Showing posts with label Patients. Show all posts
Showing posts with label Patients. Show all posts

Friday, July 12, 2019

What you can do about the negativity bias in medicine

Ever notice a tendency to focus more on what’s wrong than what’s right? To notice what people do wrong more than what they do well? Or to offer criticism or advice more than positive appreciation?


Well, you are not alone: Our brains are hardwired for a negativity bias. That means that negative experiences and information grab more of our attention, are more memorable and their effects last longer than positive experiences. At the end of the day, it’s the negative experiences that we remember more rather than the positive ones.

The negativity bias not only affects how we feel, it also impacts work culture and patient care. Let’s first look at its implications on the workplace.

If people are more strongly impacted by the negative than the positive AND if we tend to notice the negative more, then people are probably getting more criticism or “helpful” advice (which, when unsolicited, is perceived as criticism) than they are appreciation or positive acknowledgments.

This is what I consider low-hanging fruit for improving interactions at work. We know that it takes about eight or nine positives to counteract the negativity bias. By giving employees specific and genuine recognition for a job well done, we can shift the workplace culture to one of greater collaboration and appreciation.

And best of all, it’s easy and free. Tell people what specific behaviors they are doing or have done that made a positive impact. Recognition or appreciation is rewarding to the brain. What’s more, anything that is rewarding tends to be repeated. Not only does positive feedback make people feel good, it reinforces behaviors that we want to be reinforced, a win-win.

An additional benefit of mitigating the negativity bias is that when people feel appreciated by others, they are more likely to want to collaborate and contribute. Their morale and engagement at work improves as well, making them more productive and effective.

Now let’s shift our focus to how the negativity bias impacts patient care. The negativity bias is alive and well in medicine. It starts in medical school where students are frequently exposed to teaching methods that create feelings of shame, ineptitude and incompetency. Early on in their careers, physicians learn both the importance of preventing and avoiding errors as well as the need for perfection.

And yet, we know that mistakes are inevitable. We also know that if we talk about them, we are more likely to prevent their recurrence. The problem is that healthcare workers often avoid acknowledging that an error has occurred. This is typically due to a culture where mistakes are accompanied by some form of punishment, and people often feel humiliated and blamed. Hospital settings can also perpetuate a culture where the negativity bias is enhanced with physician peer review committees and incident reporting systems.


We need a solution. We need to transform a culture of blame into a culture of learning, where the reporting of medical errors is welcomed because it serves as a teaching opportunity. Even the word “error” can sound daunting and intimidating. I encourage healthcare professionals to instead think of errors as learning opportunities to make it easier to talk about.

Here are five practical strategies to mitigate the negativity bias and improve patient safety and outcomes:
  • Build a culture that rewards the reporting and discussion of medical errors and reframes them as learning opportunities. Rewards can take the form of verbal and/or written recognition. There might be a “case of the month,” where managers identify a case or cases with the greatest learning opportunity.
  • Provide a system that encourages reporting of near misses, which are also great learning opportunities.
  • Ask questions focused on the what, why or how and less on the who when creating a learning opportunity from a near miss or an error. This will help minimize feelings of blame and shame.
  • Delay submissions of incident reports until after you speak with the person who is identified in the report. This avoids the problem of many reporting systems where people write someone up rather than communicate directly.
  • Augment learning from errors or mistakes with lots of acknowledgement of what people have done well. Remember, it takes about eight or nine positives to overcome the effects of the negativity bias.

To paraphrase Alexander Pope, "To err is human, but to learn is divine."


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Thursday, June 27, 2019

How to discuss cognitive screenings with your Medicare patients

Most clinical screening tests are designed to give providers a heads up on the potential development of a disease. While most patients readily agree to screening tests, the idea of screening for any possible cognitive decline often is a scary topic for patients — and creates a complex decision-making situation for providers.


