Archive for September, 2012

Empathy in Health Care

Daniel H. Pink proposed a simple test of empathy in business whereby the subject is asked to write the letter “E” on their forehead.  If they write the letter so others can read it then they are empathetic.  Clearly not a scientific test although there are other tests developed by psychologists which do measure how empathetic a person might be.  Empathy is an attribute we all want in our health care provider and some have more of it than others.

The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy.    Stefano Del Canale, MD, PhD, et al.  Acad Med. 2012 Sep;87(9):1243-1249.

The above article suggests a link between empathy and better results for patients.  Recently the Wall Street Journal published a list of things to be considered when choosing a primary care provider (below).  The first on the list is about empathy:

  1. Does the physician make you feel comfortable and listen to your concerns and opinions.
  2. Does the office seem to function smoothly?  How easy is it to get an appointment or get care outside regular office hours?
  3. Does the practice track your care and alert you to gaps?
  4. Do specialists’ results automatically get sent back to your doctor and discussed with you?
  5. Does the practice accept your insurance, or charge your directly?  Will it help you keep costs down when possible?

When you are looking for a health care provider finding one who will take new patients is hard enough.   Trying to pick one who is empathetic from the phone book is just not reasonable.  In fact, there are lots of traits one would like to have in a provider like timeliness, honesty, communication skills, medical knowledge, and surgical skill just to name a few.   A good recommendation from a friend is worth a lot.  Be careful when picking a highly charismatic provider since charisma  is not the same as empathy or skill.

Health care providers self-select a specialty to some degree based on personality.  Family doctors and nurses tend to have good interpersonal skills.  Nurse practitioners often are very empathetic people.   Pathologists and radiologists don’t have much (live) patient contact for a reason.  Some surgeons (who work while your are asleep) don’t always have high empathy scores — but in that circumstance surgical skill really is what you want.

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Getting Satisfaction

OK, patients are not satisfied with many provider visits.    Some people just avoid health care or just complain about it.  Consider that mummies have been found who had serious health problems during life.  Is that what we want, a postmortem in a thousand years? — “yep, he didn’t get good care”.

It is  not the patient’s job to make health care give satisfaction, but that may be what is necessary while we wait for system changes.   And yet, many patients currently walk away from a provider visit, the hospital or outpatient surgery feeling satisfied with the care and satisfied their questions were answered.  How did they do it?  What did they say?  Were they just lucky to have the “right” provider?   Getting satisfaction currently involves being proactive, doing your homework and speaking up.  Those who do are getting some degree of satisfaction.

First, understand the cycle each health care provider works in.

The “agenda” for the visit is made in step #1.   Make a list of 3 things you want to get accomplished during the visit and keep the list in hand.   Be assertive with the list right after the greeting “Just so I don’t forget I made a list of things I need today: 1)____ 2) ____ 3) ____”.  For example, this might be “review my stomach pains,  would a specialist help, get prescription refills”.  ABSOLUTELY do not wait until step #5 with these questions.  Make sure all items were answered by step #3 — if not, look at the list and repeat the items not addressed.

Make step #2 easy.  Have an up to date history in hand including past illness, past surgery, current medications and allergies.

Make step #3 understandable.  Before the visit research the symptom or known diagnosis on the Internet (like http://www.mayoclinic.com).  So when the situation is discussed you have some basis for questions, and ASK THEM.

Make step #4 interactive.  As each action is listed if you don’t know what it is (like CBC or CT scan) then  speak up “what is that and what will it tell us”.   If a procedure or surgery is suggested make sure to understand the top 2 risks and what the provider and you can do to reduce the risk.  And, what are the alternatives — understand the alternative of not doing the surgery or procedure.  Understand how you will get test results (make it clear you want the result as soon as  available whether  “normal” or not).

An informed and engaged patient will ask the above questions.  Many patients ask such questions.  Don’t be demanding, just persistent.  Give the provider a chance to do the right thing since most really want to please patients.  And, give the provider a second chance.  If there is a problem with the plan or medications discovered later, call the provider’s office for clarification.  But, repeated failure to respond to these simple questions means it is time to find another provider.

