Assessment tool puts value on personal touch
Trust, interpersonal relations are core domains
Good listening. Trust. Caring. Empathy. These interpersonal aspects of the medical experience, which many say have been undermined in the managed care era, are the focus of a new assessment tool developed by The Health Institute at the New England Medical Center in Boston.
While it is unclear how widely used the new tool will be in performance assessment and quality improvement, researchers are already using it to determine how insurance arrangements affect the physician-patient relationship.
The Primary Care Assessment Survey (PCAS) measures these seven domains that are derived from the Institute of Medicine's definition of primary care:
r accessibility;
r continuity;
r comprehensiveness;
r integration;
r clinical interaction;
r interpersonal treatment;
r trust.
Patients complete 51 questions that ask them, among other things, about their doctors' patience, friendliness and warmth, caring and concern, and the doctor's knowledge of them as a person.
"It evaluates some aspects of care that have, until this point, been overlooked by tools that ask patients for satisfaction or for information about their care," says Dana Gelb Safran, ScD, senior policy analyst at The Health Institute, who developed the instrument.
For example, while a patient satisfaction survey may ask how satisfied patients are with the doctor's thoroughness, the Primary Care Assessment Survey asks detailed questions about the medical interview, preventive counseling, and the thoroughness of the physical examination.
"I think this is going to have a very powerful impact on the way we think about assessing our performance," says Andrew L. Epstein, MD, a Newton, MA-based internist and consultant who is developing an assessment and intervention program for a practice management company based on Safran's work.
Relating well to patients is more than just a public relations issue. How well doctors interact affects patient loyalty, physician effectiveness, and overall clinical outcomes. "The PCAS scales were strongly correlated with three important outcomes of care: patients' adherence to their physicians' advice, satisfaction with the physician, and self-reported changes in health over the past four years," Safran says.
While patients may have a chance to comment about the doctor's interpersonal skills on a satisfaction survey, the PCAS hones in on more details.
Returning to 'art of medicine'
"In the past, tools to assess patients' experiences of care have typically lumped together all interpersonal aspects of care and have lumped together quality of communication with interpersonal treatment," says Safran. "We separated those two issues. While they are highly related - physicians who are good interpersonally and probably also good communicators -- they are separate issues. How well a physician communicates with the patient is actually a fundamental indicator of the quality of care," she says.
To Epstein, this work reflects a revival of interest in the "core of doctoring," or what is often referred to as "the art of medicine." Yet Epstein notes that researchers and clinicians are now looking at "what happens that leads to trust and satisfaction and how we can develop that as rigorously as the skills of bioscience."
In his work with The Bard Group, a Newton, MA-based firm that specializes in health care leadership, organizational effectiveness, and service, Epstein has worked with Safran to develop ways to assess and improve interpersonal skills for both physicians and staff. Epstein asserts that patient trust and satisfaction ultimately lead to better clinical outcomes and business performance, including improved patient retention.
"If you take [Safran's] data seriously, what you have to say is that trust and satisfaction are the products of health care," he says. "Without the highest levels of trust and personal connection, patients don't do what's advised for them. And patients aren't satisfied and may not come back."
Matters of trust and caring may seem too "touchy-feely" to learn in a training program. But Epstein and others are focusing on specific skills that lead to trust.
For example, communicating empathy is a distinct action that can put patients at ease and build trust and the "therapeutic alliance," says Debra Roter, DrPH, a professor at the Johns Hopkins School of Public Health in Baltimore and an expert on physician-patient communication.
"It's very important to inquire explicitly about feelings and emotions, not just because these things are related to patient satisfaction, but because they uncover important things about a patient's life that may be related to their problems," she says.
The PCAS targets other issues that are integral to primary care but rarely addressed by other measurement tools, such as continuity and integration.
For example, the survey asks patients how they judge "the quality of specialists or other doctors that your regular doctor sent you to," and patients report how long they have been seeing this physician.
Physicians who want to improve in some of these areas will need organizational support, notes Safran. "The ability to change them depends a great deal on the environment in which the clinician is practicing," she says.
Safran hopes to find out more about the organizational influences in a current study. She is comparing how different Medicare models (for-profit HMOs, not-for-profit HMOs, and fee-for-service arrangements) affect these issues of trust, continuity, contextual knowledge of patients, and interpersonal relationships.
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