Leana Wen, MD, MSc, an emergency medicine physician and the director of Patient-Centered Care Research at George Washington University in Washington, DC, has spent a lot of time talking about how patients can do a better job of advocating for themselves when they interact with the health care system. Her book, When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Testing, (St. Martin’s Press) is now out in paperback.
However, Wen also readily acknowledges that providers are a big part of this equation as well. “Doctors and patients together are in a health care system that is not ideal. We know that our health care system rewards us to do more to people rather than for them,” she explains. “We know that doctors are under more pressure than ever before to see more patients in less time, and we know that patients are not happy about this — and neither are doctors.”
Nonetheless, recognizing the constraints within the current health system, Wen notes that there are things emergency medicine personnel can do to facilitate a more effective and responsive health care experience for patients. For instance, she recommends that nurses take the time to encourage patients to think in advance about the information that they need to convey to the medical provider. “Some patients may not be able to prepare their story because they have been in a car accident or another emergency situation, and there is no time,” she says. “But otherwise, there is almost always some time that patients have while they are waiting to speak to the providers.”
Nurses can, for example, encourage patients to write down key elements of their story, and, possibly, even rehearse it with family members or friends who may be with them in the ED, says Wen. This can help to ensure that patients are able to tell their whole story when the doctor arrives. “Similarly, if patients have questions, they can write these down while they are in the waiting area so that they are as prepared as possible,” adds Wen.
Along the same lines, the triage nurse or tech can encourage patients to write down a list of the medications they are on as well as any medical conditions that they have. “All of these things will save time for the provider and, therefore, enable the provider to spend more time listening,” observes Wen.
A big frustration for providers is when patients struggle to coherently explain what medical conditions or problems they have, notes Wen. However, with prompting by emergency personnel, patients can be encouraged to effectively use their waiting time to organize their information and prepare.
Engage patients in decision-making
Providers themselves can do a better job of engaging their patients in shared decision-making, advises Wen. “Explain to your patient why you are doing certain tests,” she says. “Explain what it is you are looking for and what is the most likely diagnosis. That helps the patient understand, and it also helps the patient engage with you in the thought process.”
This type of communication can help to avoid repeat tests or other unnecessary procedures, notes Wen. For example, she explains if a physician tells a patient that he plans to do a computed tomography (CT) scan to check for appendicitis, this gives the patient an opportunity to point out that she had her appendix removed 20 years earlier. It’s an unnecessary test avoided and money saved.
It is also important for the provider to ask the patient what he or she is most concerned about, says Wen. “Often what they are most concerned about is not anything we may have even considered,” she says. “For someone with chest pain, we may be thinking ‘are they having a heart attack,’ but maybe the patient is concerned about a gallbladder problem because he may have had a similar attack that was painful in the same area.”
By asking a patient about his or her concerns, the provider can get crucial information that can be helpful in formulating an effective plan of care, observes Wen. “We in emergency medicine have to rule out life-threatening problems, but we also have to think about what is the likely cause of what is going on,” she explains. “It is not just that somebody has syncope. What caused the syncope and how do we address that?”
By engaging with the patient, providers have a better chance of avoiding misdiagnoses and unnecessary tests and procedures, notes Wen. For example, in her book, Wen describes the case of a man who presented to the ED with chest pain, and proceeded to undergo a whole series of tests and procedures to confirm that he did not have a heart attack or a pulmonary embolism. However, the patient suffered complications from all the tests.
“If the providers had spent more time talking to the patient, they would have figured out that he had been moving boxes and that he literally had a muscle strain,” observes Wen. “All of these things happened as a result of not listening to what the patient had to say in the first place.”
Take the time to explain ‘why’
While there has been considerable grumbling among providers about the growing focus on patient satisfaction measures, Wen believes that attention to the patient experience is long overdue. “Ultimately what we really need to do is design a health care system and an emergency care system with the patient in mind,” she says.
With regard to provider complaints that metrics for patient satisfaction may unfairly penalize them for denying unnecessary procedures or prescriptions to patients who demand them, Wen suggests that such concerns may be overblown. “Yes, you do have patients coming in saying that they need antibiotics and if you don’t give them antibiotics they are going to go to somebody else. That is possible,” she says. “But in the vast majority of cases, [the problem] is that physicians don’t have the time to explain why antibiotics are not needed. I have certainly found in my experience, and in research too, that when physicians take the time to explain why a CT scan is not needed or why antibiotics are not needed, patient satisfaction is actually higher.”
Wen adds that communication is the number one driver of patient experience. “The converse is true, too,” she says. “Miscommunication is the number one cause of malpractice, so I think the problem is less with patient demands than it is with time.”
Remember the basics
Wen urges medical educators not to overlook the basics of providing good care. “We have so much technology at our disposal that it is the sexier thing to teach. It is easier to order tests, but also sexier to teach about how to interpret MRIs, use robotic surgery, and all these things,” she says. “But we are forgetting the basics of what it means to be a doctor, and that the patient comes in and wants to be heard. The patient wants to know what it is that he or she has and wants to get better.”
However, instead of focusing medical students on how to do a good history, educators often focus on teaching them how to use technology, says Wen. “Certainly, technology is good and we want to make sure that future doctors know how to use it,” she says. “But we cannot forget to teach the basics of what it means to be a doctor: to combine both the art and science of medicine.”
Leana Wen, MD, MSc, Director, Patient-Centered Care Research, George Washington University, Washington, DC. E-mail: