 45-year-old man with a vfib cardiac arrest. When the patient died and everyone was clearing the room, it occurred to Matt that the guidewire was left in. He sat at his desk for the next half hour, not sure what to do or say. Did the guidewire have anything to do with the continued PEA arrest? How could he have missed it? How will he face his colleagues when they find out about it? What will he tell the family? Will there be a lawsuit? Is his home and children’s education fund at jeopardy? Head in his hands, Matt wondered for the thousandth time if he really should be practicing medicine.

Though Sarah, Tom and Matt are facing very different circumstances, they all have one thing in common—they are experiencing burnout. According to Dr. Mark Mariani, director of Multicare’s Physician Wellness Program, burnout is a syndrome of depersonalization, emotional exhaustion, and low personal accomplishment that leads to decreased effectiveness at work.

Though not a new phenomenon, the rates of burnout among physicians in the United States have risen dramatically. Ongoing research by Dr. Tait Shanafelt at Mayo Clinic shows the percentage of reported physician burnout in the United States has risen from 30% in 2011 to an alarming 54% in 2014. During the same time, burnout rates in other professional fields in the U.S. held steady in the high 20-percent range.

Specialties at highest risk for burnout include emergency, family and general internal medicine, but large increases were also seen between 2011 and 2014 in orthopedic surgeons, radiologists and rehabilitation.

The trend has many medical professionals understandably worried. In addition, the study shows that 39% of the doctors who took the survey screened positive for depression, the rate of suicidal ideation in the last 12 months jumped from 4 to 7.2%, self-medication and substance abuse is a problem, and burnout is causing many to consider early retirement or reduce their working hours.
“There are costs to the healthcare system as burnout directly affects quality of care, patient satisfaction, nurse turnover and financial performance of the healthcare system,” says Dr. Viral Shah. “There are also personal costs to the physicians that experience burnout—sleep problems, depression, anxiety, substance use, fatigue, and getting into conflicts at work and home.”

The Mayo Clinic will conduct another survey in 2017, but with more than half of the physicians in the United States reporting burnout, it’s past time to do something about this.

According to Dr. Shanafelt, five dimensions that contribute to burnout include excessive workload, inefficiencies in the practice environment, loss of flexibility and control for medical professionals, loss of meaning in work, and a loss of work/life balance (40% of physicians work more than 60 hours per week compared to 7 percent of the general public).

“This is a system-based problem,” says Dr. Shanafelt in a recent radio interview. “U.S. medicine is at a tipping point now, with over half of our physicians experiencing burnout. We need healthcare organizations to address this problem with strategies to focus on improving efficiency in practices … delegating clerical work to support staff, creating an environment that cultivates flexibility and control over work, a greater connection with colleagues, and where addressing the problem is the shared responsibility of both physicians and organizations.

“The current degree of burnout is alarming given the strong links between physician burnout and quality of care, as well as the connection between burnout and medical errors. Physicians who are burnt out are more likely to reduce their professional work effort or cut hours, which could compound the anticipated shortage of physicians in the U.S. during the next decade.”

For those experiencing burnout—a lack of self-efficacy, emotional exhaustion, and depersonalization—there is hope. Thought leaders such at Dr. Shanafelt are taking an academic approach to study the syndrome and come up with solutions; MultiCare’s Physician Wellness Program is in the process of developing an organized approach to addressing burnout; and Physicians Insurance has partnered with Leading Well and Vera University, a division of Vera Whole Health, to offer courses that teach physicians how to prevent and overcome burnout.

But first, the #1 need to be addressed, according to Dr. Mariani, is for physicians to recognize that they are experiencing burnout. They need to know there are solutions available, no matter how complex the situation may be.

“Like with anything cultural, it is not a quick answer or pill that will change this,” says Dr. Mariani. “It’s going to be a long road, but we need to start our journey now.”

 

Next: Watch for our upcoming blog article Burnout: Stop It before It Stops You (#2 in a 4-part series on burnout).

Tools for Increased Efficacy with Challenging Patients

Dr. Baruch Roter

My patient Michelle isn’t doing so well. Her A1C is stuck at 8 and her BP is too high. She takes her meds and comes in, but she drinks soda and doesn’t exercise or check her blood sugars. It’s pretty frustrating!

Studies show that many patients don’t follow the guidance of their physicians. This results in bad health outcomes as well as discouraged clinicians. What can be done?

