3 Ways to Strengthen the Patient Relationship (S1E9)

Hello. Welcome back to the Cash Practice Solution. I’m your host, Dr. J. In our last episode, we got deep into the patient relationship and how insurance practices versus cash practices influence all of that. Today, we’re going to look at the three pillars of the doctor-patient relationship: the patient’s story, empowerment through shared decision-making (real shared decision-making, not faux), and unrestricted care – without any third-party interference. I really love this because I think if you understand how to build a patient relationship and how important it is, and the power of it, you’re going to just make this a real center of your thinking because it’ll change everything. People want to be known, they want to be cared for, they want to be loved, and you can do that. As their care provider, you can do it.

Pillar 1 – The Patient’s Story

Let’s start with the central pillar (this holds everything up) – the patient’s story. [The history part of the H and P]. Everybody who’s trained in medicine knows the grind of doing H and P’s, where you just get all of that information dumped on you. It used to be just an incredible hassle. When I was trained a million years ago, we’d have to do sometimes 10 a day, and it took an hour (or more). What used to be a grind is now easy. With intelligent technology that simulates face-to-face interviews, the technology does an excellent job of screening – just like a really experienced expert in the entire spectrum of medicine technology makes this  available. There’s technology that currently exists. In the past, people would do their intake paperwork (almost never happily), and typically too many times, you’d have to do it again and again .It would be finished, and then it would get dumped in the back of some file cabinet or drawer, and nobody would ever look at it, because it was just kind of a requirement that has to be in there, and it’s not necessary. The story actually gives us valuable information on how best to treat the patient. This is now readily accessible and available. Now, brilliant software integrates the intake interview into the EMR (into the electronic record), so that doing that history process that used to take an hour (it’s just repetitive and grinding), helpful, no doubt, important. But with technology, you can cut that down to 10 percent of the time. 90 percent of that work is done with the patient and technology and it’s presented to you in  a format that makes this information valuable. You can use this information as a screening tool, and get the intake done in 10 percent of the time. It’s beautiful. Our practitioners – they do a complete (really thorough) new patient intake interview in less than 20 minutes. Visit us. When I first started, it took me about two hours to do a functional medicine interview (and two Excedrin because I would get a headache from doing it). It drove me crazy.  Now, armed with a complete health history, and all the details, before you actually see the patient face-to-face, it helps you focus so that you’re on target for “what does the patient really need?” You’re not spending a lot of time with screening questions that are negative. Those are all done for you. Saving this time makes connecting on the personal level way smoother and really efficient. Because the data, (which is absolutely critical), is just one part of the story. You have to have it. It’s really important. It has to be gathered, but it doesn’t have to be you, collecting and collating the information. The part that has to be you is the empathy, the eye contact, and listening. And when you do that, you have time to do the medical portion. You’ve got the 45 minutes left to complete the physical and the treatment plan. Connecting with the patient (eye to eye, person to person, hearing their story, kind of feeling it, what’s going on with the patient), you can get that done. And if you get really good at this process, the data that’s collected – (that 90%), you take that, you look at the screening, do your 10 percent of personal interview. During the physical exam, you can do that. As you’re doing a physical, (probably anybody with experience knows), you’re just not silent so you can ask follow up questions to fill out the story. You talk and listen and have an interaction. Even during the discussion of a treatment plan, you can have an interaction and talk and say, “Hey, I’ve got some ideas. I think possibly you would really do well on a program that would include some [Vitamin D3, K2] because you have a family history. You do have a family history, right? The patient has provided you with this through the technology. You just verify their responses. If you want to talk about a precious commodity or a rare gift – undistracted listening, it almost never happens. You’ll often hear people complain (you know, “that’s the problem with my husband, he never listens”, or “that’s the problem with my wife.”). And many times that is the biggest compliant about doctors – they don’t listen to the story. On average a practitioner only spends 7 min face-to-face with a patient. When you’re able to listen, you’re giving somebody a gift that they can’t get anywhere else. That 90 percent of that history – it’s kind of hard to stay tuned in when you do it again, and again, and but when the technology does it for you and presents the data to you, it’s quick. It takes [really] 20 or 30 seconds to review it. Then you can listen, because you have the energy for it. It’s a very different environment and it actually works. That listening gift that you give somebody – it is an incredibly powerful patient relationship builder. Get their story. That’s the big, huge pillar in the middle of the structure.That’s it. 

