Diane talks with James Hohmann, national political correspondent for the Washington Post and author of the "Daily 202" newsletter.
Guest Host: Indira Lakshmanan
Communication between a doctor and patient is ripe for misunderstanding – time constraints, medical jargon, and emotion are all in the mix. Some surveys say a majority of patients misunderstand their directions after a visit to the doctor, or even leave the hospital without knowing their diagnosis. But today, healthcare providers are giving patients new ways of reaching doctors for questions or concerns – including email, texting, and even video chatting. Some say this is the inevitable future of medicine, and will improve the patient experience. But many urge caution, pointing to drawbacks for physicians and patients both. A conversation about how our digital world is changing doctor-patient relationships.
- Dr. Robert Wachter Professor and interim chairman, Department of Medicine at the University of California, San Francisco; author of "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age"
- Dr. Kavita Patel Fellow, Brookings Institution Center for Health Policy; primary care physician at Johns Hopkins Medicine; founder, Tuple Health, which works to improve communication with patients
- Cindy Brach Senior health researcher, Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services; leads AHRQ’s health literacy activities; member of the Institute of Medicine’s Roundtable on Health Literacy
- Dr. Saul J. Weiner Professor of medicine, pediatrics, and medical education at the University of Illinois at Chicago; co-author of the new book "Listening for What Matters: Avoiding Contextual Errors in Health Care"; deputy director of VA Center of Innovation for Complex Chronic Healthcare
AHRQ Health Literacy Universal Precautions Toolkit
How To Fight Burnout In Medicine
On Tuesday, Feb. 9, our panel discussed how technology is changing doctor-patient communication. Many of you asked in your calls, emails, tweets, and Facebook messages whether more digital communication with our healthcare providers could worsen doctor burnout. While we touched on this during the show, one of our guests, Dr. Saul J.
Practical Tips For Better Communication With Your Doctor
Our show on Tuesday, Feb. 9 highlighted technology's potential to improve how you communicate with your doctor - but it can be difficult to know how to approach your doctor or how to navigate the issues that come with this sort of communication, such as knowing when it is appropriate to email and protecting your privacy.
MS. INDIRA LAKSHMANANThanks for joining us. I'm Indira Lakshmanan sitting in for Diane Rehm. She's on a book tour. If you had a question after your last doctor's visit, chances are you phoned the office, waited on hold for a long time and eventually left a message that may or may not have earned you a callback. Or perhaps you used an online patient portal to securely email your healthcare provider. Some doctors allow patients to email or text with them directly and there's even the option now to communicate with a medical professional via video chat without ever leaving your home for an appointment.
MS. INDIRA LAKSHMANANBut in giving patients all kinds of new access to doctors, are we actually making their experience better? Here in the studio to talk with me about improving doctor/patient communication in the digital age, Dr. Saul J. Weiner of the University of Illinois at Chicago, Dr. Kavita Patel of the Brookings Institution, Cindy Brach of the Agency For Healthcare Research and Quality and joining us from a studio at WKQED, Dr. Robert Wachter of the University of California, San Francisco.
MS. INDIRA LAKSHMANANIf you would like to join our conversation, you can call us at 1-800-433-8850. You can also send us an email to email@example.com. You can join us on Facebook or you can send us a tweet. Welcome to all of you.
DR. KAVITA PATELOh, thanks for having us.
MS. CINDY BRACHThank you.
DR. SAUL J. WEINERThank you.
DR. ROBERT WACHTERThank you.
LAKSHMANANSo Dr. Saul Weiner, I want to start with you. Before we even get to the digital side of things, what do we know about how doctor/patient communication functions today and where does it break down?
WEINERI find it helpful to begin by thinking about what the goal of healthcare communication is. And I think it's really that the care plan will work for the patient. And I think that when we take that very broad view, we're in the best position not to miss any of the key elements of communication. Oftentimes, I think physicians tend to have a rather lens and sometimes patients do, too. They think in a sort of transactional way.
WEINERYou know, I need to figure out what your diagnosis is and then I need to prescribe a treatment and then I need to make sure you get that treatment and that's kind of a very narrow way of looking at things. But I think, in reality, if we're gonna have a conversation about communication, we have to recognize that people have complex lives and that in that communication process that occurs between the doctor and that patient, there has to be enough bandwidth to encompass not just what's your diagnosis and what pills do I prescribe.
WEINERIf the person has asthma, for instance, it may be that their asthma's getting worse because they can't afford their medication. It could be that they lack the cognitive skills or the education to follow their treatment plan. And so really, the idea here is to make sure that when we have this conversation about communication that we keep it broad enough so that we're encompassing all of those elements.
LAKSHMANANAll right. Dr. Wachter, what do you see as the main problems in doctor/patient communication?
WACHTERWell, it often is challenging in a 12-minute office visit to go through all of the things that Saul just went through. And I completely agree that because of the length of visits, if we consider the time that the doctor and the patient have with each other to be the time that the two are together physically, it tends to become very transactional. It tends to be, you know, just the facts, ma'am, a few quick questions, trying to make a diagnosis, trying to figure out what pills to prescribe and then you're onto the next thing.
