Introduction
It is well noted that primary care and medical subspecialists who are not interventionalists, spend a great deal of their time caring for patients in the office. Over recent years, with the focus shifting to value based care, the primary role of the office visit has been to capture data for the EMR to enhance risk scores, assessing patients for care gaps that need to be closed to improve quality scores, review medications to ensure that the patient is adherent and filling their medication and, in general, trying to move patients out quickly in order to meet the ever-increasing demand for these visits.

Physicians feel the pressures of all of the above and are trying to balance the demand of professional life with personal life and increasing their value when participating in a group setting (medical group or broader group, such as an IPA or ACO). Also, demands associated with maintaining certification in specialty boards, meeting quality criteria set up by regulatory agencies and both State and Federal Governmental agencies only add to the pressures doctors are feeling. One significant issue is that they frequently forget is that patient satisfaction with their own services, as measured through various survey instruments, as well as patient transfers and complaints, is often sacrificed in order to focus on the above concerns.

If you look at this from a generational perspective, those physicians who lived through the days of “hanging out a shingle” like the television doctors of the 60’s and 70’s who built practices based on relationships they had with patients, such as Marcus Welby, MD, Trapper John, MD or Dr. Quinn Medicine Woman, have become greatly disillusioned and tend to push retirement plans forward. Alternatively, they look to sell their practices to hospitals, venture capital backed groups or insurance companies with a clear path to moving out. Some of that doctor-patient relationship was eroded when managed care came in and directed patients to physicians who participated in networks, not-so-gently moving patients to more “cost-effective providers”. Other changes and events occurred, such as COVID 19 pandemic, telemedicine and a general change in behavior and value held by patients regarding their physicians. Information, both true and erroneous that is available on the internet, created enough challenges that many doctors felt that the days of having a true doctor-patient relationship were coming to an end.

Now, technology has taken over a good part of the visit, with the focus on the EMR, teaching patients about ways to self-manage care using tools they can get at home, such as glucose monitors, heart rate and rhythm monitors and BP measurement. Patient communication is no longer typically a call to a patient to go over results or see how they are doing but is now focused on the development of a portal where the patient can go in and check their lab or x-ray results on their own and send a question to their doctor via a message center…and wait for a response. Technology also gave us telemedicine that has become a mainstay in patient visit offerings, but clearly has seen a significant downturn in utilization since the end of the COVID 19 pandemic, though its use in certain specialties, such as behavioral health, remains a valuable tool for ongoing patient care. In other cases, the use of telemedicine as an alternative to the ED visit has helped reduce costs and diverted some cases away from the extremely busy ED environment.

Physician attitudes have also changed. What was once viewed as a career completely focused on serving patients, has seen a major change with younger physicians demanding a more balanced work and family life. The provider well-being is now seen as an important aspect of the Quintuple Aim in healthcare.

The question is, how has this impacted the patients’ perspective of the value and satisfaction of an in-person visit to their doctor?

The Three A’s
In an earlier piece I discussed how lay individuals determined the quality of a physician and a physician visit using the “Three A’s” principal:

• Availability: Able to see the person when the person wants to be seen (same day for an illness, for example)
• Affability: The patient feels like they are treated special and the focus of the doctor
• Ability: After the visit, the patient has confidence in the diagnosis and treatment regiment prescribed by the physician, usually because he or she sat down and explained their decision to the patient in a way that the patient understood

What we have to determine is whether a physician who is focused on the following can really extend the qualities that patients are looking for in The Tree A’s:

1. Closing gaps in care
2. Determining past conditions to appropriately address risk scores
3. Performing medication reconciliation and adjustments
4. Completing all elements of the EMR to achieve the appropriate coding level
5. Answering questions from patients who have studied their medical condition on the internet and want answers to what seems like banal questions
6. Overbooked schedules
7. Review of results coming in from labs, radiology units, consulting physicians and other sources
8. Responding to messages from the patient portal, phone calls, pharmacy, referrals, managed care organizations and other sources that derail them from their focus

Refocus the Visit
Physicians can and should take charge of the office visit and keep in mind this is the key engagement vehicle between the physician and the patient. The outcome and feeling the patient walks away with from this meeting will likely determine how they respond to any survey, including important ones like CAHPS, HOS and other instruments used to measure quality of physicians. It will also determine their level of understanding of their medical conditions, and the level they participate in with decision making regarding their ongoing treatment of conditions.

The idea of taking the following steps should be to allow the physician to not only accomplish the tasks that improve objective quality measures but allow a focus on the patient and the chief complaint, re-establishment of a positive doctor-patient relationship and allow an overall improvement in the patient’s well-being.

1. Prepare ahead of time for the visit: Review the patient’s medical record 24-48 hours prior to their visit. Understand their chronic conditions, test results, treatments, and major concerns, as well as any social determinant issues and other family related or care giver related problems that may impact their overall health.
2. Pre-visit huddle: Conduct a pre-visit huddle with the care team. Identify and plan referrals for closing gaps in care, next steps in treating current issues with the team. Collect insights that the team may have regarding updates in the patient’s or their family’s status.
3. Focus on the patient: During the visit, make sure that you focus on the patient and not the EMR.
   1. Make eye contact.
   2. Empathize with the patient and their caregiver.
   3. Do not emotionally detach from the patient but stay professional.
   4. Ask about work, social life, and try to understand how this impacts the patient’s well-being
   5. Ask about caregiver issues and how this might affect the patient’s ability to adhere to treatment regiments (transportation, keeping appointments, medication, food, etc.)
   6. Try to get a good sense of the mood of the patient beyond the PHQ screening (based on eye contact, emotional lability, tears, a sense of doom)
4. Patient education and teach-back: Once the exam is completed, talk with the patient. Discuss their condition and offer reasoning behind your determination in an easy-to-understand way that is not patronizing. Ensure that the patient understands what you said by asking them to repeat back what they were told and support them with corrections or agreement.
5. Follow up contact: While a patient portal may be available, setting up a follow-up time for a personal contact may be in order so they can discuss what is occurring and how they are feeling. Technology is not for everyone.
6. Completion of the EMR: Of course this needs to be done in a judicious way, but can be done either while the patient is dressing or before the next patient.

Conclusion
Achieving improved quality scores in an efficient manner, while supporting and improving the patient and provider experience is paramount in a successful practice. While many of us have seen the changes in expectations of all stakeholders involved in healthcare, the one thing that remains steady is the relationship between doctor and patient. We need to refocus on that relationship, build on it and keep it foremost in the healthcare process.

If you need further assistance with improving quality or efficiency in value-based care, COPE Health Solutions has a solution for you. Please feel free to reach out directly to us at info@copehealthsolutions.com or to COPE Health Solutions at 213-259-0245.