The good news is that there are well-proven methods for working more successfully with these challenging patients. In this blog, I will introduce basic ideas and practices for building effective partnerships with our patients. Then I will share simple ways to use two behavior-change methods to empower your patients and help them make improvements in their health behaviors.

Our capacity to be present, compassionate, and nonreactive increases our effectiveness and also helps us manage our own stress when working with challenging patients. All this is supported by personal development work.

The first step in creating a truly effective relationship with our patients is to build rapport with them. The more our patients feel connected to us and trust us, the more power we have to influence their choices. Taking a moment to ask patients about nonmedical issues tells them that we care about them as a person, not just as an object of our medical attention. We can meet the patients’ need to be heard, as well as garner important information, by asking open-ended questions, giving them time to express themselves, and using reflective listening in which we offer the idea back to them to confirm that we have understood them correctly.

The better we understand their thoughts, feelings, and beliefs concerning their health, the better we can build consensus with them. If we present a plan as a done deal, we may not know that they actually don’t agree and that the plan seems to be in conflict with their desires or beliefs. Actively soliciting their feelings and input on a co-created plan greatly increases the chances of their following through with that plan.

So, once we build a strong therapeutic connection with Michelle, how do we get her to actually change her unhealthy behaviors? A core tenet of behavior change is that the more a person believes that he or she has the capacity to change, the more likely it is that he or she will be able to make that change. This is known as self-efficacy. The other basic notion is that behavior change is supported more by affirming patients than by talking about their unhealthy behaviors in a way that leaves them nihilistic and feeling bad about themselves.

Appreciative Inquiry (AI) is a method of behavior-change dialogue in which only positive statements are made. A simple way to use AI involves asking patients to talk about a time in their lives when they felt healthier—what did they do to be healthy, what motivated them, and what strengths of theirs does that illustrate? Then, ask them to describe their dreams for a healthy future. What would it look like, what would they be doing to be healthy, and how would they be supported in living healthy lives? In the last phase of AI, patients are reminded of the strengths and successes discovered in the discussion. We then help them figure out action steps they can take now. The big difference from the usual dialogue is that patients are discussing behavior changes in the context of an acute awareness of their strengths and their capacity to change, and that they have a clear vision of a healthy future to move toward with our encouragement.

Motivational Interviewing (MI) is another valuable and very easy-to-use method for behavior change. In MI, the patient’s motivation and confidence are enhanced. Let’s say the patient is supposed to stop drinking soda. The patient is asked, “How important is it to you to stop drinking soda? On a scale of one to ten, with one being not important at all and ten being the most important thing in your life, how important is it to you?” If the patient responds with a low number, the typical clinician response would be, “Why isn’t your number higher? Why aren’t you more motivated?” In MI, the patient is asked instead, “Why is your number that high? Why isn’t your number one or two?” The patient is prompted to make self-affirming statements, such as “I know it’s important for my health, and I really care about being healthy.”

The other question from MI that patients are often asked is, “How confident are you that you can stop drinking soda? On a scale of one to ten, with one being not confident at all, and ten being very confident, how confident are you?” Using a similar method to the one above, the patient is prompted to make self-affirming statements, such as, “I have been successful in the past in changing my diet.” These self-affirming statements build upon patients’ existing motivation and confidence and increase their self-efficacy.

We can learn to build mutually satisfying and highly effective partnerships with our patients. Using proven, simple, and efficient behavior-change methods, we can help our patients make critical lifestyle and health-behavior changes and very significantly improve their health. And that will increase our own self-efficacy, satisfaction, and happiness with our practice!

To see how I worked with Michelle and to learn much more about creating partnerships with patients and empowering them to change, please view the video webinar, Empowering Patients: Tools for Effective Partnership and Behavior Change.

Dr. Baruch Roter is a family physician with 25 years of experience teaching and working in community health centers. He teaches health-care workers about mindfulness, compassion, burnout prevention, happiness, patient-centered care, and behavior-change methods. He can be reached at Baruch@HeartfulHealer.com

Avoiding Errors with Better Inter-provider Communication

Dr on phone -low resYou might think that you’ve been doing a great job of communicating with other providers and specialists and you’re ready to close this page and read something else. But before you do that, consider this:

A study published in the Journal of the American Medical Association (JAMA) found that there’s a big discrepancy in reports of successful communication between primary care physicians and specialists. While 69.3% of primary care providers report that they “always” or “most of the time” pass along crucial patient information to specialists, only 34.8% of specialists say that they “always” or “most of the time” receive the information. Additionally, although 80.6% of specialists say that they “always” or “most of the time” send the results of a consult back to the primary care provider, only 62.6% of providers report receiving the results.1

Clearly, there’s a problem here.