WACHTERAnd patients lives are much more complex so this movement to create ubiquitous connectivity and do allow patients to manage themselves or have tools that help them manage their problems in the context of their real life rather than all being stuffed into at 12 or 15 minute visit, to me, that trend is very healthy, although it creates a number of new challenges that we have not yet overcome.
LAKSHMANANWell, you refer to the 12 to 15 minute visit and I think you're referring to how health insurance providers are sort of forcing doctors to see more and more patients and for billing purposes and that really cramps up a doctor's time, makes it hard to, you know, take the time that may be necessary to figure out what's wrong with this person, if it isn't immediately apparent.
WACHTERYeah. I mean, I think it's easy sometimes to pile on to the insurers. There's a fact of economic life that people are only willing to pay either via insurance or via their own -- money out of their own pockets for so much time with a doctor. Doctor's time tends to be fairly expensive. And so we've seen the emergence of concierge practices, for example, where some people are willing to fork up a few thousand dollars out of their own pocket.
WACHTERAnd really what they buy is more time with the doctor. But whether it's the insurance company, it's the intermediary or the patient or the employer providing the money, there's this tension where in order to really go through all the things that you would want to go through between a patient and a doctor, if you're going to limit the interaction simply to the time that we're spending together in an office, it's not going to be very long, even if the insurers were out of the mix.
WACHTERMaybe it's 15 minutes, maybe it's 20 minutes. And so we have to figure out a way of creating a new relationship so that it's not so fast and not so transactional and that really is where this new era of connectivity and digital tools comes in. And that's why it's very exciting, although it's also very fraught, because we haven't figured out a whole lot of the consequences. They require us to completely rethink the nature of the doctor/patient relationship.
LAKSHMANANAll right. Well, we're talking about connectivity and new tools. And Cindy Brach, I'm struck about how a rising number of doctors seem to have computers in their offices. I have a doctor who consults test results and types notes while talking to me in real time, looking at the screen instead of at me. So, you know, it raises the question for me, what about lack of eye contact. You have a computer, that's great, but it is impairing communication?
BRACHWell, you raise an important point that we've found in focus groups of patients of doctors who are trying to be more patient centered and bringing an electronic health records into their offices, that they are spending a lot of time focusing on entering the data into the record. But I think that we're really missing an opportunity to use that screen as an educational tool. You know, pictures are very powerful and I'll give you an example from a woman in Iowa who is an adult learner.
BRACHHer name's Norma Canoyer (sp?) and I did an oral history interview with her a number of years ago and she described how, because she doesn't read, after a colonoscopy, she didn't read the instructions and she went around lifting heavy things and had a great deal of pain afterwards. So when her doctor said, well, I'm afraid we've had a lot of stuff and you're gonna need another one of these pretty soon, she said no way am I going to do that.
BRACHBut then, he took out a piece of paper and a pen and he drew a picture of the colon and what they found and was able to explain how these things were growing inside her and could become cancer and she really got it through that visual. So if we had screens where the patients could see the screen, too -- and my bathroom remodeler does that. She has a screen that faces her, a screen that faces me and we face each other so we can have the eye contact and yet, she can show me a picture of what my vanity's going to be looking like. We can do that in the doctor's office, too.
LAKSHMANANAll right. Although, I suppose what your colon is going to look like is a bit more important than what your bathroom is going to look like. But Dr. Kavita Patel, I mean, you know, we're brought forward with this issue about visual learning and how either a screen or even a simple notebook and piece of paper can help people understand better what's going on with their bodies, what they need to do. How do you actively address misunderstandings with your patients and how do you even know if there's a misunderstanding?
LAKSHMANANSomeone may walk out of your office thinking they got exactly what you said, but, in fact, they didn't.
PATELRight. So I really do think it takes a village to try to put healthcare together because even in the seven to twelve minutes that I have, if you do -- and I know Saul has done this -- if you observe and kind of watch interactions between doctors and patients, it's usually mostly the doctor's doing the talking so there tends to be very little listening going on. We know this from just watching, you know, thousands of interviews with patients.
PATELSo I actually have -- we've carefully tried to kind of make sure that everyone from the front desk staff -- who can sometimes be the most important person in the interaction because they see people when they're coming in and then they also see them when they're leaving. And then, I would also tell you that I try to always end each one of my new patient visits when they're coming to see me for the first time, I do give them my cell phone and my email.
PATELAnd we have a very robust patient portal. I warn them that my cell phone and my personal email are not HIPAA secured and so we talk about what that means.
LAKSHMANANHIPAA meaning the...
PATELPrivacy protection. It's the patient privacy law that we have in the United States to protect patient communications and data and a number of other aspects of healthcare and personal health information. But I warn them and I say, but here is my number and my email so when you need something or you remember something because you didn't even have a chance to ask me because we only had about 10 minutes, then you should. And what's really revealing is that in primary care settings, often the most robust conversations happen outside of that clinical visit because the third person in my room is the computer.
