Talking through time: Trends in communication and the evolving patient-physician relationship

Flashback to 1913, the year the American College of Surgeons (ACS) was founded “to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.”1 Approximately 6 percent of the U.S. population owns a telephone.2,3 Face-to-face interactions are the cornerstone of the patient-physician relationship. The “father of modern medicine,” Sir William Osler’s adage, “Listen to your patient, he is telling you the diagnosis,” is accomplished through office visits and house calls.4

Today, communication is handled much differently. An estimated nine out of 10 Americans own a cell phone, and just as many have access to the Internet at home.5,6 Physicians no longer make house calls, and for a growing number of patients, text messaging and telemedicine are alternatives to phone calls and traditional office visits. How has the way we interact and communicate with our patients evolved since the College was established, and how will this paradigm shift affect the future of the patient-physician relationship?

Current use of technology in patient communication

Despite the invention of the telephone in 1876 and the development of electronic health records in 1972, e-mail in 1993, and Facebook in 2004, advances in technology have had surprisingly little effect on patient-physician communication. A Nielsen study in 2015 showed only 28 percent of the approximately 5,000 Americans surveyed had access to a patient portal, 15 percent to online messaging or e-mail with their physician, and 9 percent to text message appointment reminders, despite 34 percent, 28 percent, and 28 percent of patients, respectively, stating that they would like to use these forms of communication.7

Although advances in communications technology have had a limited effect on the logistics of patient-physician communication, democratization of information facilitated by the Internet has forever changed the dynamics of the patient-physician relationship. Perhaps the most notable change is the evolving role and expectations of the public regarding patient care. According to a 2014 survey by the Pew Research Center, 72 percent of adult Internet users say they have searched online for information on a range of health issues, most frequently about specific diseases and treatments.8 As a result, patients now come to their physicians with more knowledge of their specific health condition than ever before. No longer seeking unquestionable paternal guidance, patients expect to play an active role in their care, particularly in the form of shared decision making.

Because most patients consult “Dr. Google” and social media before seeking medical attention, many surgeons have become active curators of online medical information. Although social media may have yet to find a role in direct patient care, numerous surgeons have forged a professional online presence to provide patient education to the general public as well as emotional support to patients at large. Surgeons are making this type of contact with patients through blog posts, Facebook pages, YouTube videos, tweets, and tweetchats.

Deanna Attai, MD, FACS, co-moderator of the #BCSM (breast cancer social media) Twitter support chat, is an example of a surgeon who uses social media to connect with the general public. Dr. Attai considers social media to be a powerful tool for providing patients with education, support, and guidance.9 She specifically uses Twitter to disseminate information about new studies, dispel myths, and encourage second opinions when appropriate. She also has discovered that social media offers an unprecedented opportunity to learn from her patients. Dr. Attai’s experience moderating the online breast cancer chat has fostered a deeper understanding and appreciation for the patient experience—insights that she may not have been able to glean from 15-minute office visits. [Personal communication between Dr. Logghe and Dr. Attai, March 19, 2016.]

The evolving surgeon stereotype

These changes in the patient-physician relationship are transforming the public’s perception of surgeons and our profession. The traditional surgeon archetype has been the “mythical surgeon”—someone paged in the middle of the night, a well-coiffed demigod who glides into a patient’s room with only a few moments to frame the gravitas of the situation before urgently charging to the operating room to save the patient’s life. Patients did not communicate with the traditional surgeon; they experienced him (gender intentional), left only to wonder in awe. Lack of access to medical information compounded by reverence for the dedication and expertise of the surgeon seemingly obviated the need for patients to understand the profound effects of their disease on their own experiences.

The democratization of information over the last two decades is changing patients’ perceptions of the surgical profession, and that change has produced a subtle yet significant reshaping of the way that patients receive their care. Today’s surgeon is stepping down from Mount Olympus to engage with the public through commentary on Facebook and Twitter and other social media platforms. As one patient-blogger stated, “These surgeons go home at night like the rest of us and eat dinner, toss and turn in bed wondering about the complexities of life, brush their teeth, laugh, cry, wipe a child’s tear, hug a friend in need, run, weight lift, play the violin…”10 In short, these new lines of communication with our patients are driving the ascent of a new surgeon archetype: the “human surgeon.” This trend toward the humanization of the surgeon has paralleled the shift in patient care from physician paternalism toward patient autonomy and shared decision making.

