What Do Patients Expect?

As a healthcare professional, it is important to know what your patients expect from you and how best to provide for their care. However, according to a recent study in the British Medical Journal: Quality and Safety, there may be a disconnect between patients and providers.

89.4% of healthcare providers say it's important to ask about patient expectations
16.1% of healthcare providers actually do ask about patient expectations

Why the vastly different numbers? It is perhaps, in part, because healthcare providers may not feel that they can adequately meet the needs of their patients, so they do not ask what is expected of them for fear of not reaching those goals. 80.4% of providers admitted that they didn't feel that they could adequately meet the expectations of their patients based on their current training. This highlights a large problem in patient care and one that should be rectified with increased concentration on training goals.

"These [sic] data suggest that healthcare organizations should take a more active role in increasing clinicians' awareness. Conducting training to cope with patient expectations and initiating structured programs for addressing patient expectations might in turn improve outcomes." ~ Dr. David Bates, Senior Vice President for Quality and Safety (Brigham and Women's)

Medical schools and continuing education providers must step up their offerings in order to fully prepare healthcare providers for their patients' needs. By practicing with less-than-adequate training and fearing the lack of ability to meet patient needs, these healthcare providers are doing a disservice to their patients and themselves. Only by working together, both the patient and provider, can the healthcare industry become a truly team effort.

EMRs and EHRs Are Increasing

Medicine is going mobile. More and more physicians are utilizing apps and other technology advancements to make patient care easier. Patients, too, are finding the use of mobile technology and accessible online information to be beneficial to their health. According to a recent Manhattan Research report, 28% of US adults access health information with their mobile phones.

Additionally, the use of electronic medical/health records is increasing, with 56 million patients already having accessed their data through this format and another 41 million saying that they are interested. Physicians have a notable list to choose from to integrate into their current practices. Here are a few that are currently available or will be available soon:

SAP EcoHub iPad App: Though still in development, this app will allow doctors to instantly access patient information in terms of vitals, diagnostic images, and full medical records. The site currently has a presentation to show what is planned for this exciting new addition to the mobile health market.

Practice Fusion: This company has teamed with LogMeIn to allow iPad access for patient records. The EHR with Practice Fusion can help physicians prescribe electronically, schedule appointments, bill for services rendered, and fill out patient charts through mobile access.

Epocrates EHR: Perhaps the most well-known EHR solution, ePocrates was designed by doctors to provide the services that health professionals need. It is easy to learn, easy to use, and can be customizable to individual practices. The technology integrates with electronic labs, allows the physician to prescribe electronically, includes adjustable charting and patient notes, as well as providing multiple points of access for the physician.

The world of mobile technology and electronic medical/health records is expanding. It's an exciting market and one that has just begun to be tapped. The increased accessibility to patient care needs is sure to improve the medical marketplace overall. With a group effort between physicians, patients, and technology, the future is open to many possibilities.

Being Uninformed Means Med School Grads Aren't Ready

The need for more primary care physicians is well-known, as the amount of patients will far outnumber the amount of providers needed with the expansion of healthcare reform. Even more disheartening is the fact that current medical school graduates may not be getting the training necessary to fulfill these roles, according to a recent Johns Hopkins study.

PCPs will need to be able to provide care not only for immediate health concerns, but ongoing health maintenance for problems such as high cholesterol, diabetes, and hypertension. However, current medical training does not provide enough instruction to fully prepare the student to take on such healthcare needs when they graduate.

“The average resident doesn’t know what the goal for normal fasting blood sugar should be. If you don’t know what it has to be, how are you going to guide your diabetes management with patients?” ~ Dr. Stephen Sisson, General Internist and Associate Professor of Medicine (Johns Hopkins University School of Medicine)

The issue comes from the focus of medical schools towards hospital care rather than long-term health maintenance. Acute cases are often well-understood by graduating physicians, but when dealing with maintaining healthy levels when living with long-term conditions, these medical professionals are often exhibit a knowledge deficit. It's important that medical schools deal with the way they train and better prepare their students for medicine in the real world, where 90% of cases will be outpatient doctor visits as opposed to hospital care. By creating more knowledgeable PCPs, the entire medical industry can benefit.

Part-Time Physicians

With the coming changes in healthcare, translating into larger patient numbers entering the medical marketplace, the demand for physicians is continuing to rise. However, there still aren't enough medical professionals to cover the demand. Current projections show a gap of 63,000 doctors in 2015 and that number increases to 91,500 in 2020, and 130,6000 in 2025. With this in mind, it is essential that more physicians be trained, as well as keeping the current physicians in their positions full-time. However, this is not always the case.

