Survey Takes Hard Look at Physician-Patient Conversations

Responses Reveal Communication Gaps; Social Determinants Rarely Discussed

November 07, 2018 10:57 am Michael Devitt – Results of a Harris Poll survey of more than 2,000 American adults show there are considerable gaps between what primary care physicians (PCPs) discuss with their patients and what patients would like to discuss with their physician.

Survey respondents presented a diverse range of views about what it means to be healthy. Ninety-two percent of adults agreed with the statement, "Health is so much more than just not being sick."

When asked to further define health, respondents typically provided multiple answers. Adults 65 and older included an average of about seven factors in their definitions of health, adults 18-44 chose four, and those 45-64 chose five. Among the factors most frequently cited:

• 73 percent of adults defined health as not being sick,
  
• 59 percent defined it as being happy,
  
• 56 percent defined it as being calm and relaxed, and
  
• 53 percent defined it as the ability to live independently.

Definitions of health varied significantly by age group. Eighty-two percent of adults 65 and older cited being able to live independently in their definition of health compared with only 36 percent of adults 18-44. Conversely, 25 percent of adults 18-44 included having a job in their definition of health, whereas only 10 percent of those 65 and older defined health in this manner.

Respondents then were asked which health-related topics they typically discussed with their PCP.

Although 74 percent of adults said they typically had discussions about physical health with their physician -- and more than 50 percent had discussions about test results, medications and exercise -- discussions about other key factors, including issues related to social determinants of health, were reported by less than half of respondents:

• 42 percent had discussions about the patient's diet,
  
• 40 percent had discussions on sleep,
  
• 36 percent had discussions about the patient's mental health,
  
• 20 percent discussed why it is personally important to the patient to be healthy,
  
• 13 percent discussed the patient's personal environment,
  
• 11 percent discussed what brings the patient joy and happiness, and
  
• 10 percent had discussions about the patient's spiritual health.

In addition, 48 percent of respondents overall reported having at least one chronic health condition. The two most common chronic health conditions reported were depression (19 percent) and anxiety (18 percent). About one in 10 respondents said they were living with chronic pain (11 percent) or diabetes (10 percent), and 12 percent reported having a chronic health condition other than those listed on the survey.

Fifty-two percent of adults said they and their physician didn't discuss much more than medical needs, such as physical symptoms, test results, medications and surgical history. Conversely, 53 percent of adults wished their physician would talk to them about nonmedical therapies such as nutrition, acupuncture, massage therapy and meditation, and 45 percent of adults said they wished they and their physician talked more about why they want to be healthy.

Q&A on Survey Results

Family physician Wayne Jonas, M.D., is the executive director of Samueli Integrative Health Programs. Jonas talked with AAFP News about the survey's results, which he presented during a recent webinar,(www.dropbox.com) as well as their implications for patients, PCPs and the U.S. health care system.

Q: The survey indicates a disconnect between what physicians want to discuss and what patients want their physicians to discuss. What do you think is causing this?

A: Part of the disconnect stems from how doctors are trained. Medical training sharply limits the ability of physicians to make healing their primary mission, and the current model of care does not allow for much time to capture the personal, social, behavioral and environmental factors that contribute to most chronic diseases. Unfortunately, patients will often defer to their doctor about what is discussed during their appointment, so if it's not brought up by their doctor, they may not be likely to mention it.

Q: Physicians seemed to emphasize physical health at the expense of other factors in their discussions with patients. Is this simply because of the way physicians are taught, or is it indicative of some other issue?

A: These results show that patients are not getting what they need from the current system to effectively manage their health on their terms. So, while medical training does contribute to how the typical doctor-patient relationship plays out, the state of our current health care system is also to blame. The system is set up to prioritize disease treatment, but we know that 80 percent of health is influenced by factors outside of the doctor's office. We need to place more of an emphasis on prevention and person-centered care if we are ever going to get out of this cycle.

Q: Many respondents associated social factors such as having a job, being able to spend time with friends and family, etc., with being healthy. How important are these factors, and how can physicians better engage with patients in discussing social determinants of health?

A: Research has repeatedly shown that even with full medical access and optimal medical treatments, a population's health improves only by about 15 percent to 20 percent. It's important that we understand a patient's experience in the world so that we can better understand where their issues are originating. So, for instance, if a patient lives in an unsafe neighborhood, it may be unrealistic to ask that patient to go for a walk after dinner to get exercise. You would need to come to another solution with the patient that fits in with their environment.

Social determinants of health contribute about 40 percent to the overall health and well-being of the population. What physician or health care system can afford to ignore something that contributes to 40 percent of healing?

Q: Patients want to talk with their physicians about a lot of topics, but a physician can't realistically cover everything in a 15- or 30-minute visit. What strategies can physicians use to best leverage their time to include these discussions?

A: It's true -- the relentless demands of the modern health care system force us to use most of our time dealing with a vast bureaucracy of insurance regulations, digital record-keeping, and volume-driven visits, but we're not talking about expensive technology, or huge changes to the medical infrastructure. It's a shift in our thinking. This could be as simple as integrating a few questions into a routine office visit or exam to evaluate those aspects of a patient's life that facilitate or detract from healing. Simply incorporating these questions into a visit can paint a picture of the patient's life experience and help to fill in some gaps that may be preventing the patient from getting better. This approach focuses on getting to the root of a patient's problem, and it doesn't have to take up too much time in the visit.

Q: Bottom line: What would you say to family physicians about the survey results?

A: The results show there is a significant disconnect in how patients and their doctors are discussing and approaching overall health. Speaking personally, as physicians we should be asking, "What matters?" instead of just, "What's the matter?" so we can better understand why our patients want to be healthy and what might be getting in the way of their health goals. Practicing with this approach allows us to get back to the reason we became physicians -- to heal.