The Distracted Provider!

The article Is Your Doctor's Distraction a Good Thing tackles a complex problem in the era of the electronic medical record.

A major ongoing complaint is my doctor never listened to anything the patient said.  Add the issue of not making eye contact with the patient because you are staring at a computer screens is leading to chronic discontent in the doctor-patient relationship.

The provider is faced with the task of coordinating endless data streams in a limited time frame.  The provider must obtain the data, synthesize the data, and then incorporate it into a non-friendly computer program.

These are complex multi-tasking events even for the computer literate.  Something has to be lost in these complex transactions.  This is the face-to-face interactions where the patient gets their emotional needs met.  Not all of medical care is pills, but it is psychological reassurance that everything is OK and hopefully will get better.  The important thing for any provider to do is take the time to make eye contact.  Even a short period of eye contact is valuable; and to be effective the indication that is provides, that one is listening, continues through the other non-eye-contact activities.  This is a basic communication necessity that physicians are all too prone to ignore in the midst of thinking about, and sorting out the issues of a patient's problem. 

The article states that the interfaces and programs will improve and hopefully reestablish the human, for the time being, to human interactions that people crave.  I can acquire a Google MD, but it is much more difficult to gain perspective on the various conditions.

Using Shared Decision Making as a Tool

Shared decision-making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions.  This is ne of the new trends allowing patients to directly participate in their care.  The goal is to give the patient sufficient data to make an informed decision with the clinician to determine the curse of their medical care.

In the article, What is Shared Decision Making?, the author defines as a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences.

Traditionally medical care was 100% paternalistic, where Dr. Welby knew what was best in all situations.  With the tremendous growth of information available the consumer can google all the information they may or may not understand.  Even if they understand, they do not necessarily have the context to make appropriate decisions.

The provider is the person who adds the context, but it is easy for the provider to bias the process.

There are certain situations in medicine where shared decision making is inappropriate.  A patient who needs life-saving surgery or immediate cardiac care should not create an excessive dialogue.  Other not so urgent problems with multiple treatment options is another story.

There is one place where shared decision making can be used as a tool to eliminate medical-legal testing, CYA procedure, unnecessary hospitalizations, and the overuse of our extension and expensive pharmacopeia.  This will also appeal to practitioners who believe in the motto, "Trust Me" and/or "In My Experience".

Keep in mind that any action has risks.  While one might wish that the benefits of an action outweigh the risks, we all know this not to be consistently the case.  Thus any decision on which an action or the act of inaction is based has risks, and a risk/benefit ratio can be surmised.  Actualized risks have costs, the most central of which are risks to the patient and the patient's health, the secondary, and tertiary, tiers of actualized risks are litigation, blame, and social or interpersonal dispute regarding responsibility for the decision.  In traditional care models, the physician bears the secondary levels of risk; indeed in Marcus' time there was little litigation, and the risk of a questionable decision was small.  But in our current dominant medical model, there is considerable risk to the care of patients, and to shouldering the decision making process.  Hence, medical care is expensive.  Broad shoulders require huge payouts and large premiums.

In a share decision model, who would bear the risk?  Would it too be shared?  Or perhaps when the patient is a decision maker, he/she agrees to assume all the risk of the decision.  How would the elements of a negligence claim be parsed?  Duty, Breach of Duty, Proximate Cause, Damages.  Shared decision-making may be an advance, but some pieces have to be in place.  For example, standard forms upon which a doctor checks off the options, risk, recommendations, and the patient perhaps on the other side of the sheet notes his acceptance, decisions, and signature.  More forms, that's for sure.  Lots more forms.

Take advantage of the consumers' willingness to participate in their care by having informed discussion with them.  Talk with them like a family member, and give them the same advice.  The monetary savings will be astronomical and your public relation scores will sky-rocket.