A recent article looks at the number of physicians who work part-time and it is increasing. Since 2005, the number of part-time physicians has gone up 62% and 40% of female physicians (35-44) report that they work part-time. Additionally, in a 2008 survey, the causes of physicians choosing to work part-time may lay within the administrative duties that medical care requires (64% of males and 32% of women), as well as increasing familial responsibilities (54% of women). And dissatisfaction in their careers has been shown in 49% of respondents, as they reported that they would consider leaving medicine entirely. 

How can this trend be changed? One area to look into would be the bureaucratic requirements that are put upon doctors. Can these be lessened, eliminated, or made easier? And if outside responsibilities, such as family, prevents full-time work, can the system sustain a shared schedule between a few physicians so that patient treatment doesn't have to be compromised? A collective practice of three physicians dealing with a patient load would be more beneficial than trying to fit a full case-load into limited physician time.

It is important, now more than ever, to make sure physician demand is met in light of increasing patient numbers entering the medical arena. The system cannot sustain a high level of care if physicians are only available for a limited time. By working together and making patient care a group effort, it's possible to balance the need for limited hours with the demand of increased patient load.

US Healthcare Failing

The state of US healthcare has been in question for a while now. We often fall behind other countries in terms of providing accessible care. The changes that come with healthcare reform is meant to alleviate some of these issues. However, with a new report just released, it's evident that US healthcare must make strides to provide care to the wider population.

“Overall, the National Scorecard on U.S. Health System Performance, 2011, finds that the United States is losing ground in the effort to ensure affordable access to health care...Of great concern, access to health care significantly eroded since 2006. As of 2010, more than 81 million working-age adults—44 percent of those ages 19 to 64—were uninsured during the year or underinsured, up from 61 million (35 percent) in 2003." ~ National Scorecard on US Health System Performance

On a scale of 100 points, judging health outcomes such as newborn mortality, childhood obesity, and high blood sugar in diabetics, the US scored only 64. The ranking is dropping as well, from a score of 65 in 2008 and 67 in 2006. This is quite unsettling and should be rectified before even more new patients enter the medical arena, thus stretching resources even more. 32 million Americans will be gaining the right to care with new healthcare laws. With a system that is already lacking in equal care, how will it support the influx?

“If we target areas where we fall short and learn from high-performing innovators within the United States, we should see significant progress in the future.”~ Dr. David Blumenthal,  Commonwealth Fund Commission Chairman

And when the US is compared to 16 other industrialized countries in terms of mortality which could have been prevented with sufficient care, we rank last. With premature deaths in the US 68% higher than in the best performing countries, it's evident that changes must take place. Better access and quality of care is essential in changing the US rankings and making sure that all patients receive the best medical treatment possible.

Medical Homes Not Widespread

Medical homes have proven to be very effective for patient care. These types of physician practices coordinates patient care between multiple healthcare facilities so that ongoing patient care can be maintained. And many practices put forth that they provide such coordinated care, but a new study shows that this is not necessarily true.

Published on October 18 in the online journal Health Services Research, "Adoption of Medical Home Infrastructure Among Physician Practices: Policy, Pitfalls, and Possibilities” looked at physician data that was exchanged between the National Ambulatory Medical Care Survey and the National Committee on Quality Assurance, which maintains standards for medical homes. In 46% of cases, national standards for medical home qualification were not met. Often, these were in cases of smaller physician practices, which 90% of Americans utilize, as opposed to larger practices.

“Our study findings are particularly worrisome because the medical home model of care is seen as providing higher quality, more cost-efficient care. Ideally, medical homes will help keep patients with chronic diseases from getting lost in the shuffle of our complex, fragmented health care system, yet a growing number of patients do not have access to them.” ~ John Hollingsworth, M.D., M.S., Robert Wood Johnson Foundation Clinical Scholar (University of Michigan)

Health care reform was meant to increase the number of medical homes by providing incentives. However, small practices are not able to handle the increased needs that these types of medical scenarios require. This may cause these practices to close because of the inability to compete and this would, in turn, cause less access to care. The approach to increasing medical homes must be dealt with carefully and with full knowledge of the possible implications the changes will cause. It is important that improved care be provided to all patients, despite the economic limitations of patients or providers.

Being Informed Means Being Able To Say No

Hands-on training is one of the best ways for medical students to learn. They can be involved in actual treatment, as well as get the benefit of knowledge from established physicians as they work alongside them. However, it's very important that patients know that these students will not only be in the room while their surgery is being performed, but also that they may take part in it. In a recent survey published in the Archives of Surgery, 316 surgery patients were asked about what information they wanted in terms of medical student involvement, as well as the impact this knowledge has upon their consent.