PATELThe fourth person in my room is the clock and those things are competing against the patient many times.
LAKSHMANANCindy, you wanted to jump in quickly.
BRACHYeah. Well, you were asking about how do you know if they're understanding, which is a really key issue because doctors traditionally overestimate what their patients understand in writing or in verbal communication and so in AHRQ's Health Literacy Universal Precaution's toolkit, one of the tools that we try and give providers to address these issues is something called the Teach Back tool, which I know Kavita's very familiar with, where you actually ask the patient to explain in their own words what they understood.
BRACHAnd this is often an a-ha moment for doctors because they sort of are assuming that what they're saying is going in and they find out, actually, that they have not been as clear as they needed to be and then they try another way to get their point across.
LAKSHMANANAll right. We're gonna take a short break. When we come back, more about doctor and patient communication in the digital era, what we can do to make it better. We'll also be taking your calls, your comments and your emails. Stay with us.
LAKSHMANANWelcome back. I'm Indira Lakshmanan sitting in for Diane Rehm. And this hour we're discussing doctor-patient communication in the digital age with Dr. Saul Weiner, a professor of medicine at the University of Illinois at Chicago, co-author of the new book, "Listening for What Matters: Avoiding Contextual Errors in Health Care," and deputy director of the VA Center for Innovation for Complex Chronic Healthcare. Also Dr. Kavita Patel, a fellow at the Brookings Institution Center for Health Policy, a primary care physician at Johns Hopkins and the founder of Tuple Health, which works to improve communication with patients.
LAKSHMANANAlso Cindy Brach, senior health researcher at the Agency for Healthcare Research and Quality, which is part of the U.S. Department of Health and Human Services. And from San Francisco, Dr. Robert Wachter, professor and interim chairman of the Department of Medicine at the University of California, San Francisco and author of the recent book, "The Digital Doctor: Hope, Hype and Harm in the Dawn of Medicine's Computer Age." So, Dr. Patel, before the break we were talking about moves towards emailing and texting patients. You said that you, yourself do it. I wonder whether your colleagues also do this, other doctors you know, and what do you see as the pros and cons?
PATELSo it's a great question, Indira. And many of my colleagues do not do it. And, in fact, institutionally speaking, many institutions discourage this because they really would like to encourage more patients to use our online patient portal, which I also endorse because there are a lot of great, valuable reasons to do that. But many of my colleagues still would like to have a little bit of a privacy wall. I've been practicing for 15 years and I've never had a patient abuse my personal cell phone. And when they use it, it's for valid reasons. And I'll say that, for purposes of communication, email is just very ubiquitous. So when people can straightforward email, they somehow feel like it's a better approach for them.
PATELAnd then I also have a mix. I went and just for the purposes of the show, looked at my own patient panel and it really does break down into about a third, third and third. I have a third who just communicate with me via the personal email, a third who use a patient portal and a third who still prefer to pick up the phone, call the front desk and leave a phone message, which as you already said may or may not get to me.
PATELSo that's definitely true.
LAKSHMANANWell, Saul Weiner, I want to ask you about this. Because, you know, do -- you're at the VA system, so I wonder if you're even legally allowed to email or text with your patients, since it's a government agency. I have to say, I spent half of yesterday emailing back and forth with my child's pediatrician about dosage and refill and how much should it be and how much should he be taking and this, that and the other. And if I had had to rely on a patient portal, I think I would have been very frustrated. It was much easier to just sent an email directly.
WEINERYeah. Actually, believe it or not, the VA has done a great job in this area. I am a primary care physician also in the VA. And the VA has set up a portal called My Healthy Vet. And that's for communicating with your doctor. I routinely get emails from my patients. And I'm actually required to reply to them very quickly. And if I don't, that will cut in to my pay. I'm held accountable for it and monitored and on a regular basis I'm given printouts on how I'm doing in terms of response time.
WEINERIn addition, we have something called message manager where we communicate with our healthcare team. Remember, communication has to go in both directions. You need communication between doctor and patient and also within the healthcare team, nurse, clerk physician, pharmacist, social worker. And, again, I'm actually monitored on my response time. I have to get back to those in 24 to 48 hours or I do get dinged. So, yes, absolutely.
WEINERAnd I would completely agree with Kavita, I think it's terrific. It's very useful, particularly for transactional things. I think it's important to understand the limits of it. So last week a gentleman asked me for -- and he needed a new cane, he'd lost it on the bus coming to his appointment. The brace on his right ankle had given out. He needed me to send him back to prosthetics. That's the kind of thing this transaction is excellent for. I think where it falls short is -- the mistake is to think it's the be-all and end-all of everything. A lot of good healthcare and getting healthcare right requires understanding a lot of contextual issues with patients. And that's the sort of thing that doesn't get sorted out very easily electronically.
