Minnesota Physician cover stories

July 2017

Past cover stories

The value of Medicaid

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

Opioid Prescribing Improvement Project

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

Quality reporting

The importance of accounting for social conditions

 

By Paul Kleeberg, MD, and Phil Deering, BA

 

Like many Minnesota physicians, Dr. Lynne Ogawa first saw her Minnesota Statewide Quality Reporting and Measurement System (SQRMS) outcomes toward the end of the last decade. At the time, the family practice doctor saw patients at the Fremont Clinic, located in the heart of North Minneapolis.

 

Why just retire?

Consider physician emeritus

 

By Michael J. Weber, JD, and Nancy Lee Nelson, JD, MPH, RN

 

If you are like many other Minnesota-licensed physicians, you might be unaware of the option to retire as a “physician emeritus.” To retire as a physician emeritus, a physician has to complete a short application with the Minnesota Board of Medical Practice.

 

Regenerative Medicine Minnesota

Transforming the future of health care

 

By Jakub Tolar, MD, PhD, and Andre Terzic, MD, PhD, FAHA

 

We have grown accustomed to the medical miracles—antibiotics to combat infection; transplantation to replace failed organs; and biologics to control high cholesterol, rheumatoid arthritis, or psoriasis—that have transformed patient care. Despite remarkable advances, many serious health problems resist conventional medicine and surgery, causing suffering and shortening lives.

 

The Minnesota Adult Abuse Reporting Center

Protecting the vulnerable

 

By Commissioner Emily Piper, JD

 

An older adult woman living in northern Minnesota was at her most vulnerable—recovering from surgery after a stroke—when she became the victim of financial exploitation by her own daughter.

 

The CARES Model

A way to engage your patients

 

By Archelle Georgiou, MD

 

Sixty-two percent of Americans say they want to deliberate with their physician about their treatment options. And, to help make the right choices, consumers have been armed with an array of health information sites, symptom checkers, cost calculators, and provider quality scores and report cards.

 

Minnesota Prescription Monitoring Program

Important updates responding to an epidemic

 

By Barbara A. Carter

 

In a recent survey conducted by the American Medical Association, in which 44 of the 49 state prescription drug monitoring programs (PDMP/PMP) responded there was a 180 percent increase, between 2014 and 2016, in the number of physicians’ and other health care professionals that had registered for an account with a PDMP/PMP.

 

Regenerative Medicine:

Efficacy, Economics, and Evolution

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The CARES Model

A way to engage your patients

 

By Archelle Georgiou, MD

 

Sixty-two percent of Americans say they want to deliberate with their physician about their treatment options. And, to help make the right choices, consumers have been armed with an array of health information sites, symptom checkers, cost calculators, and provider quality scores and report cards. Unfortunately, the majority of patients simply abdicate decision-making to their doctor. Only 15 percent of consumers actively use health care apps and only 20 percent of patients raise the topic of treatment alternatives with their doctor.

 

While patients willingly delegate decisions to their doctor, they may simultaneously, and quietly, feel unsettled about the treatment plan selected for them. This “decisional conflict” results in patients being more likely to change their mind and delay their decisions. Retrospectively, these patients are more likely to feel regret—even if they have a good health outcome—when they realize they could have looked at more information and weighed the pros and cons carefully. And, they are more likely to blame their practitioner if they have a bad outcome.

 

Decisional conflict

A cardinal symptom of decisional conflict is when a patient asks, “Doctor, what would you do?” When people feel most vulnerable, they look for guidance and reassurance and hope their doctor will make the right decision for them. Empathically, most physicians answer this question; unfortunately, this merely deepens the patient’s conflict especially when the decision is between equally effective treatments. A physician who shares the health care choice they would make for themselves oversteps the boundaries of professional expertise and enters the zone of imposing personal bias into the recommendation.

 

A physician’s values and preferences are well informed but not a substitute for the patient’s because doctors’ and patients’ values are not always aligned. Only an individual can decide what tradeoffs they are willing to make relative to risks, complications, disability, pain, disfigurement, inconvenience, or financial investment.

 

The CARES Model

My recently published book, “Healthcare Choices: 5 Steps to Getting the Medical Care You Want and Need,” offers consumers a roadmap, the CARES Model, for making health care decisions. The model does not presume or imply that a patient has medical expertise or that their role is to replace the clinician. It emphasizes that doctors are experts in evaluating symptoms, establishing the path to a diagnosis, and using evidence-based information to lay out treatment options. Patients, however, are experts in themselves and responsible for understanding, identifying, and sharing their unique needs, beliefs, and preferences. Together, patients and doctors are equal partners in achieving health care outcomes.

