Abstract:
Every doctor, symphony conductor, or race car driver knows that hundreds of steps must be taken in order to be successful at medicine, music, or NASCAR racing, respectively. These same stellar performers also know that there are dozens of behaviors that must be avoided so that every member of the audience or each patient can have a positive experience. In the past I have written and lectured on what top-performing doctors need to do to have an outstanding practice—that is, one that maintains the loyalty of existing patients and continues to attract new patients to the practice. This article focuses on 10 behaviors that must be avoided whenever possible. Avoiding these mistakes and blunders will not guarantee a robust, healthy practice but will ensure a practice that will be appreciated by all the patients who interact with the doctors and the staff.
1. Never turn your back on your patients in the examination room.
Communication is enhanced when people are face to face with each other. That does not happen when the doctor spends the majority of time looking at the paper chart or the computer screen. Whenever possible, there should be no barriers between the doctor and the patient. Figure 1 shows a patient/physician/computer configuration that is to be avoided. Figure 2 shows a preferable arrangement where the doctor can look at both the computer screen and the patient. Experts say lack of eye contact is the biggest problem that results from having to input information into a computer. Eye contact establishes trust and a bond with patients, and a lack of it can be alienating. It also takes away the physician’s opportunity to read body language and get other nonverbal cues from patients.(1)
Figure 1. Doctor having his back to the patient. This is a never ever.
Figure 2. Doctor facing the patient. This is preferred.
A study performed at the University of California, San Francisco, analyzed data from patient–doctor interactions between 2011 and 2013. Each appointment was videotaped, and patients were contacted after the visit to assess satisfaction with the interaction. The study reported that doctors who spent less time typing on the computer scored much higher in patient satisfaction, achieving excellent care ratings 80% of the time. Doctors who spent more than one-third of the time looking at the computer instead of the patient achieved an excellent rating less than half the time. The researchers noted that high computer use by a clinician was linked to lower patient satisfaction and less rapport between patients and physicians.(2)
This problem can easily be solved by using a scribe. The scribe takes the history of the present illness, the review of symptoms, and the past medical history. The scribe then conveys his or her findings to the doctor, who enters the exam room to ask a few questions and perform the physical exam. The findings are entered into the computer by the scribe. As a result, the doctor can focus on the patient and does not need to ever touch the computer or look at a computer screen.
Another suggestion is to use the computer screen to educate patients about their health—for example, by showing a graph marking changes in his or her blood pressure over time, or showing trends such as cholesterol or prostate-specific antigen levels.
2. Never put your hand on the doorknob of the exam room when speaking to a patient.
Nearly every doctor has had the experience of reaching for the doorknob as the encounter with the patient comes to an end, only to have the patient bring up a question or a new complaint. You have probably already closed the patient’s paper chart or electronic record. The fact that you have put your hand on the doorknob indicates that you have terminated the encounter and that you have moved on, at least psychologically, to the next patient. There is a very simple solution: before standing up to leave the exam room, ask the patient, “Have I answered all of the questions that you have regarding your visit today?” Or you can simply ask patients, “Anything else?”
Another “never” similar to the doorknob phenomenon is for the doctor to look at his or her watch. Again, this indicates boredom and readiness to terminate the encounter. If you think this does not matter, remember the town hall-style presidential debate in Richmond, Virginia, in 1992, when then-President George H.W. Bush infamously checked his watch during a question from the audience, then stumbled through his answer. It seemed that President Bush wanted to get this debate over with—that his heart wasn’t in it. Many pundits believe this was the turning point of the campaign and cost him the election. The same can said for doctors: they can lose patients’ attention and, perhaps, their confidence, if patients believe the doctor is paying more attention to his or her watch than the patient.
3. Never allow pharmaceutical reps to have access to the office when you are seeing patients.
What message are you sending to patients who have been patiently waiting in your reception area when someone with a briefcase walks to the front desk and asks to see the physician and then is escorted immediately into the “inner sanctum” to see the doctor? The message is loud and clear: that the pharmaceutical representative or the salesperson is more important than patients. This should never, ever be the situation. Patients should receive priority, and pharmaceutical representatives should be scheduled before or after patients are seen. In my practice, no pharmaceutical representatives are seen during patient hours. They can come before I start seeing patients, at lunch time (without the necessity of buying the practice lunch), or at the end of the day. It did not take long to institute this policy, and all of the pharmaceutical reps quickly got the message and did not interrupt patient visits.
There is no better way to get poor patient satisfaction scores than to use a phone tree and place a patient on hold.
Another benefit of this policy is that the reps become much more focused in their visits and in their presentation of their products. No longer do they spend valuable time asking about my vacations or my family; rather, they start right in by talking about the features and benefits of their products or asking how they can help me in my practice with their products.
