Talking to patients about high value care, and why it’s important

Last night, one of my close friends told me the story of her recent trip for her annual gynecology appointment. Her longtime gynecologist had retired, and she was meeting her new physician. After taking a history, the first new physician explained to her that since she always had normal Pap smears, including recent ones from the past several years, she only needed a Pap smear if “her husband’s penis has been inside another woman.” The message was accurate but delivered with a blunt scalpel; not an approach that would likely be successful in conveying an important message to a person who has unhesitatingly complied with her physicians’ advice over the years. Being the intelligent and pragmatic person she is, my friend spoke with her feet and sought advice from “second new gynecologist.”

This new physician’s advice appealed to her practical side: “Yes, the previous physician’s recommendation is aligned with the new guidelines but you’re here, so let’s just do the Pap smear anyway.” Another illustration that it’s not just what you say but how you say it that counts.  The devil in the details of the delivery of the message and content of the message both frame patient acceptance.

Therein lies the conundrum: How do those on the frontline of health care convince patients to change the practices that our profession has indoctrinated in them at a time where medical evidence constantly evolves, time pressures are real, and patient satisfaction is a real marker for health care quality? How does a patient adjudicate the correct advice delivered in a non-patient-centric manner versus accepting the “yes, but” mentality from those who find themselves caught in the chasm between patient satisfaction and professional standards?

Like the gray zone art and science that medicine represents, there is no simple solution to this dilemma. At a time where medical professional societies and the medical literature is increasingly populated with articles that focus on delivering high-value care, how do we take the pie in the sky and bring it down to reality level? There are no easy answers when spending time with patients is so undervalued from a payment perspective. Nonetheless, the medical profession needs to be mindful that spending adequate time on the front end to present patients with new and evolving concepts isn’t just the right thing to do, it will save patient and professional time on the back end.

Too often, unnecessary testing results in false positives that lead everyone down the wasted path of patient and professional time, and the very important human toll of additional unnecessary testing, unnecessary procedures, and unnecessary complications.

There is a growing body of literature that points to the importance of patient and family engagement in health care decision making. How we adequately achieve patient engagement given the conflicting forces is not as readily articulated in the medical literature. However, the unifying thread seems to be that precious resource of quality time spent with patients. We urge the medical profession and the patients we serve to spend a little more time discussing the devil in the details, breakdown dams and build bridges to understanding.

Along the way, we challenge the health care system to do their part and recognize the value of allowing medical professional to prescribe “tincture of talk time” in their practices rather than the usual mantra to “see more patients” which translates to “talk less.”

As for my friend, I’m not sure whether she will accept my advice that she truly doesn’t need an annual Pap smear. Note that I did not discourage her from getting her annual visit with her gynecologist as we know that many gynecologists serve as primary physicians for women of childbearing age and beyond. The time she and her physician spend together might reveal other important opportunities to maintain her health if something like a malignant thyroid mass is discovered or they discuss important issues that might address or prevent other health problems.  A tincture of time well prescribed.

Darilyn Moyer is an internal medicine physician and chair, ACP Health and Public Policy Committee.  She blogs at Daily Dose MD.

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Dr. Darilyn Moyer is the Vice Chair and Internal Medicine Program Director, Department of Medicine, and Assistant Dean for Graduate Medical Education, Temple University School of Medicine and Temple University Hospital. She is a Professor of Medicine and Assistant Dean for Graduate Medical Education at Temple University School of Medicine.