Doctors are going to have to become more patient-centered as government agencies and health plans demand objective evidence of their effectiveness at treating chronic illnesses, according to a commentary published Monday in the Journal of the American Medical Association (JAMA).
“There is a trend toward physician ratings being based on specific metrics related to the management of chronic illness” — such things as blood sugar levels, blood pressure, body mass index, and smoking rates, write psychologist Paul Hershberger and internist Dr. Dean Bricker of Wright State University. “However, the physician contribution to changing the actual outcomes is limited.”
As Hershberger and Bricker point out, research suggests that medical care accounts for about 10 percent of the differences in health outcomes among patients, while about 50 percent can be attributed to behavioral and social factors. And when it comes to heart disease, diabetes and other chronic conditions, which garner the largest proportion of our health care efforts and resources, outcomes rely mostly on how well the patient adheres to the prescribed treatment, which includes maintaining a nutritious diet, exercising regularly and making other healthful behavioral changes.
Yet many people don’t adhere to their doctor’s recommendations. Non-adherence to drug treatments for chronic illness is estimated to be about 50 percent, Hershberger and Bricker point out. In fact, about 30 percent of patients never even fill or pick up their prescriptions.
Adherence to recommendations regarding behavioral or lifestyle changes is even lower. A 2005 study of people diagnosed with heart disease found, for example, that only 20 percent followed their doctors’ recommendations to eat more fruits and vegetables or to exercise more, and only 5 percent made both changes.
Many other factors associated with health outcomes are also out of a physician’s control, note Hershberger and Bricker. For example, people with higher educational and income levels, as well as those with a more positive affect (overall emotion response to life’s experiences) tend to live up to a decade longer than their less educated, lower paid and less happy peers.
“Although physicians are not held accountable for life expectancy, these traits influence overall health and well-being,” the two men note.
Empathy with teachers
The similarities between this new predicament for doctors — the fact that, increasingly, they are being evaluated by patient outcomes over which they often have little control — and that of another group of professionals is not lost on Hershberger and Bricker.
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“Because so many variables beyond physician control affect patient outcomes, relying solely on outcome data (or proxies for outcomes) to determine physician effectiveness may be both inaccurate and unjustified,” they write. “There is a parallel with public school teachers who are increasingly evaluated using student outcomes, even though student achievement is affected by many variables other than the teacher’s qualifications and skills, such as socioeconomic factors.”
But doctors would be ill advised at this point to try to fight the current trend, say Hershberger and Bricker. “Until better measures of overall physician effectiveness are identified, physicians, like teachers, must do their best to affect outcomes in the face of performance measures that are influenced by circumstances outside their control,” they write.
That means adopting a more patient-centered approach to care — an approach that emphasizes “asking, listening, and understanding, not just the patient’s symptoms but also the patient’s circumstances, environment, perspectives, barriers, stressors, and goals,” Hershberger and Bricker explain.
It also involves something called “motivational interviewing” — “a form of interaction with patients that highlights the ambivalence patients have about health behavior.” For example, they say, instead of just telling a patient with diabetes that she needs to take her medications regularly and lose weight, “the patient might be asked what concerns her most about not having her diabetes under control” and then about how she wants to proceed regarding her health, given her life circumstances.
Time and other barriers
That all sounds great, of course, but also very Panglossian. For how are doctors going to find the time to have these detailed and intense conversations with patients? A 2013 survey reported that 45 percent of physicians said they spend 16 minutes or less with their patients during a typical office visit, and another 25 percent said they spend only 20 minutes or less with their patients.
Hershberger and Bricker acknowledge this barrier and others, including doctors not having the skills — or the desire — to engage in such patient-centered care. “Yet,” they say, “it behooves physicians to recognize that their direct effect on patient outcomes is usually limited and adjust their interactions with patients accordingly.”
“Although the physician’s direct effect on patient health may be decreasing, patient health outcomes are increasingly used to evaluate physicians,” they add. “Physicians cannot control what patients do, but to ignore or ineffectively address influences on patient behavior is to disregard what ultimately will determine patient outcomes and, accordingly, ratings of physician effectiveness.”
You can download and read the commentary in full on the JAMA website.