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We’re a remarkably visual species, aren’t we? Pictures, it turns out, are worth a thousand words. The finding shows up in research about patient diaries - I’ll post some articles here if I can find them and in informed consent.

People simply understand more readily and express themselves more easily using pictures.

Here’s an excerpt from a study quoted in DotMed (http://www.dotmed.com/news/story/7800/).

In this prospective, randomized, controlled study, the diagram method — in which patients viewed a set of diagrams illustrating 12 key points before signing an informed-consent form — was most successful in terms of patient recall of the information and increased the interaction between the physician the patient.

You’ll be hearing more about informed consent in the future. There’s a growing concern that informed consent has morphed from an opportunity to have discussion with patients to a way for physicians to cover themselves legally.

Tim’s Takeaway: Are you exploring ways to communicate with your patients pictorially? It can make your communications much more effective, and not just with patients from diverse backgrounds.

The Tennessean is carrying an article by Dr. William Stead that seems thoughtful and well-intentioned, yet introduces confusion by conflating two important issues: patient non-adherence and medication error. Dr. Stead is associate vice chancellor for strategy and transformation and director of the Informatics Center at Vanderbilt University Medical Center.

He starts the article with some useful and provocative statistics:

Sixty-one percent of patients fear being given the wrong medicine. Over 150 million phone calls requesting clarification from pharmacists to physicians are made annually because of the difficulty in interpreting the prescription.

And then inexplicably puts not medication error, but patient non-aderence at the crux of the problem.

As many as 125,000 die annually from non-adherence to their medications.

Dr. Stead chronicles a careful process he carried out at Vanderbilt to clean up the medication errors. All the while continuing to mix together issues that would be better dealt with separately.

As an example, here’s his critique of e-prescribing:

e-prescribing is better thought of as nine smaller processes — deciding what to prescribe; creating the prescription; transmitting the prescription to the pharmacy; pharmacist-prescriber dialogue; dispensing; filing the claim; taking the medication; monitoring for effect and adverse effect and refilling the prescription.

Notice that the process has a variety of vulnerabilities from a variety of sources. Both deciding what to prescribe as well as the pharmacist-prescriber dialogue are vulnerable to lack of information about other medicines the patient is taking (a medication error). They’re also vulnerable to patients withholding issues about beliefs and lifestyle that could keep them from filling or taking their medicines (nonadherence issues). Transmitting the prescription to the pharmacy is a pure technology issue. Dispensing is open to human error. Monitoring for adverse effects is often hindered by lack of trust between the physican and the patient (a nonadherence issue).

Tim’s Takeaway: Dr. Stead raises important issues. And thanksfully he’s attacking his challenges with a critical eye. If we’re going to get to the bottom of the problems, we’ve got to separate them out according to their root causes. Otherwise, we’ll be dealing with a conceptual tangle.

BBC News’s Jane Dreaper reports on a growing sense in Great Britain that the healthcare system is showing less compassion and patients are paying the price.

The case in point concerns Brigadier John Platt, a recipient of the Distinguished Service Order who led his troops across a river in Italy in WWII. He’s 101 now and was treated with little respect when discharged from from an NHS hospital. In fact, his hearing aid was squashed, he was sent home in his pajamas, his soiled clothing were intermixed with the clean, and the staff lost his teeth.

Needless to say, his grown children were distraught. “I was so furious. I think respect in that situation is the same as compassion,” they said.

Notice the NHS apology:

“Clearly some aspects of Brigadier Platt’s discharge in 2006 were unacceptable and the Trust apologises for any distress that this caused the patient and his family.

“In apologising, the Trust also acknowledges the concerns raised about some of Brigadier Platt’s personal effects.

“The Trust takes all complaints seriously so that it can learn from these experiences.”

In my mind, this borders on the kind of perfunctory apologies that get healthcare groups in trouble. They downplay the injury, don’t really convey compassion, and ring of forced contrition.

The story concludes that burnout is on the rise and a likely culprit.

Here’s a thoughtful post by Maurice Bernstein, M.D. asking whether–when the sympathy is passed around following a medical error–physicians shouldn’t get a little .

You might, at first glance, think the sentiment a little self-serving coming from a doctor. I encourage you to give his post due consideration.

One of the parents where my kids go to school is a well-respected doctor. He gave me this thought problem based on a very prestigious surgeon he knows.  

Imagine a surgeon who is so good he’s called on to do several hundred surgeries a year. Statistically, he’s going to make some irreducible number of mistakes. Say he’s very conscientious and he’s reduced his mistakes to a handful a year. If he’s doing sensitive or complex surgery, one or two of those mistakes may cost lives.

If your mother is one of those patients whose life is lost, you might think the physician deserves his anguish. But suppose your mother didn’t die under his knife today, but in fact is scheduled for an operation with him tomorrow. What would you like his frame of mind to be when he walks into the operating room?

Tim’s takeaway: We need to give Dr. Bernstein’s post a second consideration. Mistakes hurt no matter which side of the blade we’re on. If we expect a physician-patient relationship, we need to find some way to give the physician as much compassion as the patient.

The trend towards more visibility for physicians’ ratings continues.