Pillar 2 – Patient Empowerment through Shared Decision-Making

Second pillar is patient empowerment through shared decision making. So there’s what is called a hat tip – just to pretend about shared decision making. [For example] “Do you want to take, diclofenac or meloxicam?” That’s not shared decision-making. Shared decision-making is when you’ve actually made a decision based on when you’ve shown the patient what’s going on and you have a deep understanding of the patient’s story. For example, the patient states, “I have horrible pain. It keeps [me] from sleeping. It keeps [me]  from being able to be intimate. It has all these other problems that…”, that’s  the story. You know the story. It enables you to meet them where they are. When you can do that, then you can have shared decision-making because you know their story. Then you can present to them what they’re really looking for. In the recent past (I can’t remember the date), the 21st Century Cures Act was developed. We’ve worked with the OpenNotes software framework, since the beginning of the practice, we’ve been using [open notes] with the technology that we have. This is not just a random portal but an actual shared note system. It allows the patient to see every part of their medical record. Now, that’s really great – if they actually can see it and use it. Most of the time, they don’t know how to do it. Portals –  they just stink. They’re no good. So, if you could actually take that opportunity to use open notes, that means the patient has access to the whole chart – your notes, your progress notes, the lab, your comments on the lab, and graphs. If you actually engage the patient in the process, well, you’re not just saying, “yeah, it’s all there, good luck.” You’re actually engaging them.  We put touch-screen TVs in each room and our software actually presents it in a way that it’s a teaching opportunity. Our staff also uses iPads, so you don’t have to go to the expense or trouble of actually installing a touch screen. You can use an iPad, you can sit with a patient, show them, share with them in the portal (on your own site), an open notes format so that they know what’s going on. You give them logical explanations (that can be seen on graphs), “I’m looking at your lipid levels and they continue to rise but now look at this great reduction you’ve had.” No need to worry about the side effects, you’re not having any and you’re doing well”. They’ll have a better understanding. Patients love to see their lab results graphed. When you write prescriptions in or out of the office, at the end of a visit, you can pop [open] the prescriptions on your iPad (or on the touchscreen and) show them everything, and make sure that all instructions are clear and accurate. It’s shared decision-making. While looking at a patient’s screen chart they may notice their prescriptions and the conversation may go like this,  “Oh, I stopped taking that three months ago.” “Really? I didn’t know that. Why did you quit?”  “Well, I had a stomachache.”   “Okay, great. Well, let’s take that off the list and do something else.”  As you do that, you can talk about next steps and what they want to accomplish: “Are you okay without it?”, “Okay, great. Let’s do that.”  Shared decision-making is not a buzzword. So much of what we do – it’s because the insurance industry dictates it. You don’t get the benefit of it. You don’t get the power of it. Shared decision-making is a great way. Like any friend. or any colleague, you really do want to share decision-making. You want to be on the same page. You know their story, you know what they want. You share what you have, and then you come to a mutual decision. With proper technology, and the proper setting, and the time that you have, you’re being paid appropriately, (not 12 minutes for a dollar and a half). You’re actually [providing care]. It all makes sense: Shared decision-making.The patient feels hurt. Because you’re listening, you’re making decisions together. That’s the second of the pillars, shared decision making, probably the second most important pillar.  