The Medicare Annual Wellness Visit, launched in 2011, includes coverage of cognitive screening services for Medicare beneficiaries every 12 months. The parameters of the program allow physicians to “assess the beneficiary’s cognitive function by direct observation while considering information from beneficiary reports and concerns raised by family members, friends, caregivers and others. If appropriate, use a brief validated structured cognitive assessment tool.” (CMS Medical Learning Network)

The wellness visit is the perfect opportunity to foster healthy conversations with patients about cognitive function and to explain that not all cognitive decline is caused by Alzheimer’s disease, says Keith Fargo, director of scientific programs and outreach at the Alzheimer’s Association. “A lot of cognitive decline is caused by things that are treatable, including sleep apnea, depression and other medical conditions.”

And primary care physicians (PCPs), who serve as the quarterback for coordinated care, see their patients frequently throughout the year and develop relationships over years, have the distinct advantage of knowing their patients. They may be able to detect changes that go overlooked or ignored by friends and family. Plus, the physician-patient relationship may be the only one where the topic of cognitive screenings won’t be met with a strong emotional response.


Cognitive screening recommendations


The medical community’s acceptance of cognitive screenings is still a mixed bag, partly because of inadequate research indicators amid an incredibly complex neurological field. The U.S. Preventive Services Task Force (USPSTF), an independent body that develops recommendations for clinical preventive services, issued a decision of insufficient evidence of the benefits in 2014 but revisited the topic in 2017 through a detailed review of cognitive conditions and possible interventions.

The taskforce chose not to change its original view of insufficient evidence of benefits, but it recognized that mild cognitive impairment (MCI) is a unique condition among other cognitive diseases that merits more research on the benefits of screening and intervention.

While the USPSTF’s position remains one of caution, it does open the doors for more research on MCI and the development of better screening for early cognitive decline, writes the AAFP: “The diagnosis of dementia currently is initiated mostly on the basis of a clinician's suspicion regarding patient symptoms or caregiver concerns, and although the evidence for routine screening is insufficient, there may be important reasons to identify early cognitive impairment.”

However, the indicators for prompting a cognitive assessment can be a gray area for physicians: It’s a detective hunt of medical and mental hints that includes a close analysis of the health risk assessment, physicians’ own observations and patients’ responses to in situ questions. The need for a cognitive assessment also relies greatly on self-reported symptoms, so it’s crucial that physicians engage patients and their families in healthy, proactive conversations about cognition as a normalized topic during wellness exams.


So, which cognitive screening tests are recommended for use in a Medicare Annual Wellness Visit, and under what circumstances is further testing indicated?


The Alzheimer’s Association has developed a physician flowchart designed and approved for use during the Medicare Annual Wellness Visit. It outlines a suggested clinical decision-making process and recommends specific screening tests based on physician observations and the patient’s own responses. The screening tests can be administered in less than 10 minutes apiece and may reveal important data indicating the need for further testing.

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Wednesday, June 27, 2018

Two Types of Demanding Patients

Hell hath no fury like a patient who wants all his tests done, reported today, and/or to see the specialist immediately.


I divide them up into two groups. The first are the patients that are quite ill and scared as they have waited too long to get medical help and are afraid things will not turn out well. They generally tend to come in later in the day, especially on Friday or Saturday morning at the office. Friday, I can send them to the hospital lab for blood then have the lab page me with the results so I can call the patient at home.


For radiology, I call the department and ask that the films be read and have a report called to me. I advise the patients the hospital will charge more for the services when done this way. I also tell them that they should not hesitate to go to the ER, as these labs and x-rays can be done there and a decision on treatment can be made immediately based on the results.


The second group are the patients with an aggressive personality who want everything done right this minute, even if it is not an emergency. I give them the x-ray and lab slips and tell them to go immediately to the hospital.


It's funny how they change when they're informed that the hospital will be charging more for the tests, as their insurance may not cover as it is not an emergency. Referral is made to the specialist and I give them the number for the physician's office so that they can call concerning the appointment.


Since almost all the specialists are hospital employees, referrals can take weeks to months for the patients to be seen. They can get on a cancellation list, but the appointment will be at the convenience of that office. Lastly, I recommend the ER but explain that the waiting time until seen can be several hours.


When they call back demanding things I also recommend they call their insurance company so that I can make an out of town referral to a regional center for evaluation of the problem. Again they are welcome to call the center and demand an immediate appointment.

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