While advances in communication and access to information have coincided with a symbiotic evolution in the patient-physician relationship, they have also resulted in unintended consequences that are often at odds with surgeons’ own perceptions of, and aspirations for, our profession. For instance, the importance of patient-centeredness is underscored by a multitude of new regulatory policies requiring physicians to divulge practice outcomes and patient satisfaction scores.11,12 Consider the situation when the WebMD-prepared patient presents to the surgeon’s office with a clear diagnosis and an even clearer expectation of an operation. If, after thoughtful consideration of the patient’s mind and body, the surgeon recommends an alternate treatment plan, the patient may report a low satisfaction score, even if the surgeon’s recommendation embodied the utmost compassion and appropriate application of medical knowledge. From the surgeon’s perspective, these metrics betray a complexity inherent in every surgical patient that simply cannot be captured quantitatively.12

Our tradition teaches us that every patient is different, and we must embrace that uniqueness to deliver excellent care. Thus, it is ironic that the same forces that have served to humanize surgeons are, in a sense, dehumanizing our patients. When the democratization of information and concomitant shift in the patient’s expectation to participate in their care creates an incentive against the surgeon’s ability to deliver that care, both patients and surgeons lose. Surgeons of today must continue to grapple with this tension to project the image of the surgeon to which we aspire in a way that resonates with our patients.

The future of technology in patient communication

Looking forward and envisioning how the surgeon’s use of information technology (IT) will continue to evolve and shape the patient-physician relationship, it is prudent to critically assess the history of IT in the surgical workplace. The introduction of IT into the health care environment was initially heralded as a means of improving efficiency and workflow, with the promise of more time for one-on-one communication and an enhanced personal patient-physician encounter. Anecdotally, however, the need for surgeons to sit at a computer with their back to their patients while they review patient data and electronically document key clinical findings has led many surgeons to argue that technology has disrupted traditional workflow and impersonalized the patient-physician relationship.

A 2012 report from the Agency for Healthcare Research and Quality sought to objectively evaluate the effect that IT has had on health care processes, clinical outcomes, shared decision making, and patient-physician communication.13 Among 324 reviewed studies, IT applications (such as clinical decision aids, IT-guided disease management, telemedicine/telemonitoring systems, personal health records/patient portals, and electronic messaging) tended to demonstrate improvements in outcomes and metrics; however, several barriers to optimization also were identified (see Table 1). Improved outcomes generally are well received by all stakeholders in health care delivery, but the cost has been the intrusion and otherwise indelible mark that IT has left on the patient-physician encounter.

Table 1. Barriers to the use of Information technology in health care

  • Poor interface usability
  • Limited access to IT applications due to:
    • Age
    • Low income
    • Education
    • Cognitive impairments
  • Low computer literacy among patients and clinicians
  • Insufficient basic formal training
  • Physicians’ concerns:
    • Increased work
    • Problems with workflow
    • Problems with new system implementation
    • Lack of adequate funding
    • Problems with reimbursement
  • Concerns about confidentiality of patient information
  • Depersonalization
  • Incompatibility with current health care systems

To maximize the clinical benefits of IT and minimize the strain it places on the patient-physician relationship, surgeons must explore new ways of applying technology. Jonathan Weiner, DrPH, professor of health policy and management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, has identified several educational and socioeconomic factors that influence how electronic-health (e-health) can impact patient-physician communication (see Table 2).14 To improve communication, Dr. Weiner argues that efforts in the e-health domain will require dedicated investment by clinicians, managers, policymakers, and scientists, who must work hand-in-hand with consumers to drive a shift from the standard 15-minute face-to-face, one clinician/one patient interaction, toward a more global concept of population health and wellness support. Moving forward, surgeons will need to leverage these factors to close the digital divide in terms of patient and physician access to IT as well as their familiarity with its use to preserve the sanctity of the patient-physician relationship.

Table 2. Impact of e-health on patient-physician communication

  • Health IT and its embedded software will mediate almost all health information and will be the source of almost everything that physicians and other clinicians will learn about their patients.
  • Patient information will be accessible to all providers anywhere, anytime.
  • Almost all patient-provider interactions will be mediated by the electronic workflow (that is to say, supported by digital guidelines and protocols) before, during, and after any patient-provider contact.
  • Patients can become full partners in their health care and wellness-enhancing processes. These patients will have electronic access to almost as much information about their condition and the medical evidence base as their providers.
  • The art and science of care surrounding the traditional face-to-face patient-provider interaction will be forever changed as all aspects of communication, interaction, and information flow will become mediated and monitored by electronic tools.
  • The IT-mediated process will also dramatically change communication patterns between providers. IT will enable all providers to work as a team and to coordinate their actions far more effectively, even if they are at different locations.

