{"id":1885,"date":"2017-08-25T07:50:43","date_gmt":"2017-08-25T07:50:43","guid":{"rendered":"http:\/\/www.simferweb.net\/blog\/?p=1885"},"modified":"2017-08-25T07:51:24","modified_gmt":"2017-08-25T07:51:24","slug":"a-debate-on-time-of-communication-in-healthcare-an-italian-issue-only","status":"publish","type":"post","link":"https:\/\/www.simferweb.net\/blog\/2017\/08\/a-debate-on-time-of-communication-in-healthcare-an-italian-issue-only\/","title":{"rendered":"A debate on \u201ctime\u00a0of communication\u201d in Healthcare:\u00a0an italian issue only?"},"content":{"rendered":"

In Italy, a lively debate is currently under way in the health care sector. The hot topic is time spent by physicians and other health care\u00a0 professionals in communicating with patient. As one can imagine, different perspectives \u00a0are expressed by professionals and policy makers.<\/p>\n

Such a debate may have a significant impact on the rehabilitation sector. The questions raised may also be of interest for physiatrists and rehabilitation professionals working in other countries, Therefore, it might be useful to share thougths and opinions on this topic. As a starting point, we present a contribution of the President of the Italian Society of PRM (SIMFER) recently published in italian on a popular online journal on healthcare.<\/p>\n

\"\"<\/a><\/p>\n

THE VALUE OF \u201cTIME\u201d IN REHABILITATION<\/em><\/strong><\/p>\n

Blaise Pascal wrote:\u00a0 \u201cI would have written a shorter letter but did not have the time\u201d. Many physicians could recognize themselves in \u00a0this sentence, when they meet persons affected by multiple chronic health conditions, and are asked to listen, examine, select between different treatment options and explain everything to the patient in a handful of minutes, partly spent in updating the medical record.<\/p>\n

In Italy, such\u00a0 \u201ctime issue\u201d became\u00a0 a matter of\u00a0 a lively debate in the last months, when some Regional Health Authorities issued new rules imposing restricted time limits for the medical consultations and diagnostic procedures in the outpatient setting.<\/p>\n

The National Federation of\u00a0 the Colleges of Physicians (FNOMCeO) rightly made a stand against such measures, seen as an unreasonable limitation of the \u00a0professional autonomy, with a potentially strong negative impact on the patient-physician relationship.<\/p>\n

The Italian Society of\u00a0 Physical and Rehabilitation Medicine (SIMFER) agreed with the statement of the FNOMCeO, sharing its concern about the consequences of a measure apparently adopted only for economic reasons, \u00a0without any consideration of other multiple and\u00a0 complex \u00a0aspects of the care process.<\/p>\n

From a general point of view, this episode confirms the persistence of a large cultural gap between professionals and policy makers, with regard to the management of a fundamental, non-renewable resource such as \u201ctime\u201d.<\/p>\n

The majority of health care professionals rightly believe that a\u00a0 reasonable amount of time is a key factor in establishing\u00a0 a good\u00a0 relationship with the persons served, and increasing the knowledge of their health \u00a0condition and their cooperation in the care plan. Time spent in listening and talking is also\u00a0 seen as an\u00a0 important \u00a0factor in reducing the duration (and costs) of\u00a0 the subsequent treatments.<\/p>\n

Several \u201chumanistic\u201d, approaches to healthcare \u00a0that became popular in the last few years, such as the perspectives proposed by the \u201cNarrative\u201d approach in many countries, by \u201cChoosing Wisely\u201d in the USA and by \u201cSlow Medicine\u201d in Italy, emphasize the role and value of \u00a0an adequate communication with the patient during the whole process of care.<\/p>\n

Those who argue against these positions often set up economic reasons; that is, the need of optimizing the productivity of the healthcare processes in response to the increasing shortage of \u00a0the available resources.<\/p>\n

Many data appear to contradict this assertion; an adequate amount of time spent in talking with the patient could increase the quality of care and may be helpful in saving time and money, by avoiding unnecessary subsequent examinations or treatments.<\/p>\n

