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More Money, More Time: Will that Improve Physician-Patient Communications?


In a word…no.

It has been said that a physician’s patient communication skills are just as important as their clinical knowledge. After all, it is only by “talking and listening to patients” that physicians are able to accurately diagnose and treat their conditions. I have yet to meet a physician who did not agree with the importance of effective physician-patient communication…in principle.

In practice, a surprising number of physicians tell me that they “lack the time” and “don’t get paid” to communicate with patients. Physicians euphemistically explain to me how current reimbursement schemes fail to incentivize physicians to spend time talking to patients.

At face value, these objections appear to make sense. After all we know that physicians, particularly primary care physicians, are already overextended. We also know that the traditional fee-for-service model, which pays physicians on a kind of piece-work basis, is not well-suited to managing “episodes of care” for a burgeoning chronic disease population. In other words, today’s reimbursement is not properly aligned with the realities of care delivery.

The conclusion one draws from these two objections is that doctors would communicate better with patients if they simply had more time and were paid more. But is that what would happen?

I don’t think so…and here’s why.

Many physicians, until recently, were never taught (in medical school) how to be good patient- or person-centered communicators (the gold standard for physician-patient communications). Studies show that the majority of primary care physicians today employ a physician-directed, paternalistic style when talking with patients. This is the same style of communication practiced by physicians for the last 80 years. This style is characterized by the physician control of the medical interview by asking the questions, focusing patient input and providing pertinent information. Some physicians now limit patients to asking one question per visit. Over the course of their career, the typical physician will employ these same “conversational habits” in 120,000—160,000 medical interviews.

Patients, for their part, are trained as well – socialized from childhood to assume the “sick role” wherein the doctor does all the talking and their job is to passively respond to questions when asked. The average 60-year-old, for example, will have experienced 180+ visits in which they were likely expected to assume the sick role. Even the most engaged and empowered patient finds it difficult to avoid reverting back to this passive role.

What’s My Point?

The “communication habits” developed by and employed by physicians and patients took years to develop. Simply increasing the length of the office visit (more time) and increasing reimbursement alone will not compensate for nor change the way physicians and patients communicate with one another. Physicians will continue to be physician-directed and patients will continue to play the passive sick role. Absent interventions aimed at breaking this cycle of unproductive communication by promoting more patient-centered communications, longer visits and more reimbursement will mean that physicians have more time for and get paid more for perpetuating the same physician-directed communications challenges we face now.

Patient-Centered Communication Can Lead To More Productive Visits

Physicians are concerned that patient-centered communications will increase the length of office visits. Initially it probably will. But imaging how much more productive office visits could be over time if patients came in focused and prepared, i.e., with a prioritized agenda, clearly articulated expectations, realistic requests for referrals, tests and medications, understanding of time limitations and so on. The average patient makes 3 visits to the doctor a year. Patients with chronic conditions see the doctor up to 7 times a year. Research shows that the adoption of specific patient-centered communication techniques in your practice could “reset” the physician-patient dynamic in ways that could increase visit productivity as well as patient outcomes and satisfaction within the course of a few consecutive visits.

That's what I think…what’s your opinion?

Source: Frankel, R. et al. Getting the Most out of the Clinical Encounter: The Four Habits Model. The Permenante Journal. 1999.

More Blog Posts by Stephen Wilkins

author bio

Guest Blogger Stephen Wilkins, MPH, is a former hospital executive, consumer health behavior research and recent care giver. He has witnessed incredible oversights and gaps in physician-patient communications that have had “near catastrophic” consequences for patients like his wife who was diagnosed with Stage 4 Lung Cancer in 2004. He is the co-founder of Health Messaging Inc., which focuses on developing ideas and solutions for improving the quality of communications between physicians and patients. He blogs on Mind The Gap, where this post originally appeared, and you can follow him on twitter at @Healthmessaging.

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