LAKSHMANANDr. Wachter, could you help us out with some of the drawbacks of email and other forms of digital communication? I mean, we already have trouble understanding our doctors when we see them in person, as you told us at the beginning. So how does the digital wall make that even more complicated?
WACHTERI think the most important drawback is that we are burning out physicians very badly. And there is no one who would argue that what you've heard from Kavita and Saul isn't wonderful and inspiring and I think most patients would want to have that kind of access to their doctor, to be able to -- excuse me -- to be able to send an email or have a video chat. That's wonderful. But I think for all of us, we all engage in part-time practice because I think we're all in academic settings and we do a variety of roles.
WACHTERI worry very much about the plight of the full-time, primary care doctor who has 2,000 patients in his or her panel. So do the math. Think about every one of those 2,000 patients believing and wanting access to their doctor 24 hours a day. Sending an email when they don't understand a symptom or don't understand what are their medicines. In many ways, we want that to happen. But a recent study from the Mayo Clinic showed that the rate of burnout among American physicians has now topped 50 percent. It's gone up more than 9 percent in the last four years.
WACHTERAnd I think it represents a crisis in American medicine, particularly in primary care, where we've turned on these electronic pipes and yet not done really very much thinking about who -- where is the time, where is the bandwidth, who should be doing all of this? And when I talk to my own primary care doctors at my institution, they tell me now that they're taking eight or nine hours a day seeing patients in their office and they come home and they have three hours of digital work to do. Because every time their patient both has a message or sees another specialist or has a laboratory test done, it ends up in their inbox and they need to clear it.
WACHTERSo we have to completely rethink the nature of the work and who's doing what and what things does a physician actually have to do and what things could another member of the healthcare team do? We've not done that kind of rethinking yet. And so all of it is a straight shot to the physician's email inbox and it is driving them crazy.
LAKSHMANANA huge task. I wonder if doctors can have people designated in their offices who just deal with their email, who are also somehow medically trained, physician's assistants? Cindy Brach.
BRACHWell, we are moving much more to team care. But I actually wanted to sort of sound an alarm from the patient side, because Bob was talking kind of from the physician perspective. And we need to remember that not everybody has very good computer skills, is very comfortable. And the healthcare system has basically done a pretty -- has a pretty poor track record of communicating in writing.
BRACHWe have hundreds of articles documenting that our patient education information, our health insurance information, our informed consent forms are all at a level much higher than Americans can really understand them. And that's because the average reading level is about 8th or 9th grade. And people forget that average means that half of people will struggle with the information written at the 8th or 9th grade level. So, now, you take it to an email communication, where a physician who's used to using some jargon is, you know, trying to be quick, send something off, you know, may use terminology that patients are not going to understand.
BRACHAnd there's the idea, well, you know, they'll have the time to look it up. But we also are very prone to -- especially if we're anxious about something -- make a mistake as we're trying to look for information. And I'll give you a personal example, where I was told by my doctor's office that I had an abnormal Pap exam. And that meant that the screen for cervical cancer came back and they told me I had something called a non squeamish epithelial lesion.
BRACHNow, I'm not a clinician. I don't understand those terms. We're talking about cancer. Lesion sounds pretty bad. They tell me to go to a specialist to have it looked at. Buy I get on, you know, the Internet and I try looking it up myself. You know, do I have cancer? Am I, you know, 50 percent chance of getting cancer? And in my agitation, I think that I've found an article that says I have like a 20 percent chance of having cervical cancer.
BRACHNow, in fact, what it said was I had an increased risk of an already very small risk. So I got myself very worked up. And I think that when you have, as Saul said, you know, there are some things that the electronic communication is very good for and some things that it's not good for.
LAKSHMANANI think you make an excellent point and that is about our ability as patients to understand information that is given to us. And in this digital age, we all go straight to WebMD to, you know, my friends joke, it's Dr. Google. You know, you have any kind of symptom, you go to Dr. Google and try to figure out what it is. And I'm thinking of my own experience. I have a child who had a very rare form of cancer. And I did all sorts of research online and ended up successfully consulting with doctors across the country and around the world. But I'm a journalist. I do research for a living.
LAKSHMANANAnd I thought, how would ordinary people be able to figure out these kinds of symptoms, do, you know, read medical journals and figure out what they need to know to track down some doctor in France or in China? Dr. Patel.
PATELAbsolutely. And just to build on all -- on your point and Cindy and Bob's point, if you're the patient or a family member who's just trying to find out more information, and then you naturally want to reach back out to your doctor -- even if it's a doctor like one of us that's open to all these different vehicles of communication -- there's just very natural limits into what we can do even by email, phone or in person.
PATELAnd so I often feel that in this doctor-patient communication, it's very clear that we have to go beyond these borders in order to be healthy. We can't rely on just, even though we're talking about the digital aspects of communication, the limits are absolutely palpable. And many times, the most honest answer I can give patients is, I have no idea but I'll try to find something out for you. And I think that that's a reference to your ability to do all that research and time is something most Americans -- most people can't do. But most doctors don't have that either.