Preferred to be informed when residents would participate: 96% (patients undergoing major procedure) and 88% (patients undergoing minor procedure)

While the majority of these patients would still agree to undergo these procedures knowing residents would be involved in their care, they were less likely to agree with having an intern involved and even less likely if it was a medical student. This appears to be in direct correlation to how much prior training each was perceived to have received. The amount of involvement the non-physician had in the procedure affected the rate of consent patients would give as well.

Consent if residents were not providing direct assistance: 95%

Consent if senior resident was assisting: 83%

Consent if junior resident was assisting: 58%

Consent if an intern was assisting: 55%

Consent if junior resident was acting as operating surgeon (with direct staff observation): 26%

Consent if junior resident was acting as operating surgeon (without staff observation): 18%

So, it appears that it is a double-edged sword. While patients want to be informed, they are less likely to consent to care with medical residents or students involved. It is unethical to keep such information from patients, but perhaps more can be done to change the negative connotations of non-physician involvement. If students and residents are seen more as qualified medical professionals, they will likely be more welcome by patients in care.

Frequent Interaction Improves Patient Outcomes

Constant interaction between patients and physicians improves patient outcomes. This seems to be an obvious statment, but with a new study's results just released, the difference could be quite monumental. Researchers looked at patient outcomes among 26,496 patients with Type 2 diabetes, who also had been diagnosed with higher LDL cholesterol, hemoglobin A1C, or blood pressure. The goal was to lower these figures within a reasonable amount of time . The requirement for study inclusion was that the patient had to be seen by PCPs at least 2 years between January 2000-2009. Interactions with their physicians included in-office visits and non-face-to-face encounters (such as phone calls). Comparisons were made between patients who interacted with their physicians every week versus interactions every three months.

	Physician-Patient Interactions  Every Week	Physician-Patient Interactions  Every 3 Months
Median Time to Reach  Hemoglobin A1C Goals	4.4 months (non-insulin patients)  10.1 months (insulin patients)	24.9 months (non-insulin patients)  52.8 months (insulin patients)
Median Time to Reach  Blood Pressure Goals	1.3 months	13.9 months
Median Time to Reach  LDL Cholesterol Goals	5.1 months	32.8 months
Median Time to Reach  Treatment Goals  (All Values Combined)	1.5 months	36.9 months

The comparison between 1.5 months to achieve treatment goals and 36.9 months is striking. With continual interactions, patients can improve their health much faster. This may be because frequent interactions can catch problems earlier and adjustments to treatment can be made. Additionally, frequent counseling about lifestyle choices can help patients make positive changes much earlier and much easier, since they have a support system that's readily available to provide information.

What these findings highlight is a real need to increase communication opportunities between physicians and their patients. If physicians can make themselves available, even through phone or email, patients can get questions answered much faster and are more likely to remember their concerns rather than waiting for their next office visit in a couple of months. These benefits can be positive for everyone involved, as patients become healthier in a faster time period and physicians are less likely to have to treat long-term problems that may arise from continual high test results.

Disciplined Doctors

The medical industry, at times, has to discipline physicians and other health workers because of issues that arise in their delivery of care. Assumptions may be that these cases involve doctors who are newer to the career, who have yet to learn proper regulations. However, a recent study of Canadian doctors reveals the opposite.

A study published in the Open Medicine journal, conducted by St. Michael's Hospital researchers, looked at the 852 violations that came before the provincial licensing boards between 2000 and 2009. This accounted for 606 cases, most of which involved physicians that had been practicing for around 29 years. Additionally, 20% of cases were from physicians who had a prior disciplinary act on their record. This is disheartening, since it outlines a larger issue of long-time physicians either not being aware of regulations or becoming accustomed to practicing with a few cut corners.

"The medical profession must realize that although disciplined physicians represent a small proportion of total care providers, a single practitioner has tremendous potential to harm patients and the public. There is little doubt these practitioners diminish the integrity of the medical profession." ~ Dr. Chaim Bell, Lead Author On Study

The violations varied on topic, through the highest accounts (20%) were for sexual misconduct. This was followed closely by not meeting a certain standard of care (19%) and unprofessional conduct (16%). These areas of misconduct highlight needs to expand or update current training. A fracture of trust between physicians and their colleagues or physicians and their patients is a serious matter and one that should be rectified as soon as possible. By knowing and following the regulations set forth in care, the entire medical industry can benefit through improved function.

Regretting Their Choice

The need for physicians is growing and will continue to grow as more patients enter the medical arena, thanks to reformed healthcare laws. There is no shortage of job offers for those who enter the medical field. However, circumstances surrounding this journey have some regretting their choice, according to a recent article.

