2003 Vohs and Lawrence Awards
& A Focus on New Products:
••Spring 2004/Vol. 8, No. 2

Health Systems

CPC Corner
A Patient's Manifesto--Communicating in the Exam Room | pdf >>

A Commentary by Lee Jacobs, MD

"Doctor, please keep this in mind when you spend my dollar."

Introduction

There is much debate and finger-pointing as to who is to blame for the present crisis over the financing of health care. Blame is assigned to every entity involved in the process of care and, truth be told, they all probably have a level of accountability for the crisis.

However, there is very little focus on what we all would have to agree is a major contributor--the consumer making purchasing decisions is not paying the bill. No wonder health care costs have spiraled out of control! The patient-consumer is given a blank check and interacts with a provider-seller of the product who has few if any incentives to provide the most cost-effective quality product. Why, then, are we surprised that, in attempting to appease the consumer over the years, the provider has given away the store? The present financing system for health care is providing the exact outcome for which it was designed.

Change is needed. If significant and effective steps to revise the process of paying for care are not implemented, the Federal government will take over the store. A different payer, but the same lack of accountability on the part of the consumer and the provider.

As we all are aware, the present-day solution is to have the consumers of health care shoulder a portion of the financing of their health care cost. The intended result is that not only will the primary payer's bill be less, but it is also hoped that the patient will be much more involved in decisions related to choices in their health care experience. Easy to state, but what might patient involvement actually look like?

For a patient's involvement in decisions to be meaningful, the clinician and patient will need to have a drastically different conversation if our society is to take the necessary major strides to decrease the cost of health care. The key word is different, because the type of conversation proposed here is generally not taking place in exam rooms across the nation.

Here are five clinician-patient communication principles that I am calling "A Patient's Manifesto" (Table 1).

"Doctor, when you are spending my hard-earned dollar, I need you to keep the following in mind."

Principle #1 ­ Please Listen
"I want to trust you with my health--and that's a big step for me. Please hear me out because my trust is based on a belief that you know me well--what I like and what my needs are. This includes my financial capability."

Principle #2 ­ Let's Talk Cost
"Don't assume I can pay. Ask me! I may not feel comfortable raising the issue of cost each time, so can you please make certain that you bring up cost considerations for medications or procedures? If we don't talk about what I can afford, I may not be able to follow your directions--and then where will I be?"

Principle #3 ­ Do What's Right
"I would like you to ignore what you hear and read from drug company advertisements. Please use your expertise--what you have studied and concluded based on the best available information--and offer that to me. I want
the most inexpensive option that you believe will most likely resolve my problem. If I don't need that expensive blue pill I see advertised, please don't give it to me!"

Principle #4 ­ I Need To Hear My Options
"When it comes to planning the best next steps for me, please give me options. I come to you because you are the expert. However, it is my choice, and so I want to make an informed decision. With your help, I can weigh what's best at the very best cost possible. I just need to hear options."

Principle #5 ­ Please Be There for Me Tomorrow
"Finally, and most importantly, I need you to give me a feeling that no matter what options I choose or what happens, you will be there for me tomorrow if I need you."

Conclusion

What do you think? Would this be a different dialogue for you to have with your patients? The cost component of the conversation may be new to many physicians, although in reality it is just another dimension for us to consider as we get to know and care for the total patient.

I believe these five principles underscore the basics of good clinician-patient communication: listen, help the patient feel comfortable in voicing their wants and needs, present choices so they can make an informed decision, and then remind them that you care about them and will be there for them tomorrow.

Although the clinician may be caring for a patient in an environment quite different from even 10 years ago, the fundamentals of good clinician-patient communication remain the same.

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