Just Read: Listening means better patient outcomes

In my last post on listening ( see: Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda | Ted Eytan, MD ) I said I couldn’t find a newer study than 1999 … and then I met the author of this paper, Saul Weiner, MD, at the Center for Total Health (@KPTotalHealth) via an intro by Alan Spiro, MD (@AlanHSpiro), who it turns out is studying patient-physician communication, and steered me to this paper.

Cool technique: concealed recorders

As with the previous papers I reviewed, this study involved the audio recording of patient-physician visits, with a twist. With prior physician consent, patients were randomized to bring in a concealed recording device without the physician’s knowledge for a particular visit. I’m imagining a patient checking in for their doctor visit and then being approached by a research assistant to slip a recorder in their pocket. Patients do want to help if we let them :) .

403 encounters were analyzed which contained a total of 548 “red flags” “including missed appointments; nonadherence with medications; poor control of a chronic condition, or lack of follow-through with laboratories, tests, or referrals.” Audio recordings were also screened for red flags (“Doc, I can’t afford these pills”).

What the researchers were ultimately able to discover after studying physician response to these red flags and following up in the patient chart was whether:

  • A context-senstive care plan was developed
  • An improved outcome was the result (more appointments made, better adherence to plan)


patients with a contextualized care plan were more likely to have a positive outcome (odds ratio [OR], 3.7 [95% CI, 1.2 to 11.4]; P �� 0.021)…When the patient had seen the same resident at their most recent visit, they were more likely to have a positive outcome than when they had seen a differ- ent physician, regardless of whether the care plan was con- textualized (OR, 3.0 [CI, 1.0 to 8.9]; P �� 0.044).

It’s a little hard to visualize this with a chart since there are many dimensions; I did my best.

So there you have it, listening for 6 seconds longer elicits the patient’s agenda, and listening and planning in the context of the patient results in agendas with less problems down the road.

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Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda

“…asking “Anything else?” repeatedly until a complete agenda has been identified appears to take 6 seconds longer than interviews in which the patient’s agenda is interrupted” Reference: Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the Patient’s Agenda: Have We Improved? Jama. 1999;281(3):283–287

Actually I read this a while ago; I realize I’ve never turned it into a slide, until now.

I’m using it to illustrate an artifact of physician culture, part of a keynote I’m preparing (Crowdsource Request: Keynote for Labor-Management Parntership all-hands – “Social innovation” | Ted Eytan, MD).

We tend to interrupt people. On average about 23 seconds into them telling us why they are here to see us. Good news is that it improved 5 seconds in between the 15 years it was studied (1984 and 1999). I can’t find a newer study, if anyone knows of one, let me know.

Interestingly, it was found that if physicians just listened for 6 seconds longer, by repeatedly asking “Anything else?” or “Tell me more?” they were able to know what the patient was concerned about. The opposite of this is not knowing up front, and the consequences of that – the door handle conversation, the “late concern,” the problem unexplored, and a less efficient encounter, and sometimes devastating health experience.

One interesting correlation is that physicians with fellowship training (training after residency) were more likely to exhibit listening behavior than those who didn’t have the training. These were all family medicine specialists so there’s no comparison of other specialties in this study.

This fits with what I have mentioned before in the world of listening, reducing conscious and unconscious bias, being there for the people we serve in and out of the exam room. The good news is it’s easy to move away from a “Yes I know what you’re asking for,” culture to a “tell me more” culture. I know because I do it all the time – “say more.” My colleague Danielle Cass (@DanielleCass) also taught me this one – “Go on..” Try replacing this response with the one you normally use and see what happens (and let me know what happens – magical!).

Listening is the hugest innovation in health in the decade of the patient.

6 seconds :)

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Presentation: Why be Social (Media)? @BerkeleyISchool

I had the opportunity in 2013 to repeat what I got to do in 2011, which is lecture at the University of California School of Information (@BerkeleyISchool) in the following course: Info 290A. Finding Health in the US: Health Care and the Information Economy | School of Information

Below are the title slides from the 2013 lecture and the 2011 lecture. Notice how times have changed? If you do our you don’t please let me know in the comments.

2013 – “Our Cities are Changing”

2011 – “Social Media Creates Revolutions”

There’s a discussion and update on the latest data about social media use, and of course a clip of Regina Holliday (@ReginaHolliday) who is the perfect example of why social media should be used for listening as much as talking. Does that theme come across? :)

In terms of what I learned, this current class is mostly not using a lot of social media and definitely not using Twitter very much, which tracks with the national data (from the terrific @PewInternet ) that only 18% of Americans do. It’s a good reminder to social media enthusiasts that there’s a wide gap between the do and don’t.

Rest of the slides are below, enjoy. You can also access them full screen here.