Do you know how many other providers each of your patients currently sees? Are any of them specialists? More importantly, how many of them have you had the opportunity to speak with yourself? Do you ever feel your missing important information?

There’s a lot of discussion around care coordination, but unfortunately, in the fast-paced medical environment, care coordination tends to be one of the first things to fall through the cracks. On the surface, this seems understandable. You’re busy. Your colleagues are busy. You’d rather not disturb them if at all possible, and you’d prefer not to be disturbed yourself.

But what if another provider holds the key to improving your patient’s outcome? Without the information from the other provider, you might be trying to solve a jigsaw puzzle with several missing pieces. This doesn’t do your patients any favors, and it increases the likelihood of missing a crucial diagnosis, resulting in patient harm. Good communication with other providers also sends a clear signal to patients that you are invested in their health, which improves patient satisfaction. Studies have shown that satisfied, happy patients who feel that their provider cares are less likely to sue in the event that something does go wrong.

So, what can you do to improve inter-provider communication and patient outcomes?

1. Adopt appropriate health information technology (HIT). If you don’t have up-to-date HIT, you are missing out, and even worse, so are your patients. HIT makes it easy to update patient charts quickly as well as deliver reports and results and send messages to colleagues. If you already have HIT in place, take a look at it. If it’s an obscure brand, you may want to consider replacing it with a more commonly used program that will connect you with more specialists.

2. Standardize note formats. When you send written communication, are you using a standard format, or one of your own devising? Regardless of how simple you may consider your own format to be, if it isn’t in common use, it’s an error waiting to happen. Whether you’re based in an inpatient facility or in private practice, you will need to communicate with other medical professionals, and it’s essential that they understand what you are trying to tell them. HIT may resolve formatting issues, but if you are delivering an email or hard-copy orders, use a standard format with recognizable abbreviations (or, better yet, no abbreviations at all) and codes.

3. Create a care coordinator position. Your time is valuable – no question about that. When you find yourself constantly trying to coordinate communication with other specialists, it may be helpful to create a new position and hire a care coordination specialist to manage these details. The person in this position can keep close track of incoming and outgoing communication and keep you informed so you can tend to other duties.

However, take note of two key points here. First, people get sick, and vacations are necessary, so you need to have more than one person in this position. That way, balls don’t get dropped just because a person wasn’t able to come in to work one day. Second, this isn’t a “set it and forget it” type of scenario. Your patients don’t see what happens behind the scenes, and if a communication gets missed, they won’t want to hear that it’s the fault of the care coordinator. Occasional auditing to make sure that communication is happening smoothly will be necessary.

4. Pick up the telephone and call. How quickly should communication take place? If you need results from a specialist right away, it makes no sense to send an e-mail or other electronic note and then sit back and wait. You don’t know if the message was received or if it’s stuck in some kind of limbo.

Call.

Need a response right away?

Call.

Aren’t sure you understand what the specialist is saying?

Call.

Have further questions about the results?

Call.

In an urgent situation, a phone conversation or face-to-face meeting can save a life – or at least prevent serious injury. Yes, it takes more time, but the information you gather from an actual conversation with a colleague could save you a great deal of time further down the road, improve patient outcomes, and ultimately help prevent a costly error.

You can achieve better inter-provider communication by adopting appropriate HIT, creating a care coordination position, and using the phone to communicate with specialists. The improved communication you experience will benefit you and your patients in many ways.

__________________________________________________________

1 Ann S. O’Malley and James P. Reschovsky, “Referral and Consultation
Communication Between Primary Care and Specialist Physicians: Finding Common Ground”, Archives of Internal Medicine, January 1, 2011, Vol.171, No. 1 :56–65, doi:10.1001/archinternmed.2010.480.

Connecting with Elderly Patients

Patty could tell that something seemed different about Frank. As they walked their favorite trail around the lake, she noticed that her father was moving more slowly and he seemed to be running out of breath faster than she had remembered. The buttons on his shirt seemed to be slightly strained, as if he had gained weight in his stomach, and he complained about having eaten something that must have disagreed with him.

“Have you seen Dr. Jones recently?” she asked her father.

