Many of the primary care physicians I talk to are frustrated. They chose medical careers because they wanted to be healers. But they are increasingly burdened by administrative duties, electronic medical records, insurance reimbursement coding, and a host of other demands that leave them with little time to really talk about maintaining health and facilitating healing with their patients.
Now, a new nationwide survey of more than 2,000 adults shows that our patients share this frustration, and they, too, want to change the way we talk to them. At Samueli Integrative Health Programs, we commissioned a Harris Poll survey to explore doctor-patient conversations and learned, among many things, that 90% of Americans say that health is about far more than just not being sick.
People who have primary care doctors want more from their office visits. Nearly half (45%) say they wish they talked about why they want to be healthy. While 76% of patients say they talk about physical health, 50% or fewer say they have a chance to talk about vital factors such as diet, sleep, and exercise. Almost 1 in 5 patients have diagnoses for depression or anxiety, yet despite the prevalence of psychological conditions, only 36% say they talk to their doctor about mental health. Younger people, in particular, say they want to talk about more than pills and procedures, seeking instead to learn more about non-drug treatments and options that fit their lifestyle as well as their emotional and spiritual needs.
These findings offer us a valuable window into our patients’ thinking and they call upon us to change our own thinking, widen our lens, and start to ask our patients more about “what really matters” to them, rather than just “what’s the matter” with them.
How Can Physicians Get to the Heart of Their Patients’ Needs?
After 40 years of practice watching many colleagues struggle with burnout, I’ve devoted a lot of attention to figuring out how to get back to the heart of healing, and how to focus on what my patients really want and need. For me, I reframed my patients’ experience from one focused exclusively on diagnosing and treating disease to one that emphasizes prevention, health-promotion, and self-care.
Key to this is doing an office visit focused on what influences their healing and exploring in a broader, deeper way the key factors affecting their health. Back in medical school, we were all trained to employ the SOAP note (Subjective, Objective, Assessment, and Plan) and use it to chart a patient’s condition and treatment. But we know that 80% of health is influenced by behavioral and social factors outside the usual doctor’s office visit. We need to go beyond the limit of the SOAP note, beyond routine disease treatment, and focus on the whole person and their personal determinants of health.
I do this with an integrative health visit and document it with what I call a HOPE note (Healing-Oriented Practices and Environment). The HOPE Note has enabled me to more effectively address the root behavioral and social causes of the most frequent conditions I see, such as chronic pain, obesity, diabetes, and hypertension. With it, my patient and I talk about what is really helping or hindering their healing.
In our annual integrative visit, the HOPE template allows us to get at fundamental questions. We start with a quick, but eye-opening, two-page Personal Health Inventory questionnaire (adapted from the Veteran’s Administration Whole Health model) that asks patients to rank themselves on physical, mental, social, behavioral, and spiritual health on a scale ranging from “great” to “miserable.”
My patients easily do this, and it sets up a wide-ranging discussion: They write some thoughts on existential questions: What do you live for? Why do you want to be healthy? From there, our conversation transitions to specific behaviors and lifestyle factors that they might want to change. This often opens the discussion to options such as diet, exercise and sleep, stress management with yoga, meditation, or non-drug treatments such as acupuncture and manipulation. What emerges is a “HOPE list” that patients themselves create and guides our future plans for treatment and self-care.
The next critical step is to support the patient’s goals and behaviors. There are a number of valuable, cost-effective ways to help accomplish this. Health coaches have distinct skills that can provide motivation and benefits that complement those of psychologists, social workers, nutritionists, and fitness coaches — either in person or via telehealth. Online educational resources give patients more confidence in exploring self-care choices. Apps and tracking devices are useful for aiding behavior change. Group visits are an excellent option for patients with chronic conditions, providing peer support and team learning — and they are also reimbursable.
How Can I Practically Incorporate This into My Practice?
Reimbursement, of course, is critical to sustain an integrative health approach. Properly organized, there is financial reward for providers who do take this approach — even under fee-for-service payment. For instance, you can hire health coaches to add billable health-and-well-being services to your practice. Having your office business staff bill for these services under the “incident to” rules leaves providers to continue their health care and medical services and increases productivity of the whole team.
An integrative health visit and HOPE Note often identifies other conditions and their service needs that may also be billable and can be incorporated into a practice. This can be profitable for a practice. A health-and-well-being coach doing HOPE visits for half of a 2,500 patient panel can generate nearly $200,000 a year in revenue for less than $100,000 in payroll. These estimates came from Geoffrey Moore, MD, of Sustainable Health Systems and Margaret Moore, CEO of Wellcoaches, a leading health coach training and certification company.
Providers can also use traditional outpatient evaluation and management, which can be billed as counseling and coordination of care. Group visits are particularly rewarding to lead, which allow you to briefly see each patient and document the visit in the chart. Electronic health record templates can streamline the process.
We are entering a new world of medicine and healthcare, in which attention is increasingly being paid to the whole person and their determinants of health. In this emerging world, incentives are being realigned to promote health and wellness. Now it’s time to rebalance our practices. Learning to listen better to our patients’ goals and address their issues more holistically are key elements required to be successful in this new normal of value-based medicine.
Wayne Jonas, MD, is a practicing family physician and the executive director of Samueli Integrative Health Programs. He is also the former director of the National Institutes of Health’s Office of Alternative Medicine.