The concept of patient engagement is much touted, and certainly engaging with patients to help them change their behavior is an important element in improving health outcomes. But what about physician engagement?
Very little is ever said about changing physicians’ behavior, since typically it’s assumed physicians are doing the right things and it’s up to patients to listen more carefully to their doctors. But there is room for more physician engagement.
The stereotypical healthcare model involves a visit to the doctor, who spends 10 minutes listening to the patient’s health concerns before providing a medical opinion. The patient might ask some questions, but generally the doctor’s judgment isn’t questioned. The doctor writes a prescription and the patient goes away. Throughout that interaction, the patient plays a passive role.
But this model is starting to be challenged. The British Columbia Ministry of Health, Canada, for example, has a program called Patients as Partners, which encourages patients to voice their opinions to drive improvements to the overall healthcare system and practices. Such an approach acknowledges the important role of the patient.
Physician engagement clearly helps to improve the outcome for the patient. Studies that have rated physicians on an activation scale show that the more activated physicians are in terms of engaging with their patients to help them change their behaviors and better self-manage their conditions, the more activated their patients were. For example, a paper published in 2012 found higher levels of patient activation when the quality of interpersonal exchange with physicians was perceived to be better, there was perceived to be greater fairness in the treatment process, and more out-of-office contact with physicians[i].
Combing Scientific Knowledge with Experiential knowledge
Undoubtedly, clinicians have the clinical, scientific and evidential knowledge to be able to make appropriate decisions, but the patients have the experiential knowledge. They know what’s worked for them before and what hasn’t. They know when they feel better or worse. Their experience warrants serious inclusion in the discussion. But patients’ experiential input isn’t generally considered to be of the same level of importance as that of the physician. The question is, should it be?
That experience could make all the difference to the patient’s outcome. For example, if the clinician says, “Mr. Smith, in this situation, the best thing for you to take would be amoxicillin,” the clinician would have first checked the patient’s record to determine that he or she is not allergic to this medicine. If the patient’s record does not list an allergy, the clinician will assume that none exists. Patients may or may not know that they are allergic to penicillin, and if they do know, they are expected to speak up, in which case a doctor would then recommend something else. But what if Mr. Smith doesn’t have an allergy to penicillin but knows from experience that the drug just doesn’t work very well for him?
In an ideal world with data at their fingertips, precision medicine would allow clinicians to see someone’s pharmacogenomics. This information would let clinicians know which drugs that patient is resistant to — those drugs that don’t absorb well or work well for that patient — and which ones that patient is better at dealing with and will, therefore, have a more positive impact on any condition he or she might have.
Without that scientific evidence, however, the only thing the physician has to rely on is the patient’s own experience. Generally, the only way a physician knows whether a drug didn’t work is if the patient goes back and says he or she isn’t any better. If the patient doesn’t return to the doctor, it’s assumed the medication worked, but the physician has no way of knowing how well or how quickly that drug worked.
It’s unlikely that many physicians are going say to a patient, “You took amoxicillin a couple of years ago when you had something else wrong with you. Did it make much difference?” If that information is volunteered by the patient, all well and good, but it’s not standard practice for the physician to ask for that sort of information. Furthermore, it’s quite likely under the current model of clinical practice that many physicians might question how capable a patient really is to comment on his or her own health and wellness in that regard, and may deem it inappropriate to ask such a question.
Were the physician to adopt a practice of deeper engagement with the patient, however, that’s the type of question that might well be asked.
Just how this conversation can be managed and what patients can do to provide evidence of their experience is another part of that journey, and that’s where the use of apps comes to the fore.
How those apps might be used, the ability to assess the value of those apps, how the data can and should be presented, and measures to simplify the analysis of that data are important elements in moving toward better physician engagement, and these are topics I’ll discuss in my next blog.
[i] Patient–Physician Role Relationships and Patient Activation among Individuals with Chronic Illness, Health Services Research, June 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423181/