Thanks to the Internet, direct-to-consumer drug advertising and the media's voracious appetite for medical news, patients are more knowledgeable than ever before.
Armed with information, they're demanding better service and accountability from medical providers. Unfortunately, doctors' busy schedules often leave patients feeling deprived of personal interaction.
Many doctors are taking steps to turn patients' frustration into satisfaction by improving communication.
Sutter Medical Group in Sacramento, Calif., and Great Neck (N.Y.) Medical ProHealth are examples of physician practices that have increased their office hours to ensure that patients receive the attention they need. Both practices also have introduced hospitalist programs, which coordinate the care of hospitalized patients under the direction of an inpatient specialist.
"The hospitalist doesn't supersede our role, but when he assumes responsibility for lab tests and keeps a pulse on the day-to-day status of patients, our hospital visits become more efficient, giving us more time in our offices," explains Harvey Pollak, M.D., an internist with Great Neck Medical ProHealth, a 12-physician multispecialty practice. "One to two extra hours four days a week enhances Great Neck's office schedule."
Sutter, a 150-physician multispecialty practice, added 30 hours a week, primarily during evenings and weekends; opened an additional urgent-care clinic to free up valuable office hours; and rotated several internists into the position of hospitalist.
To further improve communication, Sutter has enrolled 25 of its clinicians in PacifiCare Health Systems' Art of Caring Program. The eight-hour session emphasizes the importance of doctor-patient relationships and seeks to improve communication skills and healthcare outcomes through role-playing, video and lectures.
Started in the early 1990s and revamped last fall, the program is open to any physician who contracts with PacifiCare. Thus far, 170 doctors have completed it.
Henry Ford Medical Group, a 1,000-physician multispecialty group in Detroit, takes responding to patient demands for improved service seriously. It has instituted same-day access, in which doctors reserve a few spaces each day for patients who need appointments unexpectedly. Additionally, open access (no need for referrals to specialists) and extended hours (as many as four extra per week, per clinic) help cement doctor-patient relationships.
According to Chief Executive Officer Thomas Royer, the group uses patient satisfaction information generated from physician contacts to help improve its techniques. It relies on satisfaction tools, such as surveys and focus groups, and studies complaints and legal claims by patients.
If satisfaction scores are too low, doctors are encouraged -- then mandated -- to take remediation courses. Patient satisfaction, productivity and other criteria are weighed in appraising physician performance and determining compensation.
While consumers are insisting on better service, managed care is demanding efficiency from physicians. A survey conducted by New York Doctors MSO, a management services organization with 200 primary-care physicians in metropolitan New York, revealed that 45% believe the quality of physician-patient relationships suffers under managed care.
That seems to be the prevailing opinion of many doctors around the country, including Great Neck's Pollak. He bemoans the fact that doctors don't have enough time to interact with patients beyond solving the problem at hand, which can be frustrating for both parties.
"We've lost some of the tender, loving care that we used to foster with patients. Now a visit to the doctor is also an economic issue," he says. "It's the industrialization and commercialization of medicine, but quality and outcomes don't have to suffer because of it."
Ed Palank, M.D., president of Medical Communications in Bedford, N.H., believes the culprit isn't lack of time but the failure of physicians to listen. Medical Communications develops workshops to help providers improve their relationships with patients.
"Studies have shown that physicians wait only about 17 seconds before they interrupt their patients, which causes a breakdown in communication," Palank says. "We're doing something wrong if patients are afraid to communicate for fear of disapproval or criticism."
Elizabeth Vilardo, M.D., an internist who chairs the board of Camino Medical Group, a 170-provider practice in Sunnyvale, Calif., accuses HMOs of instilling distrust in patients. "When they hear, 'You don't need that,' they automatically think that means it costs too much, so they don't believe their doctors," she says. "You have to educate patients on the consequences of their demands and explain when care is not appropriate."
That's one reason Scott Wigginton, M.D., has washed his hands of managed care. With a solo practice in Sacramento, Calif., he is a rare breed. He previously had been part of a medical group affiliated with Foundation Health Systems. FPA Medical Management bought the struggling group in December 1996 and then folded it last November. After that experience, Wigginton is content to be away from an environment he says doesn't allow enough time to address patient issues and decreases access to care.
"Managed care is leading to the deterioration of relationships with patients," he says. "Doctors are constantly watched by administrators to ensure there is no overutilization of services, which limits care. As an alternative for those who can't tolerate the HMO environment, I am available 24 hours a day, seven days a week, but expect my patients to respect my time. I know them as patients, not numbers."
On the other hand, Dan Fields, M.D., Sutter's associate medical director, says managed care has enabled him to get to know his patients better and improve care. "I am responsible for getting them care when they need it and making an effort to see them before they are sent elsewhere," he says.
Managed care also has taken some control away from doctors who have been accustomed to running the show. David Hooper, M.D., senior administrator for clinical services for the Palo Alto (Calif.) Medical Foundation, a 185-physician multispecialty group, says this can be very detrimental. He says when doctors are perceived as laborers or technicians rather than professionals, their self-esteem and trust can deteriorate -- especially in their attempt to see more patients to compensate for lost revenues.
Into this mix has come the Internet, which offers information that enables patients to ask questions and take more responsibility for their healthcare.
However, physicians throw out a word of caution as to the credibility of some online information.
Harlan Krumholz, M.D., associate professor at the Yale University School of Medicine, says he recommends to his patients Web sites he considers reputable, such as the American Heart Association's. "I also question them about why they are asking for a particular treatment they may have read about and outline the potential benefits and risks before we come to a decision," he says.
John Nelson, M.D., a physician with Intermountain Health Care in Salt Lake City and a member of the board of trustees of the American Medical Association, applauds the more educated patient. But he also warns patients that some of the information on the Internet might have an ulterior motive -- for example, promoting some product or service. He also fears that patients may adopt the medical student syndrome: They read about a disease and then think they have it.
Drug advertising educates patients about available options but often leaves physicians' hands tied when the drug is not on a health plan's formulary.
In light of all the obstacles, PAMF's Hooper sums up the best approach for harried physicians and frustrated patients: "Relationships heal. That's our organization's mantra. What heals the patient is a trusting relationship resulting in peace of mind."
Mari Edlin is a Mill Valley, Calif.-based business writer.