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A Walk about Walking with John Francis, PhD, National Geographic Fellow

Post-Walk with Dr. John Francis – View on Flickr.com

Walking is not just good for your muscles, your brain, and your heart – it connects you to exceptional people who are passionate about walking, too.

I am happy to say that my well-known love of the walk prompted John Francis, PhD‘s colleague Patti Brennan, PhD ( @pattifbrennan ) , to connect us when he was in Washington, DC last week, as part of a meeting of National Geographic Explorers Fellows Program.

Even though I read a little about his story before we met (walking, of course), I enjoyed him telling me about it himself, because it’s amazing. He spent 22 years of his life walking exclusively, and 17 years of not speaking, following the 1971 collision of two oil tankers in San Francisco Bay. He told me he realized that he wasn’t really listening to people – he was only formulating his next thoughts as he would argue about the choice to forgo motor vehicles. He’s written a book about his experience called Planetwalker, and you can read about that as well as listen to an interview of him on the National Geographic site as well as on Wikipedia. He’s been speaking since 1990.

He’s recently taken a group of students on a walk across Ohio and is planning an entire learning curriculum that’s based on walking and appreciating / observing everything in our environment. I felt a sense of camaraderie as I had a camera in my hand, which is often the case when I’m walking.

I’m posting information about John’s story here because I’m impressed by his work, I think you’ll be too, and impressed with the commitment he’s made to respecting people and the environment through listening, observing, and walking. Come join the walking revolution if you haven’t already.

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Now Reading: Another way to listen, Video Ethnography

This paper, published by esteemed colleagues at the Kaiser Permanente Care Management Institute, describes results from a program that now includes 37 teams and 130 people, who have engaged in in-depth training to understand the real experience of patients and those who care for them using video:

This method is particularly effective in helping increase understanding of vulnerable people who are not well represented in ap- proaches such as focus groups and patient advi- sory councils—for instance, frail elders, patients nearing the end of life, and those with multiple chronic conditions. Video ethnography also helps in focusing on pivotal points in health care, such as transitions between settings.4

This is a real technique that complements work to involve patients in the design and operation of the health care system. I have previously posted the link to the CMI Video Ethnography Toolkit – you can find out more about this here: Now Reading: Getting Started in Video Ethnography – Tool Kit – Kaiser Permanente Care Management Institute | Ted Eytan, MD.

Showing a video of the patient experience does not replace involving patients in other ways, however it does bring information that doesn’t come from other traditional sources. In the paper, work to uncover why medication reconciliation was not as effective as it could be, even in a system with a comprehensive electronic health record is described. A dose of reality is contained within, which is that an EHR is not enough – the ability to lead, and listen must come along with it.

Medication reconciliation at patients’ homes, in which home health nurses tried to verify pa- tients’ medication lists, was inconsistent and not comprehensive. Discharge instructions often lacked specific details. Home health nurses were unable to access Kaiser Permanente’s electronic health records while in patients’ homes and did not have a definitive list for medication reconciliation.

In a post-EHR health care organization, which hopefully the entire United States health system will be one day, the need to learn faster will never stop.

At Kaiser Permanente, we use video ethnography at various stages of the quality improvement process to identify care gaps, unmet patient and caregiver needs, and effective practices. We also use it to communicate insights to clinical and administrative organizational leaders, identify improvement opportunities, and help build collective will for change.

Here’s a link to the press release with a short video about this work: Kaiser Permanente Finds Videotaping Care can Produce Rapid Quality Improvement | Kaiser Permanente News Center

Take a look. I hope to enroll as a student this summer in a Kaiser Permanente video ethnography course, it’s my last chance in the 2012 training season. Listening can’t be beat.

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Now Reading: Yikes! What physicians in training don’t ask patients admitted to the hospital

The hospital can be a very scary place, and when I read this study, I immediately thought that it would bring to life the worst fears of our patients, their families, and their doctors too.

The paper describes structured observations of PGY-1 and PGY-2 (first and second year out of medical school physicians-in-training) doing initial history and physical examinations of patients in the hospital.

As the title says, the study was “single-blinded” – the physicians observed did not know what they were being observed for, just that they were being observed (consent was obtained from both the patients and the physicians).

And… while patients were asked 100% of the time what medications they were taking (score for medication reconciliation), they were asked what they did for a living 4% of the time, level of education 0 % of the time, and from 0 to 100% of a list of other important pieces of information. Same general trends were seen in physical exam performance. Take a look at the charts by clicking on the link above and see what thing you would want your doctor to know if you were put in the hospital wasn’t asked.

Average time observed doing physicals and history: 7.3 minutes for history, 5.29 minutes for physicals, average time claimed in a survey of the doctors: 28 minutes and 15 minutes respectively . Huge discrepancy.

36% of the time, the physicians did not introduce themselves to the patient.

72% of the time, the physicians did not explain what they were there to do.

Remember, this is admission to the hospital.

