Actual conversation heard in the hallway outside an exam room earlier this week: Doctor: “So, we’re going try this medicine for your blood pressure; you keep checking it at home as we discussed. If the numbers remain high, we can increase the dose or add another medicine.” Patient: “Well, what do we do if the pressure stays high; if this medicine doesn’t work?” My partner told me later that she had explained the plan to the patient multiple times, and despite being incredibly intelligent he just did not seem to be getting it. Is anyone listening? Try as we might, over and over, it often feels like our messages fall on deaf ears. We talk to patients about their blood pressure, tell them the importance of getting it under control, review the risks of uncontrolled high blood pressure, stress the need for compliance with medication, send a prescription to their pharmacy with five refills — and then when they come in later for a blood pressure check, and it’s still high, they tell us they took the first bottle but then figured that’s all they needed to do to cure their hypertension. It’s clear that patients are often overwhelmed with all the things we tell them, all the tasks we assign them, all the referrals we make, all the medicines we prescribe, all the lab tests they undergo. So it’s no surprise that they end up dizzy, confused, and not sure what to do next. How do we build a more patient-centered system for helping our patients get to the healthy place they need to be, to carry out the recommendations we have for them, to stick with the interventions we want them to try, to improve communication back-and-forth to make sure that everyone’s on the same page? In our brief office visits, there is almost endless information we are trying to get across, and we are expected to do so much. From clicking boxes in the electronic health record, to filling out forms, to getting prior authorization for medicines, to dealing with insurance companies and pharmacies, the one-to-one communication between the doctor and the patient is often lost, those precious opportunities to really sit and talk and counsel. Only by building a system that allows us to do that will we really be able to get back to doing the doctoring we want to do. We’ve tried printing out after-visit summaries which have detailed instructions, a list of tests ordered for the patient today, medicines prescribed, a summary plan with instructions for the next few weeks, referrals we placed, and more. I think these often get ignored, either the printed copy gets shoved in someone’s bag and is never looked at again, or the email gets clicked and opened when it comes through the patient portal, but no one ever really looks to that for the answers they need. Encouraging patients to keep going Engaging our patients to continue the healthy advice, to take the medicines, to do the exercises, to change their diets, to manage their stress, is where our efforts really should lie, and is our best hope for continuing the health care experience for our patients beyond the walls of our office, into their home, into their community, into their everyday lives. The technique of “teach back,” where we tell a patient what we want them to learn, and then they tell us what they’ve learned and what they going to do with this information, is one positive way of trying to improve this. But even then, I often hear patients tell me that the doctor they saw told them “a whole bunch of things,” and they thought they understood them, but now they need someone to explain to them “what it really means.” One of the tools that is used by our practice and practices across our institution is what is called a post-visit call, which is designed to have one of the medical assistants call every patient seen yesterday in our office, and ask them how they’re doing, if they have any questions, and some other administrative details they are required to collect. Some of the staff who do this sit near enough to my office I can hear them doing these calls, and they often feel like lip service, a bit of wasted time and effort. Most of the answers they seem to get are “I’m doing OK; everything is fine; thanks for calling.” Patients seem caught off guard, wondering why is someone calling them, and I think they are so startled by these calls that they are often afraid or reluctant to be honest and say, “I have no idea what I’m supposed to do next.” I’m hoping to try and change this so that we can do these as a more proactive way of engaging patients and continuing their care. Improving the process What if, when patients leave our office today, we let them know that we are going to call them tomorrow and make sure that everything that we planned out today is up and running, moving forward as planned, and that they can truly tell us what they think this plan should be and what they’re doing to make sure it happens? So instead of just “Hey, how are you doing? Any questions?”, it might sound more like this: “I see that Dr. Pelzman started you on a new medicine for your blood pressure yesterday. Were you able to pick it up from the pharmacy? Have you taken the first dose? Do you know how you’re supposed to take it? Any side effects?” “Can we provide you with any more information about this medicine or your medical condition to help answer any questions you might have?” “Do you know what you’re going to be doing in the next few days/weeks/months about this health condition? What resources do you need to help you get to that place? Do you have a home blood pressure cuff? Did you join a gym? Can you tell me what the diet changes you are planning to make are?” As we start to build telehealth visits, video visits, and asynchronous e-visits into our practice, our hope is that these will provide an exciting new opportunity to continue the care of what we plan to do in the office and previously only hoped was happening once patients left. When we start someone on an antidepressant, wouldn’t it be great if a member of the team had time set aside next week to call that patient, see how they’re doing, whether they’re tolerating the medicine, and then made weekly “visits” to check on their mood, to see if the medicine is helping? That would be much better than the patient coming back three months later, saying they stopped because of side effects after one week, and then just didn’t want to bother letting us know, so they continued to suffer in silence. Wouldn’t it be great if after we start a patient on insulin, we can check in with them next week, watch them inject themselves at home, watch as they check their fingerstick, review their log of glucose readings, have them open up the refrigerator to show us what they’ve got to eat, so we don’t have to wait until they come back in 3 months later and they forget their log and tell us they didn’t take the insulin anyway because they were scared of using it. The end of an office visit should only be the beginning of the patient’s journey to health, and since we know that so many of our prescriptions are never filled, so many medicines that we want patients to take are taken spottily or not at all, so much of the advice we give is never taken, so many patients never go get that vaccine done or set up their colonoscopy or have their mammogram, we’ve got to find ways to do this better. We need to change the experience of health care to extend beyond those 10 minutes we get with the patient in a more creative and active way, to engage them in their health, and to let them know that we’re right there with them all the time, even if not physically sitting next to them in the exam room. Because there is more to getting them healthy than we can ever get across in such a short time, no matter how hard we try. Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home. Source
