When I spoke at the eHITS2014 Vancouver conference on health and technology recently, I was happy to share with the mostly-physician audience my enthusiasm for a new health care initiative called Flip The Clinic. Have you heard about it yet?
This Robert Woods Johnson Foundation project asks our health care providers to start thinking seriously “beyond the walls” about the way medicine is practiced during a doctor’s visit.
Flip The Clinic was inspired by the educational concept called Flip The Classroom as conceived by the non-profit Khan Academy.
How does this model apply to a traditional doctor’s visit? In the current model of doctor-patient communication, the doctor, like the traditional teacher, metaphorically stands at the front of the room talking to the patient about the subject being taught. But in Flip The Clinic, here’s how it would look to patients:
“Clinicians prescribe information for us to learn before the visit – so that we spend our face time asking questions, instead of wishing after the visit that we’d had more time.”
Anne Weiss, a Robert Wood Johnson Foundation senior program officer, team director, and coincidentally a breast cancer patient, explains that Flip The Clinic features many ideas for how to accomplish this significant shift, but the one that really grabs her is called “new vital signs”.
For example, Flip The Clinic addresses a pretty basic question:
“How do doctors get to the root cause of a health problem?”
The innovative yet common-sense answer:
“By gathering a new set of vital signs that consider a patient’s overall well-being.”
“The idea is that the traditional vital signs, like blood pressure and temperature, are not the only relevant information about the factors that affect our health.”
Five questions to assess these new vital signs:
Proponents of Flip The Clinic recommend that patients be asked to rate their relationship to the following categories on a 0-5 point scale (0= poor; 5= great).
- Sleep
- Money
- Work
- Spouse, partner, or lack of partner
- Home/Neighbourhood
If a score falls in the 0-2 range, ask the patient to briefly elaborate on their situation. Following up on a low score may reveal a health issue’s root cause, such as new financial pressures or workplace stress that may be triggering a patient’s main health complaint. The new vital signs answers should be recorded in the patient’s medical record.
Anne says she first learned about the new vital signs when she attended a Flip the Clinic design workshop last fall at the same time she was being treated for breast cancer. And although her own treatment team obviously hadn’t yet heard the terms “Flip the Clinic” or “new vital signs”, she says that’s exactly the way they already worked together:
“The white-coats walked me through tons of medical evidence, but then they asked me to assess my attitudes toward different kinds of risks.
“They asked me about how to schedule my treatments around my job. They asked my husband about how he was faring.
“There were lots of decisions to make, and in the end, while the clinical experts had information to share, the decisions were made using vital signs reported by the world’s biggest expert in me: ME!“
These new vital signs, Anne explains, can jump-start a personal conversation with patients well outside the normal scope of the doctor-patient interaction.
But more importantly, a patient’s answers can reveal to the health care team that several interconnecting health issues might have one root cause.
While the health care provider may not be able to treat the underlying problem, just the act of identifying it can drastically alter a patient’s health – and their overall well-being. And by identifying a patient’s difficulties with a boss or struggles at home, it can also humanize or de-medicalize the clinical relationship.
But how do you fit an extra question-and-answer period into an already jam-packed clinic visit?
To address this time crunch, the new vital signs can also be gathered by a nurse, assistant, or someone else on staff. Anne says:
“By spending a little extra time with the patient now, you’re decreasing their need for medical attention later on.”
This makes so much sense to me, which is why I’ve been writing about this problem (here and here, for example) long before I knew there was already a bunch of brainiacs at the Robert Woods Johnson Foundation worried about it, too!
We know, for example, that such conversations are not even taking place before discharging a patient home from hospital, as reported in a study that found 91% of patients with chronic illness do not receive a written care plan before hospital discharge.
Patients are not being asked important questions, like is there anybody at home to help provide ongoing care? Or are there others at home depending on the patient for their care? Can the patient afford to take more time off from work to adequately recuperate? Will the patient be returning to a stressful workplace? Are there financial reasons that the patient’s expensive new prescription medications might not be taken as directed? The answers to every one of these questions can seriously impact the risk of hospital re-admission.
