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Communicating with patients
Patients will never be happy with a difficult diagnosis, but there should be accountability for delivering that news to them.

Speaking from experience

When doctors improve communication, patients become better partners

By Dr. James Merlino
Posted: November 24, 2012 - 12:01 am ET

The passage of the Patient Protection and Affordable Care Act and implementation of Medicare's value-based purchasing program have thrust the issue of patient experience to the top of the healthcare agenda in the U.S.

For the first time, hospital Medicare reimbursement will be linked to patient experience metrics. Patients will be asked questions such as: “Did your doctor treat you with courtesy and respect? Did your nurse communicate in a way you could understand?” How patients answer will impact hospital payments. This process will affect nearly every hospital nationwide.

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Caregivers and hospital administrators across the country have questioned whether the bar for achieving high performance on these metrics is set too high. Some have remarked: “Patients are not always right,” or “When patients are given a new diagnosis of cancer, they won't be very satisfied.” A colleague recently remarked: “Why are we focusing on making patients happy? We have more important things to do, like practicing medicine.” Many believe that patient experience is in fact antithetical to the more important role of ensuring safe, high-quality care.

The critics should recognize that patient experience is not about whether patients are happy or satisfied; it is about how we as providers deliver care. As the questions above illustrate, a key domain of Medicare's required Hospital Consumer Assessment of Healthcare Providers and Systems survey is how we communicate with patients. When we improve the way we communicate with patients, they become better partners in their care. They are better informed, more compliant, feel safer in their environment, are less anxious, and, yes, as a byproduct, we actually make them more satisfied.

Patients will never be happy with a difficult diagnosis, but there should be accountability for delivering that news to them in an empathetic and compassionate manner. When that terrible news is delivered, they should leave the physician's office knowing that they have started an unexpected and scary journey surrounded by people who will help them every step of the way. Isn't that what we would want for ourselves and our families? Isn't this something that as providers, we have a responsibility for ensuring?

Hospital leaders were recently asked to identify critical elements of the patient experience. Things such as private rooms, electronic health records, quiet time and food on demand were cited. Patients, who were not asked to weigh in, define the experience on a much more personal level. They want caregivers to empathize, to understand what it is like to be a patient.

Medicare's focus on the patient experience is important because it is the patient's focus. And it must be ours as well. Managing the experience is not more important than safety or quality, but it is significant to understand that the patient experience helps to drive safety and quality. They are complementary.

There are clearly practical challenges to consistently achieving an exceptional patient experience. Recently, I was seeing patients when my assistant called: “There is a man in the lobby screaming. He is threatening to take his clothes off if someone doesn't help him!” Mr. Smith (not his real name) was furious. His doctor was unavailable, he was yelling that we were ignoring him and he kept repeating that we were trying to kill him.

While that behavior is uncommon, Mr. Smith illustrates the “real world” of patient care, offering some anecdotal validation to the concerns that others have raised. His case is complicated by myriad medical, psychiatric and social issues. He is noncompliant, frequently misses appointments and has threatened to kill one of his doctors. Three days before the “lobby incident,” he missed an appointment with his surgeon. The day he decided to come in, his surgeon was unavailable, so he became angry.

His threats of physical violence allow us to fire him as a patient. However, we must do what is right for patients. He needed an operation for a life-threatening condition; firing him would have delayed the treatment he needed, jeopardizing his life. We performed his operation, and despite a successful outcome, I doubt his perception will ever be that we treated him with courtesy and respect. Are we capable of delivering a great experience to someone like him?

Fortunately, his case is an unusual one; however, it is important to recognize that patients' responses to treatment are a collection of anecdotes. Patients and families rate their perception of the experience based on a variety of different emotions and feelings. And that's their right. But should we be obligated to be judged on them? I am biased when it comes to Mr. Smith—we did the right thing for him, but I doubt he will ever agree. Don't we deserve to be more fairly evaluated?

Dr. James Merlino, Cleveland Clinic
Healthcare delivery is a tough business; our “customers”—patients—are sick, afraid, confused and, occasionally, not of their right mind. As providers, we must commit ourselves to a higher level of patient-centered care; we must pay attention to the patient experience. But we must also realize that indeed the patient may not always be right, and critical actions to provide positive medical outcomes for them might result in negative patient experience outcomes for us.

We have a responsibility to take care of patients in the best manner possible. Medicare has a responsibility to be a fair partner and ensure that their tactics and processes are robust and appropriate for our difficult environment. We all share the common goal of wanting to do what is right for patients and improve the delivery of healthcare.

Dr. James Merlino is chief experience officer at the Cleveland Clinic.

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