Patient Talk 101:Tips for Effective and Efficient

Patient Communication

Jeannie A. Sperry, PhDAssociate Professor

Director of Behavioral Science EducationDepartment of Family Medicine

Teaching Scholars AlumnusWest Virginia University

Thursday, November 20, 2008

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.

The Ambulatory Visit

1. Information Gathering2. Physical Exam3. Assessment Presentation4. Instruction Giving/Intervention

I) Information Gathering

1. Attend to the setting

2. Identify the person with the problem

3. Clarify the patient’s agenda

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 secondsC. 90 seconds

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

Agenda Setting and Expectations

909 pts at 45 FM, IM, Cardiology practices11.6% reported > 1 unmet expectation2 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.

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.”

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

Agenda CardMain 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 smokingFilled out by __patient or __nurse.

“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

Am I asking it correctly? 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 squeezing here for 2 days?”

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

Agenda Setting: Establishes Focus

Determine the patient’s complete agenda at the beginning of the interview.

Prioritize if patient has multiple agenda concerns.

Continue until patient responds “That’s about it.”

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…

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…

III) Assessment Presentation

1. ASK: What did you think this might be? Have you heard ideas from others or the internet? What concerns you the most?

2. TELL: Nontechnical terms, draw pictures, use handouts, good websites.

3. ASK: I’d like to be sure I explained myself clearly. Please tell me what you heard…

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.

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.

Empathy: Focus on Patient’s feelings

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.

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

IV) Instructions/Intervention

1. Sit together facing problem: lab values/ EMR

2. What do you think we might do to help you?

(Not all pts want antibiotic or opioid)

3. Present your plan and expected results.4. Describe potential side effects.5. Voice your personal concern for outcome.

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.

Provider:Problem Discussed: Plan:1.2.3.

Difficult interactions The Angry Patient The Noncompliant Patient The “Heart-Sink” Patient

René Descartes

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.

BATHEd Patients: Higher Satisfaction

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

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

Recommended resources:

Platt & Gordon (2004) Field Guide to the Difficult Patient Interview. NY: Lippincott, Williams, & Wilkins.

sperryj@wvuh.com