‘I Apologize for What You Are About To See’

By | August 13, 2019

By HILARY HATCH, PhD

The growing movement to include the patient voice in medicine through Motivational Interviewing, patient-reported outcomes, social determinants of health and shared decision-making

One day in 2011, as a part of my research on ways to improve patient-provider communication about health behaviors, I was shadowing Dr. G., a talented young internist with a cheerleader demeanor. He marched through 12 afternoon patient appointments with confidence and purpose. But when he saw the name of the last patient on her schedule, he turned pale, faced me and said, “I apologize for what you are about to see.”

I must have looked confused. He repeated, “I apologize for what you are about to see.”

We walked into the exam room. I’m not sure either one of us knew what to expect. The patient, a white, obese man, was seated, doubled over. He had a wad of paper towels jammed in his mouth. He threatened to pull out his own, presumably abscessed, tooth. He refused to see a dentist because he had no dental coverage, no money and no one to borrow money from. He said he would use pliers to pull his tooth, but stayed put, rocking in his seat. At the computer, the young doctor’s white-knuckled hand gripped his mouse. Click. Click. Click. He searched the patient’s chart aimlessly for help. Alerts kept popping up about the patient’s missing A1C results. It took two minutes, but it felt like 20.

Dr. G. left the room and came back a few minutes later. He gave the patient the name of a dentist who would see him at no cost. I suspected Dr. G. had called the dentist and said he would pay for the appointment out of his own pocket. The patient hugged Dr. G. He only wanted help, and Dr. G. wanted to help. The tension was resolved for the moment.

The visit note looked like nice and neat, bearing no resemblance to the interaction of human need I had just witnessed.

Problem list:

  • Diabetes Type 2
  • Major depression
  • Acute toothache

Note: “Patient complaining of tooth pain. Referred to dental for eval of abscess.”

No mention of the patient’s many major stressors. Lack of dental insurance. Poverty. Pain. Trauma. Anxiety. Possible addiction. Obesity. Social isolation. The patient’s record said he was 39. He looked 59. Not a single box in the patient’s EHR reflected those issues, despite the evidence that behavioral health problems and poverty cost people 20 years in life expectancy. There were years of A1C test results in the man’s record. A lot of quality alerts related to his uncontrolled diabetes and missed blood, eye and kidney exams. “Tsk, tsk, Dr. G.,” the patient’s chart said. No wonder he dreaded this patient. When I returned to the practice a month later, Dr. G. was gone, “promoted to an administrative role.”

The patient’s non-medical self has not historically had a place in the medical record. Dr. G., like many physicians, managed his patients with complex behavioral health and unmet social needs by sticking them on his schedule at the end of the day. Dr. G. felt he had to apologize for what I saw. He seemed to feel I would judge him as harshly as his quality report would for this patient. On the contrary, Dr. G reminded me of how many years of training it took me as a psychologist to learn how to be at ease with the incredibly uncomfortable feelings that come up in an interaction like the one I witnessed.

Dr. G.’s practice, like many others, had yet to reflect the 40 years of accumulated evidence that supports incorporating the patient’s voice and “the whole person” into medicine. Ideas such as:

  • Integrating behavioral health and social determinants of health (SDOH) into medicine
  • Motivational Interviewing to understand individual patient goals and barriers to care
  • Shared decision-making
  • Health literacy
  • Patient-reported outcomes

Each of these efforts inserts the patient’s voice and social context into care. None of these ideas are new, but somehow it feels like these evidence-based threads have finally woven themselves into a sail that has recently caught wind.

This is a movement whose time has come. Listening to the patient’s voice and story, understanding the patient’s needs and priorities, and capturing that information in in data reportable to the provider in the workflow—are becoming more common. In fact, we are seeing an unprecedented surge of practices integrating patient-reported outcomes data (PROs) into their workflows. Primary care practices increasingly are screening for behavioral health and substance use, SDOH, environmental triggers for asthma, fall risk, cognitive and functional decline, health literacy and hereditary cancer risk. Providers want to activate patients around their individual barriers to care and medication adherence. Specialists are incorporating PROs and considering that data alongside clinical outcomes. They want to know which patients lack social support and might therefore be readmitted.

Every day, my team is helping organizations around the country implement patient-reported data and programs to increase patients’ participation in their care. The goal is to improve not only the patient experience, but also the provider experience with data that is actionable and consumable, and that allows physicians to collaborate with a broader care team. We are asked to find ways to maximize and extend the reach of the provider-patient interaction beyond the 15-minute visit.

This is not a movement without ambivalence. As a psychologist, I am keenly aware that most physicians didn’t sign up to be psychologists and social workers. They are overwhelmed. Dr. G.’s patient is not terribly uncommon.

I often wonder why this movement is taking off now. I worked in an integrated adolescent primary care setting at Bellevue Hospital in the 1990s, where I learned about Motivational Interviewing for substance abuse interventions and shared decision-making for talking to adolescents about birth control and HIV testing. These ideas have been around a long time, especially in community health centers and public hospitals. Why the sudden explosion in interest and broader adoption across medicine? Here are some of the major influences.

  • Consumerism: Healthcare organizations lose money and payer contracts if they cannot attract consumers and keep their patient satisfaction scores up.
  • Value-based care, government and health-plan incentive programs: Shared decision-making, PROs, Motivational Interviewing and the integration of behavioral health and SDOH into primary care delivery have all been proven to improve outcomes and reduce the total cost of care.
  • A downward trend in life expectancy, notably among white males
  • Physician burnout: Practices are looking for ways to improve and humanize patient-provider communication.

Clearly, the movement to include patient-reported data is here, and the patient’s non-medical self needs a place in their healthcare record.

I apologize for what you are about to see. It is going to be extremely human.

Hilary Hatch is a clinical psychologist, the founder and CEO of VitalScore, and the VP of Clinical Engagement at Phreesia.

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