Patient Talk 101: Tips for Effective and Efficient Patient Communication

1. Patient Talk 101:Tips for Effective and EfficientPatient Communication Jeannie A. Sperry, PhDAssociate ProfessorDirector of Behavioral Science EducationDepartment of Family MedicineTeaching Scholars AlumnusWest Virginia University Thursday, November 20, 2008

2. Learning Objectives • Identify the primary components of the ambulatory visit and communication issues associated with each component. • Determine the patient's full agenda. • Learn techniques for improved patient satisfaction. • Identify specific strategies to address common difficult patient interactions.

3. The Ambulatory Visit • Information Gathering • Physical Exam • Assessment Presentation • Instruction Giving/Intervention

4. I) Information Gathering 1. Attend to the setting 2. Identify the person with the problem 3. Clarify the patient’s agenda

5. Agenda Setting How much time do you think passes before the average health care interview is shifted from exploring the patient’s agenda and concerns to the interviewer asking specific focused questions? A. 20 seconds B. 60 seconds C. 90 seconds

6. So what? Why do I need to find out the patient’s agenda? • Door-knob questions: “By the way, I’ve been having this pain across my chest, and….” • Results in more time and frustration for both patient and clinician. • Leads to unaddressed concerns and decreased satisfaction

7. Agenda Setting and Expectations 909 pts at 45 FM, IM, Cardiology practices 11.6% reported > 1 unmet expectation 2 weeks later, visits with unmet expectations: • Drs rated visits as less satisfying/more effort • Pt reported less satisfaction with visit, less improvement, less intent to adhere. • More pt post-visit health system contacts • Bell et al, UC Davis, in J Gen Internal Med, 2002, v 17.

8. Agenda Setting Question to Consider “What brings you in today?” • “Many patients may have several things to discuss. Before we get started, what all would you like to address today.”

9. “This is a short list of my main symptoms in the last week.”

10. Agenda Card Main reason for today’s visit___________________ If time, other concerns I would like to discuss: 1) _____________________________________ 2) _____________________________________ 3) _____________________________________ __I need refills __I need referral __I need school or work excuse __I need the attached forms filled out __I would like to discuss stopping smoking Filled out by __patient or __nurse.

11. “Is there something else?” • 20 US family physicians • “Something Else“ vs “Anything else” • Increased yes responses 90% vs 53% • Decreased 78% of pts’ unmet concerns • No increase length of visit (11.4 min) Heritage et al, 2007

12. The leading question Double negatives # of questions Closed-ended questions Summarize and ask for clarification Use patient’s descriptions “No chest pain, shortness of breath, or nausea, right? “Not been suicidal, right?” “So you’ve had squeezinghere for 2 days?” Am I asking it correctly?

13. Let me check that I heard you right… • The patient's sense of being carefully listened to was the crucial variable in latter improvement Starfield et al, 1981, at John Hopkins • Patient’s perception that physician listened carefully enough that both agreed upon problem was more highly associated with improvement than tests, treatment, charting, H&P… Bass et all, 1986, University of Western Ontario

14. Agenda Setting: Establishes Focus • Determine the patient’s completeagenda at the beginning of the interview. • Prioritize if patient has multiple agenda concerns. • Continue until patient responds “That’s about it.”

15. II) Physical Exam • After clarified agenda, • Negotiated priorities for visit, and • Provided structure for visit • Use transitional statements: • Let me wash my hands and I’ll take a look…

16. The exam • Prepare the patient for each step • Provide feedback as you go • Prepare to exit the room • Anything you need to make you more comfortable while you’re waiting for me to come back? • Now I’ll step out and go over your information…

17. III) Assessment Presentation • ASK: What did you think this might be? Have you heard ideas from others or the internet? What concerns you the most? • TELL: Nontechnical terms, draw pictures, use handouts, good websites. • ASK: I’d like to be sure I explained myself clearly. Please tell me what you heard…

18. Encouragement and Legitimization Of course you may not know what the cause is, yet many people have some idea or concern about what their symptoms may represent. It would help me if you could share any of these ideas.

19. Active Listening • Mirror patient’s body language • Acknowledge the concerns • Normalize so the patient does not feel foolish • I’m glad you mentioned your concern about heart failure. Lots of people would have that concern. Let me ask some questions so that we can get to the bottom of this.

20. Reflection and Validation increase satisfaction That must be frustrating for you. I can see why you’d be so concerned. “Chatty doctors forget patients” in NY Times 100 PCP. Audio recordings of pt visits. 4/5 times when doctor interjected personal information, never returned to topic. Empathy: Focus on Patient’s feelings

21. The doctor is the drug Clinical Empathy is a Clinical Procedure • Distress results in activation of HPA axis • Empathy shifts arousal toward homeostasis: neurobiological intervention • Herbert Adler (2007) JGIM

22. IV) Instructions/Intervention • Sit together facing problem: lab values/ EMR • What do you think we might do to help you? (Not all pts want antibiotic or opioid) • Present your plan and expected results. • Describe potential side effects. • Voice your personal concern for outcome.

23. Instructions, continued 6. Transition: As we wrap up today, let’s make sure we are on the same page…. 7. Can you help me remember what we’ve agreed to do? Ask patient to restate the plan. 8. What might get in the way of this plan? 9. Stand up. Prepare to exit… 10. If “oh by the way, doc…” Too important. RTC to discuss.

24. Provider: Problem Discussed: Plan: 1. 2. 3.

25. Difficult interactions • The Angry Patient • The Noncompliant Patient • The “Heart-Sink” Patient

26. René Descartes

27. BATHE:  A Useful Mnemonic for Eliciting the Psychosocial Context Background: What is going on in your life? Tell me more… Affect: What’s that like for you?How do you feel about what is going on?" Trouble: What about the situation troubles you the most? Handling: How are you handling that? Empathy: That must be very difficult for you. Source: Stuart, M.R. and Lieberman, J.A. III. (2002). "The Fifteen Minute Hour: Practical Therapeutic Interventions in Primary Care" 3rd Edition. Philadelphia: Saunders.

28. 4 family physicians used BATHE with 10 patients, then regular interview with next 10 patients BATHEd patients reported higher satisfaction for 8 of 11 factors Physician concern Explanations given Information given Instructions given Recommending to others Today’s visit BATHEd Patients: Higher Satisfaction

29. Healing Relationship • You are practicing medicine when you are listening • The healer can reduce suffering, even if cure is not possible • Be there with the patient

30. Recommended resources: Platt & Gordon (2004) Field Guide to the Difficult Patient Interview. NY: Lippincott, Williams, & Wilkins. sperryj@wvuh.com