PATELI mean, we have something in medicine called a curbside consult, which I practice in a community practice. I can't get to specialists and other people as easily as I used to. But that's exactly the kind of environment that you're talking about.
LAKSHMANANI'm Indira Lakshmanan and you're listening to "The Diane Rehm Show." Dr. Saul Weiner, talk to us a little bit more about this, the sort of doctor-patient knowledge-ignorance gap that is baked into any interaction we have, digital or not.
WEINERYeah, I think that's an important way to frame it. I think that we -- I was involved for many years in working with a team of actors as undercover patients. And we trained actors to go into practices -- we call them unannounced, standardized patients. Some people think of them as sort of mystery shoppers. But they would present with a script. And they would say something like, you know, my asthma's been worse, doctor. And they would mention during the visit, boy, it's been tough since I've lost my job. And they would do the same thing, over and over again, with many, many different doctors. And it was a way for us to compare how doctors think when presented with the same person.
WEINERAnd one of the things we found was that some doctors would pick up on a clue, like, you know, boy, it's been tough since I've lost my job, and say, wow, well tell me about that, and find out that the person was unable to afford their medicine, that they were on a very fancy trade-name drug, that they could be switched to a much cheaper generic and that that would solve their symptoms. And other doctors would just say, you know, it's -- I'm sorry, it's a tough economy. Do you have any allergies? And it just kind of just train, you just steamroll right through. And...
LAKSHMANANSo missing important clues.
WEINERAbsolutely. Absolutely. And what we found -- and, interestingly, the length of those visits was on average exactly the same. Because one of the reasons doctors often say they can't attend to this context is because they don't have time. And time is definitely an issue. But we also realized it has something to do with how doctors think. And the -- and what type of information they think is important. You know, if you're confused about your diagnosis, there might be a clue that you're confused. You might say something. You might allude to something. Does the physician pick up on that? Do they pursue it? And we found that some do it better than others.
BRACHAnd, you know, it's not any surprise because we generally don't train physicians to be good communicators. That is not the reason why they're selected to go into medical school. And it's only recently that the medical licensing exam has included any assessment of communication. So we're starting to think about it. But for all the physicians who are currently in practice, you know, those health systems have to support those physicians and have to help them acquire those skills.
LAKSHMANANWell, Dr. Wachter, you're currently the chairman of a department. You're involved in educating young, to-be medical doctors. Tell us how much of a role does communication -- we hear about bedside manner, that's an ancient concept -- but how much are your students assessed on the basis of how they communicate and listen and understand and talk back to patients. And, again, once they are doctors, how much are they evaluated on that as they go along?
WACHTERNot enough. And I think we're trying to build in more video and more creative uses of technology to observe people and give them the feedback that they need. But I can tell you that the young physicians today are very concerned about the scenario that you painted earlier. That, you know, the doctor is sitting down with his or head in the laptop, not paying attention to the patient. They want to connect with patients. They want to have these conversations. And they come into it truly wanting to do that. They choose to go into careers in medicine in part because they want to connect with people.
WACHTERAnd then, in some ways, we beat it out of them. In some ways, it's the time pressure, it's the documentation pressure. One of the things we didn't recognize about the computerization of healthcare was that the computer becomes an enormous enabler of documentation. Outside parties, whether it's insurance companies or the government or quality measures or you name them, basically say, oh, now the doctor is on the computer. We can ask the doctor to document that she did counsel the patient about smoking, or you name it. And they say, we'll just add in one more or two more check boxes the doctor has to check in order to make sure that they're practicing high-quality care.
WACHTERThat sounds good in a vacuum. But at the end of the day, what you've created is an environment in where -- in which the doctor is spending an enormous amount of their own both time and cognitive bandwidth just making sure the computer is happy. And I had an editorial in The New York Times a week or two ago where I said, we're hitting the targets but missing the points.
LAKSHMANANHmm. So it...
WACHTERThat the doctors are so focused on just getting sure -- making the documentation look right, that they're not longer paying sufficient attention to the patient.
LAKSHMANANSo putting a new burden on the doctor that may actually be interfering with patient care and patient communication. Cindy, quickly, before our break.
BRACHYeah. I just also want to point out that there are 25 million U.S. residents who do not speak English well. And so when we talk about being able to avail yourself of all these great new ways of communicating, that we have to remember that we don't want to increase disparities. And so we have to make sure that those channels are open and that we teach those clinicians how to work with interpreters, how to communicate with all their patients.
LAKSHMANANHmm. It's an interesting point. And we actually have a listener, Connie from Dearborn, Mich., who makes the point in the opposite direction, saying that in her area, in Metro Detroit, a lot of the doctors are foreign born. And she feels a language barrier when communicating with them. She can't always understand the accents of her doctors. And she feels like written communication could be easier in that regard.