Her father scowled. “I had an appointment last week. But you know how it is with these young kids—in and out and here’s a bunch of pills. I’m just getting old.”

Patty frowned. “He prescribed medication? For what?”

“I don’t know,” Frank said, shrugging his shoulders. “He talks too fast. All those big words. They make no sense.” He spied a nearby bench. “Can we sit down for a bit? I’m so tired.”

Worried, Patty sat with her father and they watched the ducks without speaking.

A week later, Patty received a call from the hospital. Her father was in the emergency room and appeared to have had a heart attack.

As she drove to the hospital, thoughts swirled in her head. What had gone wrong? Did the doctor miss a diagnosis? Had her father misunderstood the doctor’s instructions?

Most importantly, what could have been done to change this?

*****

What comes to mind when you think of your elderly patients? You might imagine a fragile person with thin white hair who is hard of hearing. Perhaps their mind has begun to slip and their memory isn’t what it once was. Maybe they walk with a cane or a walker. You might think first of the health complaints that become more common as people age—congestive heart failure, osteoporosis, arthritis, and dementia.

Do you bring these images to work with you? You might be inadvertently stereotyping your patients, forcing them to fit a mold they don’t necessarily belong in. It’s crucial to remember that each patient—including each elderly patient—is different and has different goals, different health concerns, and different needs.

Research has shown that patients who feel like they have a relationship with their health care provider are less likely to bring a lawsuit if a mistake is made or things go wrong. In today’s health care model, patient satisfaction is absolutely crucial.

Building relationships with your patients—including your elderly patients—can be challenging, but the payoffs are immeasurable and include improved health outcomes and happier patients.

*****

It might be helpful to take a step back and consider what your older patients expect from their health care providers. Many of these patients grew up with family doctors who provided care for each member of the family and were an active part of the community. They took their time getting to know their patients and may have even made house calls.

Over the years, the medical model has changed considerably. Many providers feel forced into spending less and less time with their patients, and the provider-patient relationship sometimes gets pushed aside because of the limitations imposed by third-party billing and the need to see a large number of patients every day.

But now the pendulum has begun to swing back in the other direction. We’re recognizing (again) the value of provider-patient relationships and the importance of taking the time to connect with and understand your patient. For your older patients, it may feel like coming back full circle, and it’s important to honor that.

While every elderly person has different needs, there are some concerns that, statistically, are more frequent in the elderly. For instance:

  • Only 3% of adults ages 65 and over are considered proficient in health literacy, according to the National Assessment of Adult Literacy.  Research has also connected lower health literacy with poorer physical and mental health.
  • 12.7% of adults ages 60 or over report increased confusion or memory loss.
    Approximately half of all adults over the age of 65 report that they have been diagnosed with arthritis.
  • Nearly half of Americans aged 65 and over have at least one major eye impairment.  Visual impairment often leads to other concerns, including increased risk of fall and fracture, increased risk of depression, difficulty identifying medications, and difficulty participating in daily activities such as bathing and dressing.
  • More than 80% of those diagnosed with lung cancer are over the age of 60,  and COPD prevalence in those aged 65 and over is estimated to be 14.2%.

These concerns may require you to adapt your conversation style. For instance a patient with low health literacy will require explanation of health conditions and medications, along with explanations of why and how things happen. Jargon will confuse this patient, and some patients may not admit to their confusion. A patient with hearing loss may require you to speak louder and more slowly or to write down instructions clearly (or type if your handwriting is hard to decipher). Patients with confusion or memory loss will also benefit from written instructions, and it may be helpful to ask them to bring someone else along, an adult child for instance, who can answer your questions more fully and help them remember your instructions. A person with lung disease may speak quietly, be difficult to understand, or become exhausted from a lot of speaking. It’s important to be patient and allow them to tell their story on their terms.

*****

What other steps can your office take to connect with your elderly patients? You may find that these steps go over well with all your patients, not just the older ones!

1.    Train your team.
Before you even come into contact with each patient, they will have already met with several members of your team—your front desk, a medical assistant, and perhaps an RN. What impression is your team making? Are they being compassionate to the needs of your patient or are their own biases showing? Problems interacting with the team may cause the patient to be less, well, patient, and will feel misunderstood before you even begin speaking.

2.    Schedule extra time and avoid interruptions.
Your patient may need more time to tell their story or you might need more time for explanation and instruction. Either way, allow more time for the appointment and train your team not to interrupt you when you are with patients. This will help you communicate more effectively and build a patient-provider relationship.

