William Osler once said, “The good physician treats the disease. The great physician treats the patient who has the disease.”
Emphasizing the importance of patient-centered care, Russell Rothman, Vice President for Population Health Research at Vanderbilt University Medical Center, adds that physicians must “understand patients’ beliefs, their motivations, their behaviors, cultural factors, and other issues that may be contributing to their current and future health.”
And we must expand our view. “The great health system treats the patient and their community to improve health,” he says.
Rothman’s group is currently participating in the Medicare Transforming Clinical Practice Initiative, where they teach practices of all shapes and sizes how to provide more value-based health care for their communities — how to measure and report on quality metrics, and how to use those metrics for rapid cycles of quality improvement. They work with these practices on becoming patient-centered medical homes, teaching the importance of addressing social and behavioral determinants of health, including the importance of engaging families in the community to improve individual and population health. And they work on engagement with local community organizations, health systems, and other clinical practices.
Many population health management programs introduced in recent years attempt to identify a high-risk population and then promote interventions to reduce costs and improve health. Some of these programs have succeeded, while many have failed or remain unproven, says Rothman. That failure could be explained by not adequately accounting for and addressing social and behavioral determinants of health.
“One factor that we think is particularly important that clinicians, clinics, and health systems can address is that of health communication, and how we use health communication to engage our patients and the community to improve individual and population health,” says Rothman. He points to the increasingly complex U.S. health care system, and that while patients are becoming sicker, hospitalizations and clinic visits are shorter, and patients and their families are tasked with greater responsibility to take care of their health. “This is a daunting task for most Americans who are not familiar with how to handle complex health care issues.”
Studies suggest that only about 50% of patients can tell you their discharge notices and treatment plans after they return home from the hospital, and that patients can only recall about 20% of what was said to them at a clinic visit. This can be particularly challenging for patients who have lower health literacy skills. More than 90 million adults in the United States have only basic or below basic literacy skills, and more than 110 have poor quantitative skills or numeracy skills. Additionally, 20 to 30 million Americans have limited English proficiency. Plus, the average American reads at about an 8th or 9th-grade level and has lower math skills.
“When many of us hear the term ‘literacy,’ we think first whether a patient can read, but literacy includes a host of different skills,” says Rothman. “It includes one’s cultural and conceptual knowledge, listening and speaking skills or oral literacy, writing and reading skills or print literacy, and numeracy or math skills. And literacy is much more of a functional skill — the ability for a patient or family member to read or be told something, to take that information and to process and then act on that information in an appropriate way.”
“Numeracy is a particularly important issue, because we use a lot of math when we communicate to our patients,” adds Rothman. Talking about medicine doses, blood sugar readings, portion sizes, procedural risk, and probability can be both challenging and intimidating for patients who don’t like math. “And here we are throwing math issues at them as soon as they walk in the door and we start talking to them,” says Rothman. Even patients with good literacy skills can have a difficult time.
Patients with lower health literacy skills have worse knowledge of their diseases, worse self-care skills, worse clinical outcomes, and higher rates of mortality. To help combat this problem, health systems and individual clinicians need to improve their how they communicate with patients and their families.
“As health systems, we often live in a bubble waiting for patients to come to us. This old approach just does not work anymore,” says Rothman. “People spend 99.9% of their time outside of the hospital or clinic, so we need approaches that can reach out to our patients and their communities and use good principles of health communication to understand their challenges and barriers and help them to address these barriers to improve their health.”
Health systems need to consider how patients can access and navigate clinics and hospitals, if they know how to contact someone for a question, and if they can understand discharge instructions. And when building asynchronous forms of interacting with patients, health apps, websites, and telemedicine, they need to reach out to the community to find out what they understand and what their needs are, and consider issues of language, culture, and other challenges. Most importantly, involve patients in the development of these tools so that they target the right people and can be understood — and actually help to improve someone’s health.
At the individual clinician level, remember to communicate clearly with patients. “Even though many of us went into medicine because we like science and math, our patients do not,” Rothman reminds the audience. Use picture-based educational materials written at the 4th to 6th-grade level. Avoid medical jargon. Focus on key behaviors. Keep information as practical and culturally relevant as possible. And bring patients’ social support, their caregivers outside clinic, into the conversation.
Understand what social factors may affect patients’ care. Do they have trouble picking up their medication? Can they afford it? If it causes side effects, will they stop using it? Do they have someone who can help them?
Clinicians must practice shared decision-making with patients, helping them to understand barriers to behavior change and working with them to set concrete, practical, achievable goals — and confirm patients’ understanding by asking them to teach back what they have learned. “Patients usually don’t tell us if they’re having trouble understanding something, so the onus is on us,” says Rothman.
“The good news is that there are opportunities for improvement,” says Rothman. “We can help clinicians and health systems improve how they communicate to their patients and to the community in order to improve individual and population health. The current emphasis on value-based health care and health care transformation is a great opportunity for us to get back to our roots, to be like Sir William Osler and treat the patient, not just the disease.”
From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.