Pillar 3 – Providing Unrestricted Care

The third [pillar] is the completely unlimited capability to apply care. You’re not being limited by insurance. You’re not being limited by payment structures. You’re not being limited by preconceived notions of the insurance company formulary or the claim that treatment is “experimental”. You don’t have to deal with that.  So, one of the most compelling reasons for going cash is you have absolute freedom to treat patients without interference from third-party meddlers. You have to provide the standard of care. That’s only reasonable. Standard of care is the minimum that you need to do to be legally okay in a malpractice suit. But that is the starting point, not the end goal. We’re providing care that’s way better than that,and actually far exceeds what’s available in an insurance-limited situation because there are no limitations.  My experience with complex illness – it’s just been really honestly heartbreaking in the past, because you have a treatment or a medication that you could use, and the patient doesn’t have the resources or money under their insurance to do it. The system isn’t set up properly for that, and so you can’t do it  – curative treatment. I’m not talking about management. I’m talking about curative treatment. It’s not available. Denial of payment for specific treatments that are curative is kind of a common thing in  the insurance context. But outside of the insurance context, when you have cash, you can actually negotiate with the patient, share decision-making, say, “This is going to be $1,200 for these tests, and this may actually resolve your problem.” “Here are treatments for it that will work.” Then, you can make that shared decision work. I had a lady recently thank me (literally), “for not taking insurance”, because she received everything she needed in one day, instead of making multiple visits to the office [as required under insurance]. She’s busy. She’s got a family. She’s got a lot of stuff going on, and she actually said the next time she came in, “my husband told me whatever I pay, you can double it,” because she was so happy. When you know the patient’s story and you’ve made a shared decision regarding the care plan, the insurance should never enter into the picture. Unfortunately, if you have an insurance practice every day is filled with prior-authorization and ridiculous form-filling. Until your practice has developed the three pillars of a healthy relationship,  you’re unlikely to experience the freedom and really enjoy it. I mean, it is fun to practice (sometimes it’s hard for people to believe), but it’s fun to practice when you have the freedom to do what you know is right, and your patients and you create agreement, and then you see the results.  We actually have a joke in the practice. I tell patients when they come in,-. I say, “I’m going to listen to you and you’re going to tell me what’s wrong. Then you’re going to tell me what to do. Then I’m going to do it. You’re going to get better and I’m going to get the credit.” It really works. Patients know what’s going on. If you can listen to their story and if you’re free to do what they know they need (which is to resolve those symptoms), make them feel well with your skills, and your judgment, and your experience,  you’re going to see results and you can only do it in a cash context. You can try to do it in an insurance context, but man, you’re going to be running uphill, hard. So, if you want to provide the highest level of care, totally unlimited by third-party interference, I’m just going to say, understand a story. Give the patient the ability to share and really give them the opportunity  to participate. If they’re not  catching it, just speak in a more understandable way. Everybody’s pretty much capable of understanding what feeling better is. They know that. Without restrictions you can do what you know is right, unlimited by insurance. So, the foundation has a lot of benefits and building on these pillars is going to increase patient loyalty.  That results in referrals. And then, you’re going to see you have a lot of patients coming to you for the kind of things that you’re really good at and you’re going to have a lot of really good outcomes. Your practice will run more efficiently and you’ll be so much happier. You’ll spend a lot less time doing things that just burn you out.  In our next episode (I love this), we’re going to share our declaration of independence, so you can join us and secure freedom for your practice. In the meantime, send us any questions that come to mind, and we’ll do our best to answer them. We’re going to do a recap in a couple episodes. And if you haven’t already, we have at, cashpracticesolution.com website, The scorecard. Go to the scorecard and we’ll actually be able to look at that scorecard and analyze your situation, and we help to guide you through the process of becoming a cash practice doctor. Thanks for tuning in to the Cash Practice Solution Podcast. I’m Dr. J, and until next time, listen to your patients. (Maybe I’ve probably driven that home), learn their stories, and love them with all your heart. You’ll be unstoppable.