LAKSHMANANI also want to read this great comment from our Website from a doctor who says, I have found that texting is a valuable tool when afterhours concerns suddenly arise. When a parent pages me with a concern, I will ask them to take a picture and text it to me -- it works well for rashes and lacerations -- or to record a 10-second video of their child and text it. Recently, I found that reporting blood sugars via text is an efficient way to help a child with diabetes who ate too much candy on Christmas. In my experience, 95 percent of the time we are able to avoid an expensive and unnecessary middle-of-the-night visit to the emergency room by responding to a simple text and attachment.
LAKSHMANANInteresting point. We will discuss it more when we come back. We will take your calls and your questions. Stay with us.
LAKSHMANANWelcome back. I'm Indira Lakshmanan, sitting in for Diane Rehm. This hour, we're discussing doctor-patient communication in the digital age with Dr. Saul Weiner, an internist and pediatrician at the University of Illinois at Chicago, co-author of the new book "Listening for What Matters: Avoiding Contextual Errors in Health Care" and deputy director of Veterans Administration Center of Innovation for Complex Chronic Healthcare, Dr. Kavita Patel, a fellow at the Brookings Institution and a primary care physician at Johns Hopkins, Cindy Brach, senior health researcher at the Agency for Healthcare Research and Quality, an arm of the U.S. Department of Health and Human Services, and Dr. Robert Wachter, professor at the Department of Medicine at the University of California, San Francisco and author of the new book "The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age."
LAKSHMANANSo I wanted to share with you another email that we got from Nancy in Altamonte Springs, Florida, who says, please explain why so frequently a staff member in the doctor's office does not ever get back to a patient either by phone or email with the results of an outside test, such as an X-ray, MRI, et cetera, unless there's a serious problem. With so many of us monitoring our own health, we want to know the areas where we can -- that we can eliminate from our concern. Cindy?
BRACHYeah, it's actually a pretty chronic problem, and AHRQ actually developed a toolkit for clinicians on how to establish work processes to make sure that they get those test results back, and they get that information back to the patient because unless it's sort of cooked in, built into how the office normally operates, it's easy for it to fall between the cracks.
LAKSHMANANDr. Wachter, did you want to say something about that?
WACHTERYeah, I think we've problem -- we've passed the age of waiting to hear from the doctor's office about your lab tests and assume everything's okay unless you hear from that. There have been many, many cases of mistakes that happen, the patient didn't hear, and it turned out things were not okay. In most advanced health systems today, including my own, patients have compete access to their laboratory results, to their X-ray results, and there are now about 5 million patients in the United States who have access to everything, to their entire medical record.
WACHTERThat's not completely easy, if you think about it, that, you know, when I write a note about a patient, I am often -- I might be using abbreviations, I might be using jargon, that if the patient sees it, we'll have to figure out a way of interpreting that in a way that the patient can understand. But the places that have done that, and they're growing every day, it's called Open Notes, the patients like it, the physicians find that it actually is -- it works out fine, and I think we're entering an era where patients will actually see their entire medical record, and I think that will be healthier than sitting there waiting at home to hear about your laboratory results.
LAKSHMANANWell Dr. Saul Weiner, you're also a physician. I want to ask you about whether, you know, this ties in. We got a tweet from Jeffrey, who says electronic communications have put the burden of knowing on the patient. From booking appointments and diagnosis, it's too much for too many people. And I also share this view. When I've been told, I'm not going to email with you, you have to sign up for our patient portal, my goodness, I spend half an hour trying to sign up for the patient portal, and I couldn't get the account working, I couldn't make a password that worked. It was so complicated, I finally just gave up, and I only communicate with that doctor when I go in for my visits.
WEINERSo one of the things they've done in the VA healthcare system is, at least, and I see this in my own practice, is all lab test results have to be communicated to the patient through a really neat device in the medical record, where essentially we send a letter to their home, and it goes through snail mail, and for every lab result, it tracks whether we did that. And if we don't do that, we hear about it. And so that is an institutionalized way of making sure that every patient will get a letter in the mail telling them that their lab tests were normal or not normal and what to do about it.
WEINERNow I'm sure the system problem has its glitches, but I think the concept is a good one.
LAKSHMANANWe have a tweet from Julie, (PH) who asks, what about communicating with patients who have disabilities, like the growing number of people with autism?
PATELSo I have a number of patients who are transitioning from having autism as a child -- as a pediatric diagnosis, and now they're young adults, so they can no longer see their pediatrician. And one of the things that we try to do, but the medical record and our current kind of infrastructure doesn't support it, is to really understand kind of who in their care environment is part of their network and how openly we can communicate with those individuals.
PATELWhen it's your child under the age of 18, it's much easier to communicate. When they're over the age of 18, it becomes more complicated. And I would argue that that's something where the health care system is woefully behind what individuals really need right now.
LAKSHMANANCindy, you wanted to jump in?
BRACHYeah, I wanted to sort of agree with the caller, who said that there is a lot of burden that's being put on the patients because we should not be expecting patients who have very variable access to Internet, variable computer literacy, variable desire, to go and spend the time and access for themselves. I mean, the VA has Open Notes, and that's great for people who want to look at it, and the research in the VA has shown that people would rather have the access than not and be able to see those notes, even if they don't always understand them.