Sometimes people just can’t think clearly knowing a shot, pelvic exam, or prostate check are going to be done.  Thinking during a health care visit is essential.  So, if there are bothersome aspects to a certain visit ask to have those things done at a separate visit (yes it is more trouble for you but at least you can discuss problems intelligently).

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Dartmouth Atlas — Over-Treatment Revealed

Graph from The Dartmouth Atlas of Health Care 2003 – 2007
Percent of cancer patients receiving chemotherapy during the last 2 weeks of life.

The Dartmouth Atlas is a great quality tool for US health care.  The idea of small area analysis dates back about 20 years when researchers noticed a considerable geographic variation in care.   Now it has become an accepted technique to show how different regions adopt different practice patterns.   The patterns are almost always disturbing since they mean US health care is not consistent thus not reliable.  When such a map reflects billing for unnecessary care it is even more disturbing.  Such is the case in the map above:  some oncologists stop giving expensive chemotherapy when the situation is hopeless whereas other oncologists give chemotherapy until the patient is dead.   If the oncologists did not derive financial benefit from chemotherapy one might be able to believe they were just giving a heroic effort in the face of death.  But, given the financial incentive another interpretation would be prescribing something of no medical value for profit.   It seems unlikely market forces would change this practice except to make it more widespread.

Performance status is a measure of how the patient is doing generally.  If the patient is bedridden the performance status is very poor.  In that very poor condition no chemotherapy helps, and in fact may hasten death.  So, from a quality assurance standpoint close attention is needed to make sure oncologists are documenting performance status and acting accordingly.

The current thinking is when the performance status is bad it is time to stop chemotherapy and talk about hospice.

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IOM Report — What Is Missing

The IOM is a government organization that studies medical care and issues reports.  The reports are scholarly and well regarded.  Below is an excerpt from a recent 380 page report.



*Best Care at Lower Cost: The Path to Continuously Learning
Health Care in AmericaReleased:September 6, 2012America’s health care system has become far too complex and costly to continue business as usual. Pervasive inefficiencies, an inability to manage a rapidly deepening clinical knowledge base, and a reward system poorly focused on key patient needs, all hinder improvements in the safety and quality of care and threaten the nation’s economic stability and global competitiveness. Achieving higher quality care at lower cost will require fundamental commitments to the incentives, culture, and leadership that foster continuous “learning”, as the lessons from research and each care experience are systematically captured, assessed, and translated into reliable care.

The full report is available online and worth reading.

What is the bottom line?

There are numerous areas where US health care wastes money and delivers poor care.  The wasted money is estimated at over $750 billion dollars each year.  The IOM opines an environment where everybody has the attitude of  gladly improving health care so each problem could be addressed and by an evolutionary process the US would end up with a great health care system.

Frankly, it ignores working  health care systems in other countries and fails to outline a structure for management of US health care.   All great quality improvement ideas fail without a structure .   From a political standpoint the question will be “what am I buying”?   The answer “the cost will evolve” is just not adequate.

So, in the absence of structural suggestions here is a place to start:

This system replaces all existing government health care agencies with an insurance system covering “basic care benefits”.  All private insurance would offer the basic care benefit with insurance add-on products as desired.

Top level:  Administrator
Department:  United States Health Care (USHC)
Funded by:  Congress (has a budget each year)
Subdivisions:

  • Office of budget compliance with regional offices (comptroller)
  • State divisions of quality improvement
  • National drug and equipment evaluation and approval (formulary)
  • Office of hospital, specialist, device and prosthetic payments
  • Office of primary care and drug payments
  • National patient registry
  • Office of basic care benefits
  • Office of national health records (System wide EMR)
  • Office of health research integration
  • Office of manpower training (free training in exchange for service)

Now we are getting somewhere.  An administrative structure and a payment structure.  There is huge efficiency by consolidating current US agencies like Medicare, Medicaid, Veterans Health System, Indian Health Service and all others.  Private insurance is encouraged for those items not covered by basic care benefits (e.g. heart transplants, cosmetic surgery, fertility services, extremely expensive chemotherapy etc).

You may say the forgoing is just not possible for the US.  But, consider the idea as restructuring,  a management technique used by large companies all the time.  The IOM says change is needed but we need that change NOW — we need to think like a large company and get the job done.

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