“Unclear what the most effective approach would be to change these behaviors”

This is the ominous sounding statement made in the discussion by the author, who appropriately conveys his dissatisfaction with these results, and the fact that the physicians have been taught what the right things are to do.

From my own experience, I believe him. The issue isn’t knowing what to do. In my own training, I didn’t explore the patient and family experience as much as I should have. My residency faculty really helped me with that. At the same time, they were under tremendous pressure to balance educational requirements, the needs of patients getting care, and the needs of their fellow physicians and nurses that they recruited to participate in our teaching. Sometimes this balance was not balanced in a stressful environment.

Could we recruit patients and families also?

As much as we recruit quality faculty to teach residents, couldn’t we recruit patients and families, too?

It’s a familiar experience after a resident takes care of a patient in the hospital to be asked by the patient if they can join the resident’s practice. What would it be like if each resident needed to recruit 1-3 patients that they took care of to become part of THEIR (the resident’s) care team? Imagine them asking one of their patients or their family on discharge, “Mrs. Smith, as part of my training, I need to have 3 patient advisors who will help supervise my training, would you be available?”

Interestingly, an example of the clarity that patients bring to a physician’s development at any stage of practice-life comes in the same issue of The Permanente Journal, from a patient with an adverse outcome (“Bridging Physician-Patient Perspectives Following an Adverse Medical Outcome

Until my mother went through this experience, it never occurred to me how much medical professionals ask of us. Our family was asked to entrust the care of our loved one to strangers, her life and health to a system that sometimes creates barriers for the sake of efficiency. Then in the face of an error we are expected to stay quiet and accept this devastating impact on our loved one.

This article speaks about the HealthCare Ombudsman/Mediator Program at Kaiser Permanente, which brings patients and physicians together to resolve communication, quality, and trust issues. In the same article, a physician who discloses a surgical error carefully to a patient and their family says:

This process of explaining myself, opening me up to colleague scrutiny and patient disappointment, was by no means easy. Nevertheless, I know the price paid was infinitely less than living with the thought I had caused harm to a patient and did nothing to remedy it with a truthful disclosure and a heartfelt apology.


Thereafter, I followed-up with my patient and her family, explaining the systemic changes made to prevent a wrong part from ever being introduced during a surgical procedure.

Could some of these people, during and after their healing, serve as advisors/coaches/guardian angels of our future physicians as they learn their craft? They (the patients) are who I see as my guardian angels today – this just speeds up that journey.

Is this farfetched, is this happening somewhere already? What are the nuances? Please post in the comments

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Studying leadership at pepper-spray-less Occupy DC

I have been wondering why California Occupy camps have been igniting in violence and conflict, while Washington, DC’s camp ( @occupy_DC @occupyKst ) seems to coexist peacefully with the surrounding community. These two outcomes make me curious about leadership.

There’s no pepper spray here, the camp is 53 days old today, the first time I walked through it (it’s in the middle of the city) I was immediately amazed. It feels like a community, it is hard to explain. There’s actually a dentist’s office on site, with community dentists providing care on the weekends. There’s a kitchen, of course, and there’s sanitation – and this is where differences start to emerge.

It appears that the National Park Service, with responsibility for McPherson Square, made the decision to engage with the residents here. You can see posted signs informing them of proper sanitation procedures, along with portable toilets, adorned with signs by residents urging clean habitation (see photos below). There is a police presence nearby, but no conflict.

I found some articles that describe the differences, including the conscious decision by the City Council to engage, rather than fight, the residents. The space itself is in a relatively unused part of the city and the camp actually brings activity to a place that formerly had very little. There’s even some urban planning going on within the Square.

I recorded an announcement a few days ago, by a resident who had approached local Metropolitan Police Department leadership to clarify behavior that had been seen, and the response provided was, “Thanks for telling us,” and no conflict.

Yesterday I asked one of the residents if my hunches were correct. She said she has noticed increased police presence, but there has not been conflict. I asked about health care. She said there was a medical tent right behind us. You can see the list of needs on the board, which includes an Automated External Defibrillator – they are thinking safety. I asked if anything was not going well. She said, “This weather” (it was raining). We were interrupted at that point by a human mic announcing that the DC Department of Health was coming to do a health inspection. All of this happened while we were standing in front of an Information tent, where information was being given out (just like it said).

I think it’s great to have an example, here in Washington, DC, of a different kind of leadership in an environment of dissent. Here, the results are less conflict, more collaboration, less harm, more speech, less failure, more success. For now. Also, less press coverage. I hadn’t seen these differences written about, so I decided to create this post.

From a leadership perspective, I think the Occupy movement may well result in a few textbooks (or whatever format knowledge will be in in the future) being written about how to lead.

As usual, I see many analogies to health care (and life in general).

Photos of the above plus links to the articles cited are below. Click to enlarge. Let me know what you think.

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