I’ve often wondered why so few of the many, many health care providers my Heart Sisters readers describe to me (as both hospitalized patients and during office visits) neither know nor care anything about them as a whole person. Instead, they are just the 9 a.m. procedure, the 1 p.m. consult, the 3:30 diagnostic test, too often treated like merely the obstacle between medical staff and their next break. See also: An Open Letter to All Hospital Staff
For example, I recall that while being admitted during my heart attack in 2008, I overheard a nurse describing me to another E.R. staff member as “the M.I. in Bed Eight.” I was not Carolyn. I was not a frightened real person with a family or friends or a job (in that very hospital, as it happens) – I was just the myocardial infarction in Bed Eight.
What about that time crunch, and the common belief that staff simply have no time to start focusing on those five new vital signs? How much extra time would it have required (instead of chatting over my head to each other about their weekend plans or their teenagers or what Nurse A said to Doc B last night) to actually focus on the real live person lying on the gurney beneath them?
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Q: Has your health care team asked you some of Flip The Clinic’s five new vital signs questions?
See also:
- More about Flip The Clinic
- Cardiac care for the whole patient – not just the heart
- Patient engagement? How about doctor engagement?
- Six rules for navigating your next doctor’s appointment
- The lost art of common courtesy in medicine
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Heart Sisters 
The 5 questions are really important but they strike me as key social service issues to be dealt with by a social worker.
I believe physicians can’t do everything and the more they try the fewer patients they see and the worse job they do. Health care should be a team effort. Physicians should be part of the team that includes social workers, nurses, midlevel providers and pharmacists. The days of Marcus Welby are long gone — and good thing too because the quality of that care was very poor. Perhaps we should now be more critical of the management of the team than any specific member.
Pauline’s lack of information is easily solved with a discharge video about multiple stents and a pharmacist review the discharge medications and a follow-up visit with the patient’s usual cardiologist a few days after discharge. What Pauline had is cut and dried — the communication piece, the nursing piece, the pharmacy piece and the follow-up piece were botched — symptoms of poor health care management!
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Hello Dr. Beckett and thanks for sharing your perspective. I agree completely that health care should be a team effort; my concern, however, is that many doctors seem all too willing to absolve themselves from being team leaders when it comes to viewing the patient as a whole person.
Here’s an example. Yesterday, a hospitalized friend was delivered catastrophically bad news about her prognosis by the medical specialist in charge of her care. Her friends who happened to be in her room at the time described the interaction like this: “After he delivered this distressing news, we waited for him to offer consolation or even some mention of any resources available to help her with this tremendous life change. When asked directly, he said he had no idea; he trained in the east and didn’t know what was on offer here. However, he stated there is a hospital social worker or liaison person who could help with that.”
Thus yet another doctor once again shrugs and walks out of yet another patient’s room, having apparently failed to even anticipate the devastating effect his words will most certainly have on any human being hearing them. On to the next patient… How a medical specialist (no matter where he trained!) could have “no idea” of any appropriate resources directly linked to his own specialty is beyond comprehension.
We’re not looking for Marcus Welby here. We’re looking for simple humanity and basic personality skills.
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I guess I am lucky(?) in that my Cardiology PA-c has a nurse I worked with for a few years. We manage to get in all the 5 Flip questions in our “chat” prior to the PA-c coming in for the visit. Also lucky that when I call with a question or request, they know I’ve already done my Nursing Assessment of my situation. Not everyone has this convenience.
Having been on the other side of the stethoscope, I understand how important it is to have your questions answered, if only you could remember the question you wanted to ask. Journal keeping has helped me a lot. It’s for those questions that occur to you, but are not significant enough to make an appointment or call. I carry this over into a hospital stay. Writing thoughts and questions down as they occur so the next time a Doctor wanders in I can ask. I do the same for my husband, keeping track of his questions and concerns.
Patients need to take some ownership of what to report, on the other hand, medical staff need to be open to accepting conversation about their patient’s lives, as what happens outside the exam room/hospital has a bigger impact on the patient’s health and well-being.
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No question that if you have a prior working relationship with any health care professional, you’ve just upped the likelihood of being seen as a whole person. Funny you should mention writing things down: we’ve given a close friend who’s been in hospital for 3+ weeks a simple steno pad for jotting down all questions, big or small, given the parade of docs, techs, nurses, students in and out of her room hour by hour. I now consider this a must-bring “gift” to bring every hospital patient!
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This is a great article and needs to be really pushed out to the public and practitioners regardless of whether the care setting is the PCP office, an urgent care or other medical clinic.