3.    Use decision aids such as anatomy models, images, and written instructions.
Make your discussion as memorable as possible by using decision aids to help explain. A model of a mobile joint, an image of the circulatory system, and instructions that are printed in a larger size font will go a long way toward increasing patient understanding and improving compliance.

4.    Check your nonverbal communication.
Speaking is only one aspect of communication. What is your body saying to your patients? You might think you’re ready to listen to your patients’ concerns, but if you are looking at a computer screen, checking the clock on the wall, or sitting in a closed-off position, your patients may pick up on the fact that you are feeling impatient. They may feel like they are bothering you and will be less likely to share important information.

5.    Document your communication.
Make sure that your chart notes include the communication you had with your patient, everything from the patient’s health history to the instructions you gave and the medication you prescribed.

*****

Let’s go back to Patty and Frank. What happened at Frank’s appointment with Dr. Jones that could have been done differently?

Listen to what Frank had to say:

“You know how it is with these young kids—in and out and here’s a bunch of pills.”

It’s clear that Dr. Jones missed an opportunity. Frank did not feel valued or listened to. He felt rushed and didn’t feel comfortable expressing his discomfort. He was provided with a prescription for medications and he didn’t understand why he needed them.

“He talks too fast. All those big words. They make no sense.”

Dr. Jones likely hit Frank hard with a lot of jargon. Frank may also be having hearing difficulties, but Dr. Jones didn’t take a moment to find out. His rapid-fire speech delivery likely frustrated Frank.

Simply by slowing down the appointment, checking to see if Frank was understanding, and discussing the diagnosis and recommended medication, an unfortunate outcome might have been prevented.

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    Functional Health Status Among Older Adults.” Archives of Internal Medicine 165, no. 17 (2005): 1946-1952. doi: 10.1001/archinte.165.17.1946.
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    “Self-Reported Increased Confusion or Memory Loss and Associated Functional Difficulties among Adults Aged ≥60 Years—21 States, 2011.” Morbidity and Mortality Weekly Report 62, no. 16 (2013): 347-350. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6218a1.htm.
  4.   Barbour, Kamil E., Charles G. Helmick, Kristina A. Theis, Louise B. Murphy, Jennifer M. Hootman, et al. “Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation—United States, 2010 – 2013.” Morbidity and Mortality Weekly Report 62, no. 44 (2013): 869-873. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a1.htm?s_cid=mm6244a1_w.
  5.   Lee, Paul P., Zachary W. Feldman, Jan Ostermann, Derek S. Brown, and Frank A.
    Sloan. “Longitudinal Prevalence of Major Eye Diseases.” Archives of Opthalmology 121, no. 9 (2003): 1303-1310. doi: 10.1001/archopht.121.9.1303.
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    (eds). SEER Cancer Statistics Review, 1975 – 2011. National Cancer Institute: Bethesda, MD. Based on November 2013 SEER data submission, posted to the SEER website April 2014. Retrieved from http://seer.cancer.gov/archive/csr/1975_2011/.
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Communication Is Critical to Your Success: 5 Changes Your Organization Can Make Today

doctor explaining info to patientWhat key factors lead to improved clinical outcomes?

Skill and knowledge, of course, are obviously necessary. But communication is also vital and fundamental to developing good rapport and helping patients become engaged in their own health care. Experience has shown us that when patients are engaged, they are more likely to speak openly and honestly about their health issues, better understand their treatment options, and follow through with recommended care.

It is, perhaps, a no-brainer that improving clinical outcomes is a primary goal for all providers, and multiple studies have found that a positive patient experience is correlated with better outcomes. Ultimately, it comes down to patient experience of care.

Patients value quality service on a par with excellent clinical outcomes. This means that to achieve a quality patient experience of care, you need to successfully deliver both superior customer service and quality clinical care.

It’s also been demonstrated that physician compensation is increasingly connected to a patient’s experience of care. Both public and private payers are coming to understand that how a patient perceives their care is a direct indicator of quality.

Historically, providers have tended to focus on the quality of clinical care and left customer satisfaction initiatives to administration. But today, with the prospect of improved patient outcomes and significant financial incentives on the line, everyone in your organization should have the same goal of promoting and improving the quality of patient service.

So which changes can your organization make today that will mutually benefit both you and your patients?

