I'm a big believer in empowered patients -- people taking charge of their health. But in truth, in this country, the empowered patient is the exception. Most of us aren't so savvy, nor so motivated, to roll up our sleeves and drive our care decisions. Most patients don't ask to see their records; most patients don't take their drugs as prescribed; most patients don't research their treatment options (though most seem to use the Internet); indeed many patients don't actually do what their doctors advise at all. Most of us don't follow the basics of good health: get exercise, eat properly, avoid stress. Just judging by the national obesity rate, too many of us squander our chances to improve our health, and the result is what medicine unfortunately calls "noncompliance" -- the failure to follow doctors' orders.
And this frustrates doctors, big time. Good, well-meaning doctors see noncompliance every day in their offices and they are baffled by it. As one doctor recently put it: How can we help people who won't help themselves?
Every doctor, no doubt, has their own strategies and techniques to address this. Places like Sermo help flush some of these strategies out. But it would be disingenuous of me to advocate for patient engagement so vociferously if I didn't consider the other side of the equation: How physicians might successfully engage their patients. So drawing on the insights of Dr. Rothenberger and his ace stable of practitioners, and inspiration gleaned from the cardiology nurses of Minnesota, I've put together a humble five-point prescription for doctors and other care providers: Five things they should seek to give every patient -- strategies to tap the most underutilized resource in medicine: their patient.
1) Transparency: The all-knowing physician is a myth that no longer serves patient nor doctor. It sets up false expectations for patients, who often come away from the doctor's office without the definitive diagnosis or treatment, and it holds the physician to an impossible standard of perfection. Better that everyone lay their cards on the table. Physicians might share what they know about a patient's condition or course of treatment -- and also make clear what they don't know.
When mulling a course of treatment, let the patient know what the range of choices is, and then explain why the recommended course seems to make the most sense. The presumption that patients can't handle ambiguity, that they can't parse probabilities, is entirely wrong. Life is ambiguous, it is uncertain, and we all inherently understand that. Outside of medicine, we experience it every day. Making the ambiguities evident, shining a light on the dark, so to speak, lets patients reckon with their health just as they do with other parts of life.
2) Repetition: For doctors and nurses, the hospital or clinic is their office. They're used to it. It's routine. For patients it's anything but. White coat syndrome extends way beyond higher-than-usual blood pressure. Every comment from a doctor or nurse is charged, every word choice studied for inflection. But that doesn't mean we're actually grasping what the doctor is saying. Even if our needs are minor, for patients the doctor's office is charged with anxiety and fear. That look on our face? It means you've lost us.
And then, when we're out the door, anything we did understand is gone. I know this personally: I have listened deeply to a suggestion that I take an over-the-counter medication, and then, by the time I get to Walgreens, blanked on the dosage and frequency my doctor suggested. Anything that's not written down -- i.e., everything except a prescription -- is going to be lost. If your patient doesn't bring a pen and paper, write your advice down for them.
3) Resources: It's no surprise that I think patients should get full and immediate access to their records, notes and lab tests. Even if the patient can't make heads or tails of it, it's an important gesture of reciprocity, partnership and, I would argue, ownership. This stuff is ours. But there are other resources that a doctor can help their patients with. I'm not talking brochures and pamphlets -- I'm talking about the Internet (again). In part this is simply pragmatic. Patients are going to go there in search of more information and answers, and they might as well start where their doctor suggests they do. And there's no reason this shouldn't augment the doctor's care; they're already overworked and pressed for time. Use the outside world, identifying informative websites and online support groups.
And about the Internet: Physicians should flush out this elephant in the room. You know your patient is already on there, doing all sorts of research. What they find may not be relevant, but it's filled their heads with ideas. Even if they don't come in with papers and print outs, they've already got preconceived notions about what's wrong and what they might do. Get it on the table. Ask patients what they've read online about their condition (this is quid-pro-quo transparency). Listen. And then, if necessary, explain why it doesn't pertain. Even the most misguided patient has taken a worthy first step towards engagement: they care about their health. Start there and use it.
4) Patience: Just because patients don't do what you tell them to, that doesn't make them irrational. They may have what, to them, seem like perfectly reasonable reasons to ignore their doctor's advice. Understanding these reasons, flushing them out, can be a way to pursue other, more promising approaches. Conversely, just because patients may not do what they should doesn't mean they've given up, that they've decided to live in ill health. Failure is a part of life, and it certainly is a part of our health (witness the eight or so times it takes a smoker to successfully quit). But humans are resilient creatures, we are persistent, and helping patients understand that they can make their way towards better health with a few missteps comes as a great relief. Take it from a Catholic: Going to the doctor's office is very much like going to the confession booth, and in both places the confessor is probably embarrassed to tell the full story. Diffusing that anxiety, forgiving the missteps, can be a great motivator.
5) Goals: A great impediment to sustained and better health is the fact that we don't think about it that much. Most doctor's visits, after all, are about a problem (it bugs me to no end that the intake form at many doctor's offices, including mine, presumes poor health with the first question: "What is your Chief Complaint?"). Even if that's why we walked in the door, that shouldn't be how we walk out. Rather than send patients out with a to-do list, physicians might send them out on a path, with milestones and purpose. Fact is, we do better when we have an objective, when we feel that we're making progress towards something - that's human nature. A great way to create engagement about health is to create a sense of purpose, that the drudgery of tasks required - new drugs and new diets - isn't just managing our health, but is in fact building towards something.
So that's my prescriptions for doctors. And patients, you should ask your doctors for these things, if they're not offering.
No doubt putting these into action would require, first and foremost, time -- perhaps the most precious resource a physician has. But my hope would be that they could be worked into the habits and dialogue that already take place, and that they might make that communication smoother, less fraught, and more productive. I would be eager to hear if there are other strategies out there.