BRACHBut we still have a responsibility to make sure that all of those test results get to patients in a way that they can understand them.
LAKSHMANANAll right, let's take a call from Tampa, Florida. Sara, you're on the line.
SARAHi, I'm a millennial and a veteran, so I love the VA secure messaging portal. My question was, what value do you think it would add if perhaps a patient could email or fill out a form ahead of an appointment so that the doctor can order labs if needed and perhaps even diagnose the problem, that way that the quality time is spent on the back end treating the issue, as opposed to troubleshooting it?
LAKSHMANANAll right, good question from Sara. Thank you. Saul, you're a VA doctor. Tell us.
WEINERWell, my patients, and I'm a primary care doctor, I'm not a specialist, so it applies to primary care in my case, but my patients can email me any time, including before a visit, and they will often do that. They'll send me an email saying, you know, when I see you, I'm going to need X, Y and Z.
LAKSHMANANAgain through this secure portal, though.
LAKSHMANANThat's right. Okay. We have an email from John in Fort Worth, Texas, who says doctors are taxed physically and mentally and are under unrealistic time constraints. As a nurse, it is our job to effectively communicate to the patient the diagnosis, the type of medication, side effects of medicines and future instructions to ensure adequate care. Perhaps nurses need to be held to a higher standard. And it sounds like John himself is a nurse. Dr. Patel?
PATELI totally agree. I will tell you that in primary care settings, the majority of our practices do not have RNs, nurses, because, one, we actually have a nursing shortage and problems obtaining nurses, and there are just not enough. Two, it's -- the primary care kind of financial structure doesn't allow for our practices to end up having a nurse. And so I would say that most of what you're describing with kind of effective communication is usually done through things like community health workers, medical assistants in a primary care setting.
PATELBut I agree that if we had the appropriate staffing, that that could be a possibility.
LAKSHMANANDr. Wachter, you wanted to jump in?
WACHTERYeah, Indira, I would just ask everyone to fantasize about a future world where patients are on portals, your experience getting onto the portal is disappointing, and think about if the portal experience for your retail was like that, or your pharmacy was like that, you'd probably go to a different pharmacy or go to a different retail vendor. It needs to be that patients can access their health care providers when they need to via video chat, via email, can get a lot of their needs attended to while they're in their home through smart algorithms that are monitoring certain things like their sugars or their breathing if they have diabetes or emphysema, and that the staffing in the physician's office is recast so that the nurse does what a nurse can do, and a technician can do what a technician can do, and the doctor is used for what a doctor uniquely can do.
WACHTERRight now we have none of that. There are some advanced practices really beginning to think about what the practice of the 21st century needs to look like, but for a millennial, they're not going to accept the idea that I'm going to take off a day from work to go and drive and park and go to see the doctor for a 12-minute visit when I could've gotten that at home or through a video chat.
WACHTERAnd the problem is the financial structure of medicine, and I think our imagination has not allowed us to kind of take the model and essentially throw the old model aside and rethink what health care needs to look like in a digitally enabled future.
LAKSHMANANDr. Saul Weiner.
WEINERYeah, I think there are two pieces to this. One is the one that Dr. Wachter's getting at, which is how we could do so much better with the use of technology. But I also want to get back to something that Dr. Wachter said earlier, which is right now, we're evaluating doctors in health care almost entirely by what's recorded in the medical record and what's in claims data.
WEINERAnd if you think about it, that's kind of odd. Usually the way you evaluate whether something is being done well is you observe it, and nobody is really observing health care. My team has spent a decade, as I said earlier, sending fake patients in to test the system, what some people think of as mystery shoppers, and we've also invited over 1,000 veterans to record their care, audio-record it, and then we analyze what we hear.
WEINERAnd one of the things I've learned is that people, including doctors, will do -- will focus on what they're being measured at. So right now doctors are being measured at how good a job they do making the medical record look pretty and complete, and the patient can almost become sort of like a data source, just sitting there while the doctor, you know, is focused on making sure everything looks terrific.
WEINERAnd I just want to mention, I think I'm a big advocate for the whole mystery-shop idea and the thing -- the fact that we need to spend a lot more time in health care finding ways to directly observe what's happening and using that to improve processes and also provide both positive and corrective feedback to the entire health care team, from the front desk clerk all the way to the physician.
LAKSHMANANSo also that means observation, knowing whether doctors know how to communicate. I mean, we've gotten several emails asking about, you know, how doctors get evaluated on this and also saying that part of the problem with doctor-patient communication is follow-up, and people don't really know how they're supposed to ask follow-up questions after they leave the office. It's hard. I'm Indira Lakshmanan, and you're listening to the Diane Rehm Show. Cindy?