Doctors and nurses tell me that it is a frequent situation when the patient makes the appointment and tells the scheduler that they are “not well” but cannot define their need for care. A 15 minute or less appointment is given. If the patient would state one of the FIVE aforementioned in your piece, then more time would be allotted.
The doctor then sees he has 15 or less minutes with a patient who ends up taking more time because of issues within the big FIVE that were not mentioned. The appointment then takes more time, and puts the caregiver practice behind to everyone’s annoyance.
Patients should be comfortable saying such words as personal, financial, marital or situational anxiety to otherwise schedule better time for care. Perhaps a primary care office could offer those same words to patients in advance so they would feel more comfortable making an appointment and receiving appropriate time with the practitioner.
Getting ‘good’ time scheduled with the doctor means better outcomes.
Good job Carolyn.
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Thanks Joan – very well-said! And you raise such an important point about patients’ potential unwillingness to raise topics like financial or marital problems – even when they may indeed be affecting health outcomes. Many of us are too embarrassed (or too conscious of not wanting to “waste the doctor’s time”) to mention these important realities.
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The current vitals are hard data upon which to base further testing and diagnosis.
The five flip questions – and their responses – are open ended and subject to interpretation. The LAST thing we need is the opportunity for a nurse or doctor to provide their opinion on hearsay and then document it so that the insurance companies can have a ball in cost cutting. Worse yet, suppose the physician thinks you are depressed or anxious because of external circumstances and does not order testing based on his guess that you have something else.
The paramedic with my second heart attack argued with my family instead of taking me to the hospital. He insisted that I was having an anxiety attack – and even told that to the intake ER nurse – when he finally did transport me. I spent 16 minutes on the gurney in the hall without being hooked up to an ekg – the nurses commenting about my monogrammed pj’s and pedicure. When they finally did the EKG, they were all SHOCKED that I was, in fact, having a heart attack and alerted the STEMI system. I am now living with the result of their negligent “guess”.
The patient needs to clearly communicate with their medical team and not wait for them to drag the information out of them. The patient is provided with a written discharge and, if it was not done, then request written discharge instructions. The patient needs to obtain their full medical record to learn what their physicians and nurses really think… (it’s pretty interesting). You have to own the responsibility of your health.
Lastly, why is it that cancer patients and their families have so much social services support throughout treatment? The counselling, the PT/OC, the support groups, the education on how to live with a cancer patient.
It’s time – past due – for the same level of support for cardiac patients.
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Hi Anne – your ER story is a nightmare! Nobody should ever have to argue with a paramedic about whether or not to seek emergency care – and certainly not a patient having heart attack #2. But I’ve heard this story from both angles (sometimes it’s the paramedics who argue with the ER docs who are ordering EKG leads removed from a patient misdiagnosed with “just” anxiety).
As for discharge plans, the reality is that these are few and far between, and many patients are not functioning at top speed to even be able to assess what they should be asking for prior to discharge. That’s where family and friends can really help act as patient advocates.
And I’m in total agreement on the subject of cancer survivorship support that needs to be replicated in cardiac care – I wrote more on that in “Where’s The Survivorship Model For Heart Patients?”
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When I received my last two of ten stents last year, it was on an emergency basis, having been transported 3 1/2 hours away by ambulance. Blessedly, it had not progressed to a full-blown heart attack and my heart is still efficiently pumping away.
But what impressed me in this university hospital was the number of doctors and other medical personnel who came into my room during the next 24 hours to speak with me or tell me things. This did not include nurses. I had been heavily medicated the evening before, and wasn’t at my brightest.
I cannot tell you even one doctor’s name, nor most of what they told me. Of course, I had no questions then. But even now, I have questions about the whole thing, saving them for my cardiologist who, of course, wasn’t there.
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Ten stents! Wow, that’s almost the “full metal jacket” we hear about, Pauline! Thanks for bringing up an important – yet often under-appreciated – issue, our post-crisis inability to clearly understand what health care providers are saying to us. No wonder we smile and nod and act as if we do understand.
Lots of interesting research out there about patients’ recognized inability to comprehend (even in signing consent forms) which is yet another reason that docs and others need to slow down, speak plainly, ask patients to repeat key points to confirm basic understanding before rushing off to the next patient.
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