Merritt Hawkins, a physician staffing company, polled 300 medical students in their final year of training. They found that 78% had 50 or more job offers awaiting them when they graduated and 47% had 100 or more. The market seems to be booming, which is important in unsteady economic times. But despite their bright futures, full of opportunities, nearly 33% would choose another career if they could begin their education again. Factors in these stark admissions include the fact that medical school saddled them with large debt, they must participate in the economics of healthcare in order to make a living, and the fact that so many new patients will flood the market soon. It's not such a bright future as they had originally hoped.

“With declining reimbursement, increasing costs, malpractice worries and the uncertainty of health reform, the medical profession is under duress today. Many newly minted doctors are concerned about what awaits them.” ~James Merritt, founder of Merritt Hawkins 

It's important that these concerns be dealt with soon, as time is running out to ensure that there will be enough physicians to cover the needs of healthcare. How can the industry counteract the growing regret? One change would be to restructure costs of medical training. Suggestions have included reduced or free training in exchange for placement in certain areas, as well as more governmental subsidy of education. Another change would be a restructuring of the healthcare system, including the insurance industry, so that patient care does not have to come at a price of making the bottom economical line.

In whatever manner we seek to bring about change, it will not be easy. But considering the feelings of these newly-minted doctors, entering the workplace for the first time and not being pleased with their career choice, it's evident that something must be done.

Physician Awareness of Social Media

Social media continues to grow its user base among discussion groups, Twitter, Facebook, and other outlets. As we mentioned earlier, physicians are mainly engaging in social media for personal use, though the use of professional outlets is expanding. There does seem to be a discrepancy between awareness of professional use and patient use, though.

In the QuantiaMD survey, 28% of doctors mentioned using professional physician communities to learn from their peers and experts in the field, which in turn benefits their practice. However, the interaction with patient communities seem to be much lower, despite physicians feeling that online patient communities can help foster positive results in care through the online support and information systems that are in place for these patients. Only 11% of total survey respondents were aware of such social media opportunities for patients. But, despite this low number, those that are aware are recommending them to patients, or considering doing so. 

How, then, can this number be increased, if the benefit is known? One way would be for physicians to make a conscious effort to become educated on these social outlets so that they can recommend them to patients. By knowing which groups would provide the most benefit, physicians can expand their support capabilities to outside the office. With time already limited, it's important to take advantage of as many tools as possible to benefit patient interaction outside of the office setting. Social media is one such tool that can be utilized for a positive patient outcome.

How To Deliver A Diagnosis

Proper doctor/patient communication is essential in having a successful diagnosis and treatment choice. A recent report in the Journal of the National Cancer Institute gives information to help patients to receive as much information possible during their cancer diagnosis. However, these tips are informative for physicians in any type of diagnosis as well because it can help guide medical professionals on how to give a more patient/physician dialogue.

Use Simple Language: Don't give patients completely inaccessible medical terms. They may not understand the word choices you're making, so try to explain in terms that they'll be able to relate to and also confirm that they understand what you've just said before moving on.

Give Absolute Risk Statistics: Telling a patient that the prescribed treatment will lower their risk by a certain percentage without giving a comparison does not adequately inform the patient. Instead, frame the information as a comparative, such as "The drug will lower your risk from [for example] 4 percent to 2 percent."

Inform on Possible Side Effects Both For Treatment and Without: A treatment may cause side effects, which the patient should know about, but not taking the treatment may cause side effects as well. Share both possible outcomes with your patients so that they can make a more informed choice which is best for them.

Make The Diagnosis Personal: Giving rates of possible outcomes is done in general terms. However, patients need to know how the situation will impact them personally. Take into consideration their health status and the surrounding circumstances so that you can inform them of personal risk instead of general outcome possibilities.

By helping patients become better informed about their health, it will lead to more successful outcomes in their treatment. Connect with your patients and make the journey towards treatment a joint effort instead of a generalized situation.

Nonverbal Clues

Physician base their treatment decisions on test results and patient information. However, the way a patient acts also is a factor. A new study by the University of Michigan shows that nonverbal clues can lead physicians to have additional clues in diagnosis. If a patient is acting agitated, does not maintain eye contact, has a noted tone of voice or physical appearance, or expresses a multitude of other nonverbal clues, physicians take that into account when making make a diagnosis.

On the opposite side of the table, patients take into account their physicians' actions in determining treatment choice as well. If the physician appears to be in a hurry, is not listening to patient concerns, doesn't maintain eye contact, or lacks the ability to put them at ease, they may re-evaluate the doctor/patient dynamic and choose any healthcare provider to take over their treatment.

Healthcare is a group effort. It's just as important to a patient how their doctor appears as it is to a physician how their patient appears. The exchange of information is not confined to just written or verbal, but instead takes into account the entire environment. By being present and well-invested in the exchange, both patients and physicians can assure a better treatment outcome.