Adding Motivtion for Visit as part of the Chief Complaint

When writing, Dragoning aka dictating, typing and or clicking a classic history and physical exam, there is a traditional format to follow.  What may be left out is the underlying motivation or deeper concern that led to the actual visit.  Most physicians try to discern a "Reason for Visit (RFV)", and there was an academic effort not too long ago to replace the Chief Complaint (CC) with RFV, but CC is too thoroughly entrenched in the medical world.  This effort was driven by recognition that even the most common complaints - say chest pain- have underlying, relevant forces that make an individual decide to go to the ED.  Such forces can include- "MY wife made me come.", "I thought I was going to die.", or "It was about time I did something."- indicating a longer history of symptoms than might initially have been thought.  Of course, there are many, many other motivating forces of this type.

Motivation therefore includes concerns, worries, fears, family pressure, employer pressures, generalized anxieties, and specific desires.  The list goes on and n, and few are irrelevant.

Concerns about a potential serious illness like a stroke or heart attack are often very real and very present.  Eliciting early on in the encounter that the patient was worried about a stroke, for example, adds quick perspective to the evaluation.  Moreover, a very important reason for trying to elicit such concerns is that addressing them is key to patient satisfaction, and proper thoughtful care of individuals.  The patient who is too embarrassed or afraid to say anything leaves unsatisfied because their concerns were not evaluated.  Hence, it is frequently the physician's responsibility to tease these details out, as best as possible.

Another major and related dimension to motivation is the parallel issue of the real reason for the visit.  For example, we often learn that a family member "made me" and we become less interested in the family dynamics than in ascertaining all relevant key information.  This is the time to ask everyone available about what is actually going on.  How many have not seen the patient checked in with a CC of some non-specific somatic complaint- tired, weak etc., only to learn from the wife that he has had repeated exertion chest pain for weeks or months, mowing the lawn or taking out the trash.

Of course, patients often have specific agendas- medications, antibiotics, work excuses, etc. and once discerned and addressed can expedite care.  Once you actually get to the bottom line, beating around the bush ends quickly.

The benefits of asking key questions to elicit the reasons a patient decided to change his or her normal life course and come to the ED will lead to increased patient satisfaction, decreased complaints- the provider never listened to me- and reduction in liability concerns.  Cost savings are often additionally obtained because a focused evaluation solves the main problem earlier, without extensive testing or time.

When eliciting the chief complaint, try to keep the door constantly open for revealing motivation by adding sensitively phrased questions that do not challenge the patient or appear to disrespect their decision to come.  Saying- what are you doing here at 3 am with this complaint that has gone on for 6 months has the potential to put some patients and or families off.  A bit of rewording that acknowledges the human foibles in us all will help get to the bottom and provide reassurance.  Perhaps adding- help me understand what moved you or I know it must have been especially bad this time, can you tell me what was different?  This may help you to where you want to go without offending anyone.  In any case, finding out motivation for showing up will dramatically increase efficiency and accuracy.  It is perceived that the provider Listened and Cared about Me!

Avoiding the Malpractice Trap

Malpractice is back in the news with the Florida Supreme Court ruling that non-economic caps are unconstitutional.  In California, the cap will probably be adjusted to cost of living increases making it at least $1,000,000 for pain and suffering.

With the affordable care act putting more financial pressures on providers, not dealing the malpractice issue at all will lead to higher costs inevitably.  One main reason malpractice claims in two high risk states like Florida and California were semi under control - it is too expensive for lawyers to take on marginal cases.  Marginal cases equal low potential return on investment (ROI) regardless of the facts.

The trick is never getting named in a lawsuit.  Even if you win, get dropped, or the case is not formally pursued, there are still legal fees and emotional distress.  Providers are instructed to view malpractice as a cost of doing business, but most people cannot separate business reality from a very personal attach on their core identities.

Suggestions to stay out of trouble that do not include more tests or defensive medicine.