According to the Toledo Blade, you can find ratings for doctors as easily as ratings for your favorite restaurant. Zagat, the famous ratings guide for hotels and restaurants, has teamed with Blue Cross. You’ll find ratings for physicians on their familiar 30 point scale.

Zagat logo

A couple of points of note:

1. The Zagat rating system uses a 30-point scale to grade network physicians on trust, communication, availability, and office environment.
2. The Zagat survey does not collect information about quality of care.

Don’t overlook the telling comment by the author of the article:

“Quality of care” may be an even more subjective category than the experiences Zagat is providing data on.

Tim’s takeaways: First, patient satisfaction is becoming ever more important and transparent in the way patients choose care. Second, in fact, the author is right. Studies show that patients have such a tough time judging quality of care that they often use their own satisfaction with how they are treated as a proxy.

According to a whitepaper authored by Frost & Sullivan, it’s deep understanding. Targeted education (materials that take into account standard variables such as age, gender, and race) is no longer good enough. If you want patients to stay on their treatment regimens, you’ve got to understand their lifestyle issues, the benefits and risks they see as a result of taking the medication, and the specific barriers to compliance they face.

“Driving patients’ adherence to medication requires an emphasis on the patient’s individual barriers to compliance and persistency. The need for this tailored approach is critical for some chronic conditions such as asthma, hypertension, diabetes and osteoporosis that call for significant lifestyle changes, and have complex, long-term treatment regimens.”

In other words–tailored education is wired, targeted education is tired.

F&S’s prescription:

‘Pharmaceutical manufacturers should collaborate with physicians to assess the patient’s understanding of their illness and recommended therapy, communicate the benefits of treatment, assess the patient’s readiness to carry out the plan, and discuss any barriers to adherence that patients have.”

Here’s the problem, the discussions that Frost & Sullivan recommend are not the discussions that doctors (or nurses for that matter) are trained to have in medical school.  And they require some modicum of skill and thought, and not for the reason you’d think.

It would be easy to believe that practitioners, as compassionate as they are, need to learn to tease tender  insights from patients reluctant to reveal intimacies. Turns out, it often doesn’t work that way.

In a previous post, I mentioned a study published in the Archives of Internal Medicine this year that showed that physicians miss as much as 90% of the personal overtures offered by patients. Practitioners tend to steer the conversation away from personal issues that bear on adherence, and toward symptoms and diagnoses.

Tim’s Takeaway: This is great advice from Frost & Sullivan, and well researched. The challenge is making these conversations happen between patients and practitioners. Pharma can develop all the ultra-tailored info they want. If practitioners don’t respond when patients bring up problems, it’s just more trees cut down to create literature that never leaves the info stands in the doctor’s office.

Who can you trust to take care of your parents in Louisiana?

Tampa Bay Online just reported that Medicare has released a rating system for Nursing Homes. There’s no new data there, just a new interface that brings together the previous three years of ratings in staffing, quality, and state inspections. Finally, the measures are consolidated into a 5-star scale.

Its strengths are also its weaknesses: it gathers diverse data into rating that makes it easy to compare one nursing home against another.  As you’d guess, reformists are jubilant while the industry is aghast.

I imagine the system is, as its critics suggest, hamhanded. And I’d guess it will push nursing home owners to do better.

For now, watch out if you live in Louisiana. Nearly 40% of your nursing homes get only one star.

Here’s an article in today’s Daily Cancer News by Lynda Mandell, MD, PhD, FACR. It’s a provocative and balanced article the underscores the “non-physical needs” of cancer patients - the depression, anxiety, guilt, and daily attacks on self-esteem. These non-physical aspects of cancer can undermine a patient’s ability to adhere to treatment. The suggestion is that doctors attend to these psychological needs as well as the physical ones.

There are two rubs: The one Lynda mentions - even though oncologists are empathetic, they may not have skills particular to handling their patients’ psychological distress. The other, Lynda doesn’t mention - oncology has among the highest burn out rates of any specialty for doctors and nurses.

Google oncology and burnout and you’ll find page after page of reports. Here are just a couple.

1. The results of a 6-year study found that 42% of oncology employees have a high score of emotional exhaustion and a low score of personal accomplishment, indicating high levels of burnout.
2. Dr. Pauline Chen quoted a a study published this year in the Archives of Internal Medicine. Oncologists missed 384 opportunities to respond empathetically to their patients (or about 90% of the emotional overtures patients made).

The upshot is this: oncologists need empathy themselves. Psycho-Oncology, as admirable as it is, is asking the depleted to care for the exhausted. Who’s caring for the doctors and nurses who care for our loved ones?

Today, Press Ganey Associates, Inc. unveils an integrated approach to relationships in the health care setting–the Employee Partnership(TM) approach. The new framework will help health care organizations build powerful, sustainable relationships with their employees, resulting in superior patient care and organizational outcomes.

Why does this make so much sense? You may remember a few years ago Press Ganey published a study showing a near 1-to-1 relationship between staff satisfaction and patient satisfaction. By elevating the importance of staff satisfaction to the status of partnership they kill two birds with one stone - help health systems address physician and nursing shortages and raise patient satisfaction at the same time.

Here’s the article on nursing burnout 2 years into their career. It’s by Sheryl Ubelacker of the Canadian Press. 58% report being burned out. You can find a personal example of the problem here.

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