There is nothing more critical to the success of the doctor-patient relationship than good communication. Suggestions on improving communication have been the subject of discussions by the American Psychological Association, the American Medical Association, and medical specialty societies (AAOS, ACOG). Provider-patient interactions have even been surveyed and quantified. Over the years I have noticed, from conversations with patients of mine as well as others, that there are issues which both sides feel uncomfortable about discussing. I would like to touch on a few and perhaps offer some digital technology solutions. The citation of specific apps represents neither endorsement nor support of safety/efficacy. They are mentioned to discuss the emerging attention paid to these issues via digital technologies.
1. Sex. According to a University of Chicago Hospitals survey of OB-GYNs, the first of its kind, only half of physicians discuss sexual problems or dysfunction. When looking at men and women in general from the patient’s perspective, a New England Journal of Medicine article (from 2007) “A total of 38% of men and 22% of women reported having discussed sex with a physician since the age of 50 years.” Recognizing the potential of technology, the Harvard Innovation Lab, hosting a Dean’s Health and Life Sciences Challenge, recognized an app aimed at helping college students manage their sexual health better earned a second place runner up spot. An app called Sexual Health Guide is available both in the Apple and Android stores. New York City’s Department of Health has developed some apps in the sexual health arena.
2. Costs of care. An initiative by the American Board of Internal Medicine Foundation, subsequently endorsed by many professional medical societies, called Choosing Wisely identified tests and procedures which were useless and in some instances harmful to patients. It is estimated that unnecessary treatment is linked to one-third of medical spending in the US. As the cost of some care has increased dramatically, specifically in the area of oncology, physicians can no longer ignore the need to discuss costs with patients. Patients should be prepared with some basic questions about costs of care. There are at least three free apps which address health care costs.
3. Alternative treatments. After a diagnosis is given, patients might elect to undergo primary or complimentary treatment which may include holistic, neuropathic, or homeopathic regimens. Patients are hesitant to bring up the subject because of fear of criticism. Regardless of what treatment course the patient and caregiver choose, it is important for the patient to discuss with the physician unconventional treatments undertaken or contemplated because there might be implications with regards to potential interactions or side effects of the recommended treatment. While I will not address specific apps in this area, there are apps which have been developed which address complimentary or alternative treatments in the broad sense. There are also apps offering evidence-based guidelines for treatment developed by many medical specialty societies.
4. Advanced Directives. Having a piece of paper given to a newly admitted patient to the hospital with check off boxes of advanced directives (wishes regarding end of life care) to meet federal regulated mandates is not the ideal process of addressing such an important issue. There are many barriers to discussing advanced directives. Some apps for advanced directives include My Health Care Wishes, Incendant, ICE (developed for the State of Indiana), and Leaving Well.
5. Digital technologies. Mobile technologies have the potential to improve the doctor-patient relationship via easier ways of communicating. While most patients have used the Internet to search for health or medical information, many physicians still see this practice as a threat to their expertise or upsetting the balance of the relationship with patients. The eras of both shared decision making and digital health technology are upon us and it is no coincidence that they are contemporaries. I am eager for standards to be in place and followed by medical app developers so that reliable and effective digital tools can be shared and not be elephants in the exam room discussion.
The above list is not comprehensive about the many things not comfortably discussed at office visits. Patients are at first uncomfortable when these topics are initiated by a provider but they are relieved as well. At times the partner or caregiver is the pivotal initiator or conversant. They too must be considered as potentially critical drivers of these discussions. I have had conversations with patients about all of the above issues and still others not mentioned. The human condition is alive and well in the exam room and needs to be appreciated.