The path ahead

The challenge for the surgeon leaders of the future is determining how to maintain the core elements of patient-physician communication—creating interpersonal relationships and exchanging information to determine optimal treatment plans in a culturally sensitive and value-centered manner—in the face of the rapidly changing and often disruptive nature of technology and social media. A truly multidisciplinary effort that draws expertise from the fields of interpersonal/mass communication, clinical sciences, health informatics and IT, public health, population sciences, and health management and policy will all be required to ensure that e-health applications and e-health systems are designed with an evidence-based focus and with attention to preserving the sanctity of the patient-physician relationship.

That patient-physician relationship has been and will continue evolving with time, both as a byproduct of technological advances as well as shifting societal values. From the paternal house calls of the early 1900s to the present day physician-led tweet chats, modes of communication have changed, yet the goals of restoring patients’ health and well-being remain steadfast. Relieved of the unrealistic expectations of the mythical surgeon, the medical students and residents of today must leverage the tools of modern communication with the grace and humility of the human surgeon to fulfill the goals of the founders of the ACS and continue “to improve the quality of care for the surgical patient.”


References

  1. American College of Surgeons. Inspiring Quality FAQs. Available at: facs.org/quality-programs/about/inspiring-quality/faqs. Accessed May 27, 2016.
  2. Elon University School of Communications. Imagining the Internet: A history and forecast. www.elon.edu/e-web/predictions/150/1870.xhtml. Accessed May 27, 2016.
  3. Censusrecords.com. 1910 Census. Available at: www.censusrecords.com/content/1910_Census. Accessed May 27, 2016.
  4. Wikipedia. About Sir William Osler. oslersymposia.org. Available at: www.oslersymposia.org/about-Sir-William-Osler.html. Accessed May 27, 2016.
  5. Rainie L, Zickuhr K. Americans’ views on mobile etiquette. Pew Research Center. August 26, 2015. Available at: www.pewinternet.org/2015/08/26/americans-views-on-mobile-etiquette/. Accessed June 23, 2016.
  6. Perrin A, Duggan M. Americans’ Internet access: 2000–2015. Pew Research Center. June 26, 2015. Available at: www.pewinternet.org/2015/06/26/americans-internet-access-2000-2015/. Accessed June 23, 2016.
  7. Council of Accountable Physician Practices. Majority of Americans don’t use digital technology to access doctors. November 4, 2015. Available at: accountablecaredoctors.org/health-information-technology/majority-of-americans-dont-use-digital-technology-to-access-doctors/. Accessed June 23, 2016.
  8. Fox S. The social life of health information. Pew Research Center. January 15, 2014. Available at: www.pewresearch.org/fact-tank/2014/01/15/the-social-life-of-health-information/. Accessed June 23, 2016.
  9. Attai DJ, Sedrak MS, Katz MS, et al. Social media in cancer care: Highlights, challenges & opportunities. Future Oncol. 2016;12(13):1549-1552.
  10. Coutee T. Trending on Twitter #ILookLikeASurgeon, from DiepC Journey: Reconstructing a Purposeful Life blog. Available at: diepcjourney.com/2015/08/11/trending-on-twitter-ilooklikeasurgeon/. Accessed June 23, 2016.
  11. Berian JR, Ko CY, Angelos P. Surgical professionalism: The inspiring surgeon of the modern era. Ann Surg. 2016;263(3):428-429.
  12. Orri M, Farges O, Clavien P-A, Barkun J, Revah-Lévy A. Being a surgeon—the myth and the reality: A meta-synthesis of surgeons’ perspectives about factors affecting their practice and well-being. Ann Surg. 2014;260(5):721-728.
  13. Finkelstein J, Knight A, Marinopoulos S, et al. Enabling patient-centered care through health information technology. Evid Rep Technol Assess (Full Rep). 2012;(206):1-1531.
  14. Weiner JP. Doctor-patient communication in the e-health era. Isr J Health Policy Res. 2012;1(1):33. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3461429/. Accessed June 23, 2016.

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