Patient-Physician Communications: Sometimes It’s the Small Things

February 26, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications / 1 Comment

Wide ranging discussions are ongoing about how to systemically improve the collection and analysis of clinical information via electronic medical records and other forms of health IT. In addition there are more focused discussions about how to improve physician patient relationships. However, when a friend told me how a communication failure with her physician left her with less than optimal treatment instructions, I was reminded that at the very micro level there are additional communications issues that need to be examined.

Here’s the story: My friend had a temporary and rather minor – but certainly annoying – skin problem, and her doctor advised her that hot/moist compresses would be the best thing, and that she should wrap a potato in a paper towel and “zap it,” and then apply this to where she had the skin issue. …

Controlling Health Care Costs and Improving Quality with Effective Care Coordination

February 16, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety / 2 Comments

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media. Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending. For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.…

Chronic Wellness Promotion v. Chronic Disease Management in Medical Homes

February 9, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety / 2 Comments

One of the hottest health reform topics is Medical Homes: Medicare has Demonstration Project starting this year, several states have implemented, (or are implementing), medical home related initiatives, the Center for Studying Health System Change (CSHSC) released a great white paper titled “Making Medical Homes Work,” and the New York Times just had a story about how IBM is teaming up with United Healthcare to promote Medical Homes for their 11,000 employees and dependents in Arizona.

Definition of Medical Homes
One of the controversies in Medical Homes is the definition. CSHSC and many others use the definition developed by 4 national medical societies which combines aspects of preexisting primary care and chronic care models with the goal of creating a primary care “home” that can more effectively address the needs of patients with chronic conditions.…

Quality of Care in Medical Practices – Size Does Matter

January 19, 2009 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 6 Comments

The Journal of General Internal Medicine published a study last month that looked at primary care medical practices in Massachusetts to see how well they were able to provide the quality improving capabilities of Patient-Centered Medical Homes. These structural capabilities represent process measures that assess the quality of care in medical practices. However, these same measures could also help patients select their own primary care physicians.

Study Finds Larger Practices Have More Quality Related Capabilities
Not surprisingly the study found that larger practices, (and to a lesser extent those affiliated with larger networks of practices), provided more capabilities to improve the quality of patient care.…

Making Physicians Better, and Making Better Physicians

December 10, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Public Health, Quality of Care & Safety / 5 Comments

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions. The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

Ask permission to enter the room; wait for an answer
Introduce yourself; show your ID badge
Shake hands
Sit down.

…

Engage With Grace

November 26, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Public Health, Quality of Care & Safety / 1 Comment

Many bloggers are posting information today about a initiative to encourage conversation about a very difficult topic: How we want to die. This collective effort to prompt discussions about this topic at the beginning of the holiday season is very timely, and it is a good complement to my post last week about empathy and compassion in healthcare.

What follows is essentially the same text that appears on many other blogs along with a picture of the “One Slide” listing the 5 conversation promoting questions that are at the core of the Project:

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Engage with Grace: The One Slide Project is an astonishingly simple idea that literally touches everyone.…

Proposals for Expanding the Full Range of Compassionate Care

November 20, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety / 3 Comments

Two recent events made me think about how traditional medical care and medical education address the issue of compassion.

The first was at the annual dinner for the Kenneth B. Schwartz Center when they gave out their annual Compassionate Caregiver Award, and reviewed the accomplishments of previous awardees. These individuals have all made remarkable differences in the lives of patients and families through their empathy and personal connections.

The second event was reading about the passing of Florence Wald, the former Dean of Nursing at Yale who organized the first hospice in the United States in 1974 because of her interest in compassionate care at the end of life.…

Another Humorous? Humana Video

November 17, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Economics & Financing, Information & Communications, Miscellaneous, Private-Employer Based Health Insurance / No Comments

Last week I wrote about Humana’s YouTube videos designed to “explain” parts of the healthcare system. Well they just put another one titled, “Some Doctors Cost More. Why?”

Two interesting points about this video: First, at the beginning they describe insurance companies (like Humana) as “Providers.” (The narration uses the term “health coverage providers,” but the graphic shows “PROVIDER.”)

While physicians and other clinicians really dislike being called providers, I think they wouldn’t want to see that term used for insurance companies either, since it implies that the insurance company is actually providing healthcare. (I usually reserve the term provider to describe broad groupings of clinical entities, such as, “providers of oncology care in the Chicago area,” – which would include physicians, nurses, hospitals, etc…)

And second, the title and content of the video doesn’t focus on the total costs of care or services provided by individual physicians, but mostly only patients’ co-pays – which are lower when they use the physicians that are in-network for their insurance plan.…

Medical Homes, Hammers and Nails

November 10, 2008 / Michael D. Miller MD / Access to Healthcare, Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 2 Comments

Medical homes are being promoted as a way to improve health care delivery by increasing the coordination of patient’s primary and specialty medical care. The goal of medical homes is to ensure that patients’ care is comprehensive, appropriate and patient-focused.

One of the benefits to the patients and the healthcare system is that medical homes can help sort out the confusion that can arise from the phenomenon sometimes described as, “When you’re a hammer, everything looks like a nail.”

In healthcare delivery what this means is that sometimes the diagnoses or treatment recommendations from specialized clinicians will reflect their expertise – and thus their may be inconsistencies or conflicts in the recommendations coming from several specialists.…

Patient – Doctor Communications

October 7, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications, Quality of Care & Safety / 1 Comment

In the last couple of weeks there were two interesting articles in the New York Times about patient-physicians communications.

Value of Empathy
In the first piece, Dr. Pauline Chen discusses an academic article that explored the way physicians communicate empathy to their patients who have serious and life threatening illnesses. The conclusion of the research, (which looked at the experience of people who had lung cancer), was that physicians miss 90% of the opportunities to connect empathetically with their patients.

The researchers speculated that physicians don’t engage patients empathetically because they are concerned that this would take too much time. However, according to Dr.…

Questions and Answers About Pay-For-Performance (P4P)

August 14, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Health System Reform, Information & Communications, Therapeutic Substitution & Interchange / 1 Comment

An article in the July/August Health Affairs about Massachusetts health plans implementing Pay-for-Performance (P4P) incentives for physicians raised more questions than it answered.

The study found that P4P programs from 5 private sector payers “wasn’t associated with greater improvement in quality” compared to the overall upward trend in the factors measured. But the study didn’t address some overarching questions and basic realities about P4P, such as:

How the payers P4P incentives to the physician groups was actually translated into incentives for the individual physicians – or smaller groups of physicians inside the larger groups?
How the P4P incentives compared to the other financial incentives the physicians are facing?

…

Literacy, Communications and Star Trek – Cores for Reforming Healthcare

July 30, 2008 / Michael D. Miller MD / Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety / 1 Comment

In talking to people about the problems with the US healthcare system, two fundamental truths have become apparent.

First, people really want the type of healthcare that is envisioned in science fiction such as Star Trek, where almost any ailment is treated with a single injection or pill, or a few waves of a healing wand. Unfortunately, medical science hasn’t accomplished that, except in a few instances – antibiotics for a bacterial infection, or perhaps relocating a dislocated finger or shoulder (and those still require weeks to heal and therapy to regain strength and mobility).

And second, the ongoing problem of healthcare literacy and communications may be getting worse as the complexity of medical treatments increases.…

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