This has been shown in many health conditions , such as, for example, in dialysis, surgery, oncology, multimorbidity and chronic\u00a0 disabling conditions (Kaplan et al., 2016). The conclusion of Haas et al. in a paper published on Dec, 26th, 2014 in \u00a0\u201cHarvard Business Review\u201d was that\u00a0 \u201c \u2026attempting to improve a physician\u2019s productivity by placing arbitrary limits on length of appointments \u2026lowers costs at the front end of a care cycle. ..but they incur much higher costs later in the cycle\u2026 \u201c<\/p>\n

Besides the time spent in talking with the patients and family members, the time of interprofessional communication – if properly used – seems \u00a0to be another good investiment. A holistic, comprehensive evaluation of healthcare needs, of social-environmental \u00a0aspects and of patients\u2019 preferences in mutiple chronic conditions, through a mulitprofessional evaluation, \u00a0resulted in a 21% increase of costs of the initial assessment, but also in a 74% saving in subsequent treatment costs, according to a report from Kaiser Permanente Colorado (cit. in Kaplan et al. ,2016).<\/p>\n

These data suggest that the issues of \u201ctime of care\u201d \u00a0and \u201ctime of communication in healthcare\u201c require a much higher level of thinking than a mere conflict between a narrow-minded hyper-efficientism and the \u2013 albeit necessary – \u00a0protection of \u00a0the professional independence.<\/p>\n

We should remind ourselves that one of the reasons of the popularity of the so-called \u201calternative approaches\u201d in medicine\u00a0 is the \u2013real or presumed to be \u2013 higher attention paid to listening and talking with the patient.<\/p>\n

Should we leave such a privilege to practices often devoid of a serious scientific basis?<\/p>\n

As we know, these issues are crucial in the field of Rehabilitation; the care process in Physical and Rehabilitation Medicine requires an adequate amount of time for a comprehensive assessment of the persons and its environment, according to the bio-psycho-social paradigm which is\u00a0 one of the key features of the discipline.<\/p>\n

Time is needed to establish a good relationship with the person served, and to bridge the gap in \u00a0knowledge and expectations which could prevent the mutual understanding and the shared definition of \u00a0goals and objectives of the Individual Rehabilitation Plan.<\/p>\n

Last, but not least, time is required to circulate information and share opinions and objectives among the members of the rehabilitation team.<\/p>\n

Many experiences have shown that minimizing the time spent in communication during the rehabilitation process may result in an increase in diagnostic tests and in duration of treatments, partly caused by the patients\u2019 poorer understanding and\u00a0 compliance with the therapeutic proposals.<\/p>\n

For a long time now, the Italian Society of Physical and Rehabilitation Medicine has emphasised \u00a0the importance of these aspects in the different settings of care delivery: inpatient, outpatient and home-and-community.<\/p>\n

The pressure to maximize the number of patients and the constraints of time spent with the single patient is particularly perceived in the outpatient setting, leading to the above-mentioned negative consequences. This may be the result of a vision narrowly focused on the delivery of single, discrete health services, rather than on a comprehensive view of the whole clinical process and the final results of the rehabilitation plan.<\/p>\n

From the organizational and economic standpoint, this perspective emphasises the quantitative aspect of care and its efficiency rather than its efficacy\/effectiveness, and is supported by the fee-for-service payment\/reimboursement system currently adopted in\u00a0 the outpatient rehabilitation setting in our Country.<\/p>\n

The proposal of SIMFER is to adopt a different model in care delivery, based on a set of services which should consistently fit into a Individual Rehabilitation Plan, instead of a sum of single diagnostic and therapeutic interventions. A value-based reimboursement model should replace the fee-for-service system. Such a model should adequately consider the time and resources spent in communication, as well as the dimension of continuity of care and the outcomes achieved with regard to the initial goals and objectives.<\/p>\n

Under this perspective, many different activities can be recognized under the umbrella term of \u201cphysiatric consultation\u201d, each of them having a different dimension and value: clinical, relational, management etc.<\/p>\n

This is a crucial step of the care pathway, requiring a reasonable amount of time. The quality and the outcomes of care largely depend on how such initial phase is carried out.<\/p>\n

We, as PRM specialists, should be fully aware of\u00a0 the relevance of these aspects, and promote adequate actions to raise such awareness among the other rehabilitation professionals, the policy makers and the community at large.<\/p>\n