Patient Engagement Starts with Listening
Listen to your patient, he is telling you the diagnosis — William Osler, one of four founding physicians of the Johns Hopkins Hospital
I grew up in Farwell, Texas, a town of about 1200 people in the panhandle of the state. Our town was too small to have its own library, and after I became an avid reader, I looked forward to trips to the Bookmobile on summer Saturdays.
After one visit to find something to read, a good friend of my parents (Mrs. Anderson) offered to drive me home. I took her up on the offer, and ended up getting to hear the quadrophonic stereo in her car — a brand new technology in our little town — and telling her all about my aspirations to be a doctor. When I got home, I told my mom about how cool the stereo was, and how nice it was to chat with Mrs. Anderson. My mom, an insightful woman, said to me, “You enjoyed talking to her because she is interested in and listens to what other people have to say. If you want people to enjoy talking to you, learn to be interested in them and what they share.”
My mother’s advice was wise, yet few of us manage to practice it. For many of us, as Fran Leibowitz said, “The opposite of talking isn’t listening. The opposite of talking is waiting.” Or maybe I don’t want to do all the talking. It could be the case that I would love to hear from you, especially if you’re talking about me.
During their medical education, doctors-in-training get very good at a particular kind of listening and note taking, filtering for what is essential. When completing my classwork for my PhD (I didn’t pursue the aforementioned MD), one of my courses was with medical students at the med school. Once, after I asked a question in class, the professor asked me to talk to him after the lecture. He requested that I refrain from asking “deep dive” questions during class, because they impeded the flow of the large volume of information that the med students needed to absorb. He said he would be happy to discuss such questions with me after class. He described a medical education as an inch deep and a mile wide, whereas the PhD I was purusing was an inch wide and a mile deep. Both are challenging, albeit in very different ways.
The best doctors know that this highly filtered, get-to-the-point approach works great for learning, but isn’t the way to engage patients. The truth of the patient’s situation often lies in the depth and nuances of their story. However, today’s health technology encourages physicians to have “inch deep, mile wide” conversations, to the detriment of patients.
In the office, doctors seeing patients increasingly take notes into their electronic health records (EHRs). Satisfaction with EHRs has been dropping for the last few years. A “51 page report from AmericanEHR and the American Medical Association (AMA) shows that compared to five years ago, more physicians are reporting being dissatisfied or very dissatisfied with their EHR system. The survey on Physician Use of EHR Systems 2014 found that close to, or more than half of all respondents, reported a negative impact in response to questions about how their EHR system improved costs, efficiency or productivity.” [1]
Couple the poor design and usability of many EHRs [2] with the utilization pressures driving short appointments, and the predictable result is that EHRs encourage physicians to drive shallow conversations that focus on the broad, surface aspects of the patient’s story. For example consider Jane Doe, whose diabetes has been poorly controlled since her last visit to her doctor. During the visit, he makes (and electronically documents) several suggestions for actions that Jane needs to take. However, he never learns that Jane’s child is dealing with a learning disability, and that her husband was recently laid off from his job. As a result, Jane leaves the doctor’s office more overwhelmed and stressed than when she arrived, and the suggested interventions have little chance of success.
Technology to engage patients between office visits also suffers from serious shallowness problems. Engagement is too frequently viewed as giving the patient “nudges” to get them to take day-to-day steps to improve their health. These steps are often generic and lacking any insight into the issues that may affect the patient’s ability to comply. Furthermore, the ability to hear back from patients is usually treated as a secondary issue. Simplistic engagement models are also a result of challenges beyond the technology, such as how to avoid the anxious and over-engaged patient who wants the doctor to be available via technology 24x7.
These problems are serious and real, and efforts at improving health through technology-mediated patient engagement will fall short of their promise until we address them. The good news is that doctors can have “deep dive” conversation with patients. My own physician is a mastser of engaging me in thoughtful, eye-to-eye ways, while using an EHR to capture what we talk about. Yet, in watching him do this, I realize that it requires more effort from him than it should
We have the knowledge that is needed to create tools that help make engagement appropriate, rich, and deep. Applying it involves taking three broad steps.
- Use design thinking to enable deep, eye-to-eye conversations for physicians using EHRs with patients
- Build technology that goes beyond “demographic-complaint-diagnosis” models of health data to better include social and psychological determinants of health
- Use approaches from the rapidly expanding field of machine intelligence to enrich the technology that directly engages patients
Technology can be an ally for effective patient engagement. To benefit from it, we must change our thinking about the conversations and interactions that the technology needs to facilitate for those facing challenging health issues.
Clay Williams is the CEO of Medaptive Health, an open platform for creating compassionate health technology.
[1] http://www.americanehr.com/research/reports/Physicians-Use-of-EHR-Systems-2014.aspx
[2] http://www.thehappymd.com/blog/bid/351428/9-Reasons-Physicians-Hate-EMR-The-2013-RAND-Study