BRACHYes, I think that one of the options for doing this is, sort of as you implied, Saul, that we ask the patients. Getting patient feedback is incredibly important. And AHRQ has a series of surveys called the CAP surveys that ask about patients' experiences. And we have actually a health literacy supplement that gets into detail about are you talking too fast, are you using -- is your doctor using words that they don't understand.
BRACHAnd the hospital version of this survey, which doesn't get as detailed but that actually payment can be tied to those scores to help provide incentives to do a better job on that communication. In terms of the patient portal problem that you were describing, Indira, we should be observing patients using those portals and seeing how they find information or can't find information, what they understand, et cetera.
LAKSHMANANRight, well, we have a listeners, Jason, from Tallahassee, Florida, who says that he used to work for a company that provided portal service. He thought he was a smarty-pants IT guy, but at his own doctor's office, he didn't understand the portal system, it had a terrible interface. So clearly I'm not the only person who's had this problem. Let's take a call from Deborah in Ashland, Kentucky. Deborah, you're on the air.
DEBORAHI've heard -- it's such a widespread problem with communications in general. When we're talking about medical practices, it even becomes more difficult. I worry about physician burnout. What I have noticed, I have friends who are surgeons, and I'm not in the medical profession, and also primary care physicians, who are unfortunately in the position that they need to communicate in codes for the computer for the insurance companies and are so overwrought with making sure that they get their coding correct that they're not able to take care of their patients as they want to.
LAKSHMANANAll right, it's a good question from Deborah. She's asking about how doctors are so focused on insurance companies and diagnosis codes that they're not communicating with the patients, and they're getting stressed out.
BRACHSo this, I mean, the point that Deborah's making is exactly the current state. I will say that some of the evolutions of the way we're trying to pay doctors is actually migrating away from this notion that you have to just see people face to face and churn them out every 15 minutes. And in models where there are the ability to take on more time with a patient, places like Virginia Mason in the Northwest part of the country, places like the southern part of California, where we have clinics that can allow you to see a doctor for an hour and can actually have a very robust care team that can manage patients, those doctors are reporting that they're much less burnt out and that they're coming close to the practice of medicine.
BRACHWe're all trying to get to that point, but the caller's point is well-taken. I would only advise that this is going to be kind of a constant evolution and a conversation, and doctors have to get into that conversation and promote those models that allow for better communications.
LAKSHMANANWell speaking of these models, we've gotten several tweets from listeners asking about an app called medfusionplus.com and saying it's been very helpful to them. Can someone quickly explain that, anyone who has experience with that app? Okay, not even on our expert panel. So we're going to have to look that up and learn more about it. All right, we have an email from Bob, who says my primary care physician recently allowed me to record my annual physical. This allowed me to remember and take notes from it.
WEINERAbsolutely, and I think that that's a terrific step to take. Sometimes physicians are uncomfortable with being recorded. I think we have to accept now that everyone has an iPhone or something sort of like an iPhone. So you might be getting recorded whether you know it or not. And there have been incidents of that that have gotten into the news, where the -- what was heard was not good. So I think that physicians should always be mindful that they are being recorded or potentially being recorded, and I think there's nothing wrong with that.
WEINERI would like to think that there is nothing I talk with my patient about that I would not want to hear on an audio recording.
LAKSHMANANAll right, Dr. Wachter, with the short time we have left, tell us about the reality that so many patients feel they need to see their doctor to get the facts. We trust our doctors so much, and even in a digital age where we're doing our own research, I think a lot of the burden remains with you, the doctors.
WACHTERAnd as it should be, I think, Indira. This is a very tricky age that we live in, where patients are being given new tools, empowered by new tools, but we can take the analogy between health care and doing your taxes or making a restaurant reservation too far. We want patients to have the tools that allow them to manage themselves when they are capable of doing that, when they want to do that.
WACHTERBut there's a very famous story of the editor of the New England Journal of Medicine, Franz Ingelfinger, who was the world's expert on diseases of the esophagus, and at the end of his career, he developed cancer of the esophagus. And he went to see doctor after doctor, and each one of them said to him, Franz, what would you do. In other words, he was the world's expert on the disease that he had. And it turned out he was beset by anxiety, and his family was getting more and more anxious.
WACHTERAnd finally he went to see a close physician friend, who said Franz, what you really need is a doctor. There are times where patients are going to be able to manage themselves with new tools, new electronics, new ways of connecting to doctors or other people, but there are times where they really need to see a doctor.
BRACHAnd that's what Universal Precautions is about and health literacy, that everybody is at risk of misunderstanding.
LAKSHMANANAll right, Cindy Brach, senior health researcher at the Agency for Healthcare Research and Quality, earlier Dr. Robert Wachter of the University of California, San Francisco. Also joining us, Dr. Saul J. Weiner of the University of Illinois at Chicago and Dr. Kavita Patel of the Brookings Institution and Johns Hopkins. Thank you to all of you for joining us on this terrific topic, too many questions we couldn't take, and thanks to all of you for listening. I'm Indira Lakshmanan, sitting in for Diane Rehm.
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