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Doctor-patient communication for (physician) dummies

February 2014

Published in the February 2014 issue of Todays Hospitalist

REIMBURSEMENT USED TO BE SO EASY. We got paid for what we did, even if we didn’t do it very well. But payment, to a large degree, now hinges on how well we do our jobs.

Hospitalists are pretty quality-oriented, so we can generally live with reimbursement pegged to clinical metrics for conditions like pneumonia and heart failure. But even the biggest quality mavens get twitchy when dollars are put into play for subjective measures. And perhaps nothing is more subjective than interpersonal communication.

The Centers for Medicare and Medicaid Services (CMS) rolled out its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS or “H-caps”) survey in 2006, with public reporting of data beginning in 2008. The Affordable Care Act of 2010 pegged some reimbursement to the so-called “patient experience” as reflected in HCAHPS, beginning in late 2012.

The current survey consists of 32 questions, three of which target physicians specifically:

  • During this hospital stay, how often did doctors treat you with courtesy and respect?;
  • during this hospital stay, how often did doctors listen carefully to you?; and
  • during this hospital stay, how often did doctors explain things in a way you could understand?In each case, patients are given four choices: never, sometimes, usually and always.Survey says!
    HCAHPS data are aggregated and then posted on Medicare’s “Hospital Compare” Web site.The current data for my hospital were collected during calendar year 2012. Patients reported that our physicians “always” communicated well 77% of the time, which puts us below both the national and Minnesota averages (81% and 83%, respectively). Our doctors tied a competitor down the street but lagged another by 3%.

    A few percentage points doesn’t seem like a big deal until you consider that the CMS transforms these data into percentile. My hospital’s 77% puts us at about the 25th percentile nationally. In other words, 75% of hospitals in the country are doing better in this department. Ouch!

    I don’t know about you, but we clearly need a little help. Accordingly, I’ve pulled together some of my favorite resources for everyone’s benefit.

    What else?
    Doctors often fail to establish the patient’s full agenda. We might start with an open-ended question “”How are you feeling today?” “but we quickly switch gears to specific queries like, “Are you short of breath?” Once that occurs, the patient will never voice everything on his or her mind.

    One of my favorite techniques involves wearing patients out. I picked this up from an article published in the February 2003 Mayo Clinic Proceedings. You still start with an open-ended question but follow every patient answer with this mantra: “What else?”

    Hospitalist: How are you feeling today?
    Patient: I’ve been having heartburn.
    Hospitalist: What else?
    Patient: My back hurts.
    Hospitalist: What else?
    Patient: The food here is really bad.
    Hospitalist: What else?

    Most physicians fear that this will go on forever, but patients generally run out of things to say pretty quickly. At that point, you can take stock of what you have and start parsing through everything.

    BATHE your patients
    Another arrow in my quiver comes from Marian Stuart, PhD, a psychologist, and Joseph Lieberman, MD, MPH, a family physician. It is an approach known as BATHE, an acronym that stands for Background, Affect, Trouble, Handling and Empathy. The physician side of the conversation involves four scripted questions and a concluding statement.

    Hospitalist: How are you feeling today? (B)
    Patient: I’ve been having heartburn.
    Hospitalist: How do you feel about that? (A)
    Patient: Really frustrated. I was up all night.
    Hospitalist: What troubles you the most about this? (T)
    Patient: I’m worried there is something wrong with my heart.
    Hospitalist: How are you handling this? (H)
    Patient: Not very good. I’m afraid to tell my wife or nurse.
    Hospitalist: This must be very difficult for you. (E)

    Again, physicians fret that these discussions will take all day. Fear not: Drs. Stuart and Lieberman note that BATHE requires only about a minute.

    “I don’t understand”
    A study published in the May 2002 Cleveland Clinic Journal of Medicine by Mark Williams, MD, who heads the hospital medicine division at Chicago’s Northwestern University Feinberg School of Medicine, noted that roughly 25% of Americans are functionally illiterate. Health literacy ” the ability to understand basic health information “is even worse.

    One way to deal with this is “living room language,” the language nonmedical people would use during normal conversations in their homes. For example, analgesics are painkillers. Osteopenia is thin bones. Lipids are fats. Terminal means dying. If you need some help, the University of Michigan maintains a great plain language medical dictionary.

    Physicians should also avoid phrases like “positive test” or “negative biopsy.” Positive stress tests are typically bad and negative nodes are generally a cause for rejoicing. Unfortunately, patients may not hear things that way.

    One final trick is the teachback method, with patients explaining back their medical care to you in their own words. Here’s an example from my world:

    Frenz: Now, why are we starting quetiapine today?
    Patient: To help my mood. I have bad mood swings and fight with people.
    Frenz: Does quetiapine have any side effects?
    Patient: Yeah, it could give me sugar diabetes.
    Frenz: And why is diabetes bad?
    Patient: It could give me a heart attack.
    Frenz: And what is a heart attack?
    Patient: It’s when part of my heart dies. If too much heart dies, then I could die.
    Frenz: And what am I going to do about this?
    Patient: You’re going to check the sugar in my blood now and then.

    This guy did OK but you’d be surprised how little patients understand. Fortunately, the teachback method allows you to identify gaps and immediately fix them.

    Dollars at risk
    Our hospitalists are currently eligible for an annual quality bonus of up to 11.5% of their base salary. Of this, 12% is tied directly to HCAHPS physician-communication scores. It is a relatively small percentage of the overall package, but it can still amount to several thousand dollars.

    The big problem is that HCAHPS data reflect the patient experience with all doctors: There is no drilldown by specialty or to individual providers. Hospitalists get lumped together with rogue surgeons, specialists who talk over patients’ heads and frazzled emergency physicians.

    Any solution for low HCAHPS scores thus needs to encompass all credentialed providers, not just hospitalists. An initiative now being discussed at my hospital would produce specific strategies and tactics to follow later this year. I will circle back with an update.

    David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family and addiction medicine. You can learn more about him and his work at www.davidfrenz.com.