1. Keep well informed about trends.  Risk Management Monthly (no financial ties) does an excellent job.
2. Be aware that the patient is judging you on punctuality, and feels their time is just as important as yours.  A good strategy is to always apologize about the wait time even if you are early.
3. Introduce yourself to the patient and their support team.
4. Find out what brought them in today aka motivation for the visit i.e. wife insisted, worried about a stroke, death in the family, etc. Responding to their pressing need eliminates the provider didn't listen to me!
5. Allow the patient to speak for at least 60 seconds before the cross-exam begins.
6. Use the data other people have collected by confirming, not by asking the same questions over and over.
7. Verbalize the battle plan and make an estimate the time frame.  If possible, have your staff in the room for this, everyone is aware of the plan.
8. Check on the patient to see 1) if their pain or comfort has been attended to and 2) to give an update to the progress of the plan.
9. Do not tell jokes.  The patient is not sure if you are laughing with them or about them.
10. Use shared decision making, if appropriate.  Critical patients and their support team want to be consulted.
11. Give the patient very specific follow-up directions with specific time durations.
12. See a patient in a recheck as a second opportunity to get it right.
13. Document a clinical course and important conversations with patient, family and consultants.
14. Be aware of the limitations and positives of your documentation system.  Remember all entries are time-stamped.  Explain why the EKG was recorded being read at 14:00, but was read at 10:00 , especially if clinically significant.
15. When patients disagree with you and want to leave against medical advice, it behooves you to personally come to an agreement on the situation.  Delegating to a staff member is a huge error.  Make sure the patient knows they can always comeback, have witnesses especially their support members in the room, and give appropriate prescriptions for needed therapy.

Avoiding being named is the key to success.  Following common sense protocols does not increase time spent, but actually speeds up process because the patient and their support team are informed.  People sue because they are mad or frustrated.  They usually cannot determine quality care, but they know how they feel about you.

Using an EHR to Expand Your Urgent Care Practice

In a world where you have to document in a specific way, one should take advantage of the data accumulated in the EHR to accentuate your practice.

1. Auto fax all appropriate documentation to the primary care provider or appropriate specialist the patient has been referred to: a) PCP will consider you an adjunct to their practice rather than competition; b) encourage the PCP to send patients to the UC rather than the ED, if they are confident of your capacity and capabilities; c) create a specialist list that wants and appreciates your business; d) patients will appreciate the cohesiveness of care without having to repeat more tests and spending excess time explaining what might have happened.
2. Select an EHR that gives condensed summary of events rather than 10-15 pages that nobody will read.
3. Use your practice management reports to keep track of where your patients are coming from: walk-in, after hour referral, overflow referral, Google search.
4. At the end of every quarter send every referral provider a report of how much business you are sending and/or returning to them.  Most surgical specialists do not realize the direct impact you may have on their bottom line.  This can dramatically help when favors are needed that do not necessarily have to be solved in the ED.
5. Your practice management system's ability to keep up with real-time authorization, coverage, co-pays, and payments dramatically speed up the front-desk leading to more satisfied customers.  If one can eliminate 15-20 minutes of the office visit, which is a great bonus and encourages repeat business.

Conclusion- make sure to purchase a software suite (Practice management and documentation) that improves your bottom line!

Motivation for Visit and Patient Satisfaction

 

 

A classic history and physical exam is a key component of the medical interaction and record of the patient and provider.  The goal is a coherent, focused account of the visit in the chief complaint and history of present illness area of the chart.  Electronic and paper charting templates prompt one to include the components for completeness and billing codes.

 

They are many techniques to obtain this information, but most leave out a crucial bit of information that may lead to higher patient satisfaction scores while dramatically speeding up the process.

 

This crucial component is patient motivation for taking the time out of their complex lives to obtain medical care that may take up to 6 hours and still not answer their questions. 

 

Patients are motivated by multiple reasons:



• Fear of Illness - I was worried that I was having a stroke or heart attack!
• Family related - My spouse made me come.
• Accident or insurance related
• Problem that has persisted with no "magic cure" in sight

The list goes on...

Asking the patient the circumstances and their concerns of the visit initially will narrow the scope of the visit dramatically.  This allows the provider to focus on the acute problem at hand.

Eliminate the classic response of "You're the Doctor" - you should know and figure out what's wrong - and address their psychological needs.

Your patient will think you are an astute clinician who cares.  Your satisfaction scores might go up and the #1 complaint of the provider didn't listen to me will go down!