 

This CARES Model will empower some patients to get actively engaged in their care, and physicians generally make the time to address questions especially if an individual is diagnosed with a serious medical condition. But here’s the problem: most patients don’t feel confident initiating or fully engaging in a conversation with their physician because they perceive a power imbalance. I routinely ask people why they are reluctant to “lean in” regarding their medical care, and the most frequent response is “No way! He (or she) might get angry.” This (hopefully subjective) fear of retaliation is pervasive and present across educational levels and financial strata.

 

Patients’ passivity is not their fault—nor their doctors’. It is rooted in American culture. According to the World Values Survey, the U.S. is grounded by traditional values that include national pride, high religiosity, strong parent-child ties, and deference to authority. In other words, as a nation, we are obedient rule followers who wait for direction from our politicians, pastors, parents—and physicians. When consumers are faced with hypothetical scenarios, they agree that people should advocate for themselves and the hierarchical dynamic with physicians is unhealthy. Nevertheless, culture and norms trump rational behavior, and people become patients, they want permission to be actively engaged in their care. So give your patients what they want—permission. Let them know it is really okay—and that you expect them—to participate in their health care decisions.

Here are the five steps of the CARES Model along with complementary actions physicians can take to support and encourage patients to get engaged: 1) Condition; 2) Alternatives; 3) Respect; 4) Evaluate; 5) Start.

 

Understand your “condition”

While it may seem obvious that patients should understand their medical situation, they often overestimate what they really know. For example, in a study of patients needing a bone marrow transplant, 77 percent thought they had enough information, but when asked specific questions, only about 52 percent demonstrated knowledge of the facts. I recommend that patients ask “So what?”—five times—to truly understand the implications of their condition.

 

  • Physician’s role: Use lay language to proactively explain the “so what” of a patient’s condition. When I recently told a friend that she might have a septic knee and needed to go to the ER she ignored my recommendation until I explained the “so what”—that a joint infection could destroy the cartilage. She left my home and went straight to urgent care.

 

Know your “alternatives”

People expect their doctors to objectively offer all the options for their care. However, physicians have biases that can lead them to recommend one treatment over another even if alternative treatments offer the same or even better outcomes. I recommend patients ask “What else?”

 

  • Physician’s role: Recognize your unintended human bias to recommend treatment you are most familiar with and suggest that patients consider other evidence-based treatment alternatives. Encourage them to use credible websites such as MayoClinic.org or print the Patient Education (Beyond the Basics) sections from UpToDate.

 

“Respect” your preferences

Patients’ preferences typically fit into four major categories: 1) medical (chance of a cure or recovery versus the risk of complications or death); 2) quality of life (level and duration of pain, dependence, or inconvenience); 3) financial (costs incurred by out-of-pocket expenses as well as time away from work); and 4) personal (cultural and religious beliefs, fears, and other sociocultural factors). I recommend that patients ask themselves, “What matters most?”

 

  • Physician’s role:  Resist the temptation to answer the question “Doctor, what would you do?” Instead, acknowledge the non-clinical aspects of a health care decision. Encourage patients to create a list of pros and cons in the four categories listed earlier and offer to review them at a follow-up visit.

 

“Evaluate” your options

Patients should take time to deliberate the tradeoffs of each option and avoid the pressure of making a decision while sitting in a doctor’s office. Neurobiologic research shows that when people get advice from an expert, the decision-making parts of the brain temporarily shut down causing patients to ignore their own internal value mechanisms and offload the decision-making. The risk: decisional regret. I recommend that patients ask themselves “What decision gives me peace?”

 

  • Physician’s role: Don’t ask patients to make decisions when they are in the room with you. At a minimum, step out and see another patient to give them time to contemplate on their own. For elective surgery or major decisions, recommend that they take time to review their options.

 

“Start” taking action

Patients not only share the responsibility for decision-making but also adhering to medications, appointments, tests, procedures, monitoring, and lifestyle changes. While a common coping mechanism is to “Take one day at a time,” this mindset reinforces a passive relationship with the physician and fuels a lack of accountability to the care plan. Instead, I recommend patients ask, “What next?” and establish a clear calendar of next steps.

 

  • Physician’s role: Explain (exactly) what patients need to do over the next 30, 60, and 90 days. Prepare them for known complications that can be safely addressed at home and when these complications are serious enough to require medical attention. Discourage them from “toughing it out” or waiting for their next visit if their symptoms surpass established thresholds.

 

Patients look for guidance from their physicians. Empower them, enable them, and encourage them to be actively engaged in their health. The outcome is better care because they will receive the care they need…and want.

 

Archelle Georgiou, MD, is an executive in residence at the University of Minnesota Carlson School of Management and has a regular health segment on KSTP-TV in Minneapolis. In February 2017, she released her first book, “Health Care Choices: 5 Steps to Getting the Medical Care You Want and Need.” She is trained in internal medicine.

Minnesota Physician Publishing Inc. © 2017