4. Never make patients use a phone tree.
A phone tree is helpful for the receptionist, who does not have to triage the call and route the caller to the proper person in the office. However, the phone tree is not user friendly. Nothing is more irritating to a patient who wants to make an appointment, speak to a doctor, or discuss his or her bill than to hear “Press 1 to continue in English” and “Listen closely to our list of options, as they may have changed.” It is easy to understand why practices use such automated phone systems: they are cheaper and more efficient than hiring more people to handle all the callers. Generally speaking, it is a bad idea to agitate your patients who perhaps already don’t feel well. There is no better way to get poor patient satisfaction scores than to use a phone tree and place a patient on hold. Whenever possible, I suggest avoiding a phone tree in a medical practice. Also, avoid putting the phone on answering service during lunch hour. Patients may use their own lunch hour to call the doctor, and you want be available to your patients between noon and 1:00 PM. In my practice, each employee takes one day to eat at his or her desk and answer the phone during the lunch hour.
5. Never updating your website once it is created.
Too often, practices will make an electronic version of their brochure and think they have a website. That may have worked 20 years ago, but today the public expects much more. They are looking for current content and for an interactive website where they can ask questions and receive feedback or responses to those questions or comments.
You send a negative message when patient calls are not returned.
Search engines look at your website for frequency of content updating. If you want to rank high on the Google search—i.e., the first page of Google—you must contribute new content on a regular basis. My goal is to provide new material at least every two weeks. In order to demonstrate currency of content, you keep your content up to date and ever relevant. I suggest that you write content that informs, engages, entertains, and collects information, such as the visitor’s e-mail address. I also recommend including keywords that your patients might be using to find information on the Internet that may land them on your website. Finally, you want to be sure to include a call to action, which is intended to get the reader to connect from your website to your practice and actually convert the searcher from a viewer to a patient in your practice.
6. Never reprimand or correct an employee in front of patients.
Being reprimanded in front of patients is very embarrassing to the employee and does not demonstrate to patients that you have compassion and care about your employees. I find it best to mention to the employee that you would like to discuss some issue or matter later in the day and then meet with the employee with the office manager or the human resources person in the practice to discuss the problem and its impact on patient care.
7. Never fail to return calls to patients in a timely fashion.
“Timely” is going to have different meanings to different doctors. In my opinion, a timely response is within 24 hours. You send a negative message when patient calls are not returned. Of course, many calls need not be returned by the physician—but someone in the office needs to make contact with the patient either by phone or by e-mail. For example, if you promise the patient a report or result of a lab test or an imaging procedure and you do not have the result, it is important to call the patient and let him or her know that you have not received the report and that the patient has not been forgotten. This conveys to the patient that nothing has fallen through the cracks and that you remain on top of the situation.
8. Never be late for starting to see patients.
A physician shows disrespect for a patient if that patient has to wait 30, 60, or even 120 minutes past the scheduled appointment time to see the doctor. I know of doctors who arrive in the office 15 or 20 minutes after their first scheduled patient and then check their e-mail or even make a few non-urgent phone calls, with the result that they start seeing patients 30 to 45 minutes after the designated start time. Occasionally, of course, there are acceptable reasons why a patient may be kept waiting. While there is always the possibility that an emergency has caused an unusual delay, most practices that keep patients waiting do so even when there are no pressing emergencies. There is no better way to build a good reputation for your practice than being labeled as an on-time physician. That is certainly one of the perks that concierge doctors offer their patients—that is, ready access and not waiting an excessive amount of time to see the doctor. Whenever I see a patient who is upset about having had to wait, I will tell him or her that there will be no charge for the visit because of my delay. I feel that my reputation is worth more than the $75 office visit. I even recall introducing myself at a social event where the person said, “I heard about you, Dr. Baum. You are the doctor that didn’t charge a patient who had to wait!” Isn’t that reputation worth more than $75? Of course it is.
All of us can be more sensitive to our patients’ time.
My take-home message: None—or very few—of us can change the healthcare system, but all of us can be more sensitive to our patients’ time. There is no better way to do this than to see your patients on time.
9. Never fail to apologize when you have made a mistake.
Doctors, after all, are human, and we do make mistakes. I believe that a mistake is an opportunity to offer an apology when one is warranted. Every mistake offers an opportunity for improvement in your process of caring for your patients. An apology demonstrates that you are a caring doctor who empathizes when a patient has an undesired or unanticipated result.
10. Never answer your cell phone when you are in the exam room with the patient.
Even those doctors who feel they must carry their cell phones at all times should keep them in silent/vibrate mode and make every attempt not to permit interruptions when with a patient. I have a policy that only callers from the operating room, the emergency department, or the intensive care unit are permitted to contact me on the cell phone when I am seeing patients. In those rare instances, patients seem to understand the urgency of the situation and allow me to take the call. In all other instances, the phone goes unanswered.
Bottom Line: Ideally, we would all like to provide every patient with a favorable experience. However, this is not always possible. In this article, I have provided some guidelines regarding actions to avoid. Following these guidelines will ensure that nearly every patient who passes through the portals of your practice has a positive experience and will provide you with stellar patient satisfaction scores.
References
Reddy S. Is your doctor getting too much screen time? The Wall Street Journal. Dec. 14, 2015. www.wsj.com/articles/is-your-doctor-getting-too-much-screen-time-1450118616
Ratanawongsa N, Barton JL, Lyles CR, et al. Association between clinician computer use and communication with patients in safety-net clinics. JAMA Intern Med. 2016;176:125-128.
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