Patient engagement and shared decision making. We hear these terms a lot these days in primary care. We are told that they will lead to more satisfied patients and better outcomes. Arguing with these concepts will likely get you labeled “paternalistic,” “old school,” or “politically incorrect.” But why would you? Theoretically they make perfect sense. Who wouldn't want informed patients who care about their health?
But we practice in the real world, where things aren't always clear-cut. Perhaps you can recall a patient who came to your office armed with all sorts of misinformation from the Internet. You attempted shared decision making, but the patient left convinced that you were closed-minded and didn't know what you were talking about.
After a few experiences like that, we can likely agree that patient engagement without trust and mutual respect is not the best avenue to great relationships and improved health.
In his now famous Chronic Care Model, Ed Wagner, MD, MPH, described “informed activated patients” interacting with “prepared proactive practice teams” to achieve better outcomes.1 The patient-centered medical home model built on his concepts and added a few more. This is tough stuff. No single intervention is likely to produce a fully informed, activated patient. Better patient education handouts, clinical summaries, office discussions, disease management classes, self-monitoring, and motivational interviewing will likely help.
Now let us consider another tool. How about giving every patient a copy of your office note following their visit?
I strongly encourage you to read the article by Hannah Chimowitz and Leonor Fernandez, MD, called “Sharing Visit Notes: Getting Patients and Physicians on the Same Page.” Drawing on experience with the OpenNotes initiative, they make a compelling case for how sharing your entire office note with patients can increase patients' confidence, understanding of their health conditions, and trust in their provider. In other words, this simple gesture could increase both patient engagement and trust simultaneously.
Some objections immediately come to mind: This will create more work in your already overburdened day. Patients won't understand the notes and will contact you for clarifications. Patients will find errors and want them corrected. You will have to take more time to write notes that use non-technical language that patients can understand. You may offend patients by calling them obese or even cause undue anxiety by sharing notes with differential diagnoses that describe a low probability of cancer or another serious condition. All of this may slow you down.
The article addresses these concerns, and related research can be found at the OpenNotes website. The organization's initial research showed that after one year 99 percent of patients wanted full access to their office notes to continue, and few if any physicians dropped out (although some were not thrilled). A few of the fears described above were realized, but they were uncommon. It should be noted that large academic medical centers and multispecialty groups have dominated the initiative, which raises questions about whether the results apply to small, independent practices. There is no compelling reason to think they don't, but more study is needed.
All in all I'm ready to begin. Now if I could just get the rest of my practice to agree …