  1. Minimize distractions and interruptions. Your time with the patient should be free of any unnecessary distractions. Allow patients to share their story regarding their health issues without interruption. Do not communicate to the patient that you are in a hurry even though you may be. Interrupting the patient to “get to the heart of the matter” is disconcerting and aggravating to the patient and does not promote rapport.
  2. Sit at the same level as the patient and maintain eye contact. Maintaining eye contact can be a challenge when using computer technology in the exam room to record the patient encounter. Devise strategies so that you can complete documentation but also give the patient uninterrupted time where you can maintain eye contact. This communicates to the patient that they have your undivided attention. Consider carefully the placement of technology in the exam room so you are not turning your back to the patient during the interview process.
  3. Listen actively and effectively. Concentrate on what the patient is telling you both verbally and nonverbally, noting both objective fact and emotion. When the patient has finished talking verbally, summarize the information they shared with you and ask the patient to confirm your understanding. Be aware of the nonverbal messages you are communicating to the patient. Avoid crossing your arms or appearing distracted with administrative duties. Leaning in, maintaining eye contact, and nodding at appropriate moments are all strong indicators that you are interested and receptive to what the patient is telling you.
  4. Keep it simple and assess the patient’s understanding. It is important to develop an understanding of the patient’s ability to process and understand the information that you provide. Your patients have varying degrees of education and healthy literacy, which may affect their ability to understand the information that you provide. In general, using lay terminology that is easily understood by the patient and their family will ensure that the important elements of medical care are understood. Certain patients may request additional or more detailed discussion to which you can then respond. Using the teach-back method requires the patient to repeat the information you have provided in their own words. This is a valuable tool to help you gauge the patient’s comprehension.
  5. Encourage questions. Encourage patients to ask any questions they may have about their medical concerns and the information you provided during the exam and interview. Patients are often intimidated and fearful about asking questions, thinking they may be asking a “stupid question.” Efforts to reduce the patient’s anxiety about asking questions are important. Let patients know that you have provided them “with a lot of medical information today and that this information can be confusing.” Then encourage your patient to ask anything they like regarding today’s exam.

Making a conscious decision to implement these techniques can yield significant improvement in your patients’ health care experiences. When you take the time to build rapport and engage the patient, you and your patient are likely to find a number of benefits, including compliance with recommended care and improved clinical outcomes, which in turn, lead to an enhanced overall patient experience of care.

Watch the Volume!

volume dialWho would you say has done the most in recent years to improve the atmosphere in operating rooms around the country?

Many of today’s surgeons would likely agree that the credit should go to Steve Jobs. As strange as this choice might sound, the introduction of the iPod simplified the life of the operating surgeon by eliminating the need to carry boom boxes, cassette tapes, and stacks of CDs. The “shuffle” feature also got rid of the endless media looping that caused many a surgeon to cry out mid-procedure, “Will someone please put on a new CD, already?!?”

While controversy does exist about the presence of music in the operating theater, it’s a safe bet that most surgeons who were trained in the years following the vinyl period would say that the right music is actually an integral part of the operative experience for the surgeon, the staff, and even the occasional patient who happens to be awake at the time. The music keeps the operative action rolling, provides a calming atmosphere (unless the surgeon happens to be a metal head), and helps reduce everyone’s stress levels.

The key, however, is to respect the fact that too much noise in the OR can be a source of distraction, missed orders, confused messages, and increased risk for the patient. While we could debate whether the specific type of music is to blame, when it comes down to it, choosing the music is the surgeon’s prerogative. The volume, however, needs to be adjusted for the setting, and rave-like volumes are never a good choice.

When bad things happen in the operative theater and folks—including plaintiff attorneys—are looking for the root cause, you can bet that anyone in the OR is fair game for an interview or deposition. We all have our habits, but if yours is to blare music at a volume that causes your staff to label you as a “blaster,” this information is likely to come out in the after-action review following an incident of patient harm. You, as the surgeon, will be directly in the cross hairs.

Imagine trying to explain to a jury why you do not believe your loud music contributed to the adverse outcome when your staff have been heard to remark, “It’s so loud in that room that I can’t hear what’s going on.” You (or your insurance company representative) will likely be pulling out the checkbook on that one.

If you are in the (likely) majority who relish the idea of a full day of surgery with just the right playlist, be aware that you are not just the leader of the band—you’re also the captain of the ship. Keep the environment safe for your patient, and don’t give the plaintiff attorneys the opportunity to drop the hammer. Feel free to enjoy your music, but play your selections at a volume that complements your skills and doesn’t detract from your efforts to get the optimal outcome for your patients.

Finally, as a bit of a postscript, it is also a good idea to edit your playlist to avoid embarrassment or offense. The Ramones’ “I Wanna Be Sedated” and Pink Floyd’s “Comfortably Numb” are great (if somewhat tongue-in-cheek) selections when a deep sleep is called for. But “The Smell of Death” by Lynyrd Skynyrd and “Don’t Fear the Reaper” by Blue Öyster Cult are probably not the tunes that your patient wants to hear when arising from the fog of a good general anesthetic.

Improving telephone communication with patients

Physician on telephone with patientTelephone communications with physicians, pharmacists, medical staff, and patients can result in miscommunication and lead to treatment and prescription errors. Anna Reisman, MD, and Karen Brown, MD, point out in their Journal of General Internal Medicine article that telephone communication may be error-prone because of technical issues and an absence of visual cues.

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How coaching a patient can improve care

In my years of seeing patients, I know that sometimes they can still surprise me. I can see that they want to quit smoking, or they want to lose weight—sometimes with a feeling of desperation—but they feel powerless to achieve their goals. As their physician, I want to see them get healthy so that they can prevent infections, diabetes, and all the other effects that are so difficult for patients to manage. For each patient, how can I find the key that will unlock the solution to their good health?

Case study:

A patient in her mid-20s was generally healthy, very bright, and thinking about applying to law school. However, for reasons she didn’t understand, she had developed a crippling fear of speaking in front of people. During presentations in front of her colleagues, she was frozen when she stood to talk and she thought, “It’s because I had surgery on my face, and everyone sees me as disfigured. They don’t even hear what I’m saying.” The trauma escalated, and she felt frozen when she even thought about speaking in public. Suddenly she worried that perhaps more was going on. Maybe the surgery had caused a neurological impairment? Maybe she’d developed a tumor?

Her doctor listened and said, “First, let’s do a workup to see if there’s anything neurologically wrong.” He performed an exam and determined that there was no problem. Then he used the technique of appreciative inquiry, which focuses on the patient’s positive experiences. “Tell me about a time in the past,” the doctor said, “in which you spoke in front of people and felt good about it.” After a pause she revealed that she had been able to speak successfully in front of people in high school and college. In fact, she had been valedictorian in high school and had graduated from a rigorous college program magna cum laude. During their conversation, she admitted that her friends and family didn’t seem bothered by her facial scars.

The physician said, “You’re intelligent, and I know you can overcome this fear. I would like you to look inside yourself and start focusing on your many strengths. What do you think about doing that?” Then together they decided that she would work with a wellness coach to help her find specific ways to focus on her strengths and overcome her fears.

The coach—who was trained to relate to patients using empathy, appreciative inquiry, motivational interviewing, and more—quickly developed a trusting relationship with the patient to learn about her struggles and her hopes for her life. With the coach’s encouragement, the patient developed goals and decided how to approach new opportunities to speak in front of a group. With small steps, the patient made progress and developed a newfound confidence whenever she had a presentation.

A few months later, she visited the physician for a follow-up appointment. Her demeanor and confidence were so changed that the physician remarked, “You’re a new person!” because the difference was so profound. As they talked, she revealed that after focusing on her strengths and trying new approaches to public speaking, she developed the courage to give a huge presentation at work and was extremely well received. Then she said, “My facial scars? I think I was using them as an excuse to explain why I wasn’t speaking as well as I wanted. People don’t really care about that at all.”

Lessons learned

What does this illustrate? To me, it shows that it’s our job as physicians to find out what will work for each patient.

Before I related to my patients in this way, I was frustrated with those who just wouldn’t follow through to get better. I thought, “Well, they’re just not responsible people. There’s nothing I can do about that.” I didn’t realize that my patients were failing themselves because I hadn’t taken the time to make that caring connection with them.

Once I am able to tap into a patient’s emotional life, I can help the patient discover the barriers that prevent him or her from quitting smoking, losing weight, taking medication properly, or exercising. And once we see the problem clearly, we can work on overcoming the barriers together. Working with a trained coach helps my patients work through the nitty-gritty of the tasks. And when my patients come back to see me, I cheer their progress and use my technique of appreciative inquiry to keep them on the road to good health.

To learn more about physician coaching and earn CME, attend a weekend workshop in Seattle for the Coach Approach: Transforming Health Care through Patient Engagement. Training takes place September 8-10 and November 6-8.