umass medical school meyers primary care institute the following presentation contains some items...

UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE

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The contents of this module are accurate at the time of publication.


Patient: “I have a coupon for this new sleeping medicine. Can you please sign it so I can get samples?”

1. How might you respond to this patient? Please enter your answer below.

Questions


QuestionsPatient: “The pharmacy filled my prescription with a generic. I just don’t feel like it’s

working as well.”

2. How might you respond to this patient? Please enter your answer below.

Communicating with Patients


Objectives

• Identify communication challenges that relate to prescribing

• Describe the value of a shared decision-making model in challenging prescribing situations

• Use behaviors that demonstrate listening and understanding of the patient’s perspective

• Educate and negotiate with the patient around pharmaceutical prescribing


Provider-Patient Interaction


Does this sound familiar to you?


Briefly describe one challenge you have in communicating with patients

about prescription medications.(Please enter your answer below)


Challenges to Communicating About Prescription Medications

• Personality types

– Demanding or accepting

• Already “knows” what’s best

– Friend, advertising, or internet

• Refuses to see the other perspective

• Language/literacy issues


Communication: Self-Assessment of Skills

Create a comfortable

environment for patients to ask

questions

Give patients enough time to weigh treatment

options

Explain the benefits and risks for various treatment options

Incorporate values into treatment decisions

Identify patients’ preferred learning

style and use strategies to help them retain and

learn

How would you rate your ability to…


Shared Decision Making

1. Elicit patient’s understanding of illness and goals of treatment

2. Present options in light of patient’s goals3. Ask a patient to state their understanding of alternatives4. Discuss pros and cons of options (benefits, risks, costs

convenience)5. Ask for a patient’s decision (include checks for

understanding)6. If the patient cannot communicate or reason, solicit help7. Arrange a follow-up discussion8. Support your patient’s choice

Adapted from: Makoul, et al. Patient Educ Couns. 2006;60(3):301-312.


Evidence Favoring Shared Decision-Making

problem and symptom resolution

functional status

pain

anxietyFraenkel, et al. J Gen Intern Med. 2007;22(5):614-619; King, et al. Am J Law Med. 2006;32(4):429-501.


Step 1: Understand the Patient’s Experience and Expectations

Step 2: Build Partnerships

Step 3: Provide Evidence, Including Uncertainties

Step 4: Present Recommendations

Step 5: Check for Understanding and Agreement

Participatory Decision Making Model

Adapted from: Epstein, et al. JAMA. 2004;291(19):2359-2366.


LEARN Model

Berlin, et al. West J Med. 1983;139(6):934-938.

Listen

Explain

Acknowledge

Recommend

Negotiate


Understand Your Patient

– Acquiescent (accepting)

– Partner (involved and informed)

– Assertive (in control)

Boston Consulting Group. BCG FOCUS. 2003;(Dec):1-8. Available at: www.bcg.com


LEARN: Listen


How did the provider use the LEARN model?

(Please enter your answer below)


The prescriber listened attentively.

AAA


LEARN: Explain & Acknowledge


LEARN: Recommend & Negotiate


Was this use of the LEARN model effective?



Shared Decision Making

• There are times during interactions when you as a provider may not be comfortable with the direction of the conversation

• There are a number of skills you can use to help reframe the discussion

• You may not have to use all of them in each interaction but can select what is best for the circumstances of a particular case


Conflict Resolution• Skills

– Negative Assertion

– Negative Inquiry

– Fogging

– Repetition

Smith MJ. 1975. Bantam Books..


Negative Assertion


Negative Inquiry


Fogging


Repetition


How might you incorporate these skills into your practice?



Key Points

• Patients have different needs and styles of interactions

• Shared decision-making can improve patient interactions, adherence and outcomes

• Specific models or techniques may help prescribers improve communication and shared decision-making


Recommendations

• Talk to your patients about what level of involvement they want in their own care

• Ensure understanding and agreement, consider using the LEARN model

• Consider using conflict resolution techniques


References Berlin EA, Fowkes Jr, WC. A Teaching Framework for Cross-cultural Health Care—Application in Family

Practice. West J Med. 1983;139(6):934–938.

Boston Consulting Group. The hidden epidemic: finding a cure for unfilled prescriptions and missed doses. BCG FOCUS. 2003;(Dec):1-8. Available at: www.bcg.com

Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291(19):2359-2366.

Fraenkel L, McGraw S. What are the essential elements to enable patient participation in medical decision making? J Gen Intern Med. 2007;22(5):614-619.

King JS, Moulton BW. Rethinking informed consent: the case for shared medical decision-making. Am J Law Med. 2006;32(4):429-501.

Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60(3):301-312.

Smith MJ. When I say no, I feel guilty. How to cope – using skills of systematic assertive therapy . 1975; New York, NY: Bantam Books.


Resources• Consumer Reports Best Buy Drugs• http://www.consumerreports.org/health/best-buy-drugs/index.htm

• Journal Watch• http://www.jwatch.org/

• Medical Letter• http://www.medicalletter.org/

• Medline (through the U.S. National Library of Medicine)• http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed

Attorney General Consumer and Prescriber Education Grant Program Initiated Resources

• Brigham & Women's Hospital http://www.rxfacts.org/

• Georgetown University http://www.pharmedout.org/

• MGH Institute of Health Professionals http://www.perxinfo.org/perx.html

• University of Kentucky http://www.cecentral.com/

• University of North Carolina, Chapel Hill http://harryguess.unc.edu/

• University of Massachusetts Medical School/ http://www.umassmed.edu/meyers/index.aspx Meyers Primary Care Institute


Resources

Evidence-Based Medicine (EBM)

Organizational Influences on Prescribing

Pharmaceutical Development and Regulation

Pharmaceutical Marketing

Provider-Pharmaceutical Representative (PR) Communication Links to Web-Access and Downloadable Versions Available at:

http://www.umassmed.edu/meyers/index.aspx

Additional Learning Modules in This Series


Questions

1. Shared decision-making can lead to improvements in patient problems and symptom resolution.

A. True B. False


Answer

1. A: True.

This can include improved functional status, reduced pain and anxiety..


Questions

2. Shared decision-making can include encouragement of patient questions, providing written information and checking patient understanding.

A. True B. False


Answer

2. A: True.

A 2004 JAMA article outlined the steps of a shared decision-making model

to include 1) understand the patient’s experience and expectations; 2) build

partnerships; 3) provide evidence including uncertainties; 4) present

recommendations; 5) check for understanding and agreement.


Questions

3. In the ‘LEARN’ model of patient communication, the ‘L’ stands for:

A. LearnB. Logical discussionC. ListenD. Longitudinal care


Answer

3. C: Listen.

Listen to what the patient says and the patient’s perception of the problem.

What are the patient’s goals and values? How will this impact decision-

making and care?


Questions

4. In the ‘LEARN’ model of patient communication, the ‘E’ stands for:

A. ElicitB. ExplainC. give ExamplesD. use Electronic resources


Answer

4. B: Explain.

Explain your perception of the problem to the patient.


Questions

5. In the ‘LEARN’ model of patient communication, the ‘A’ stands for:

A. AdaptB. AssessC. AccommodateD. Acknowledge


Answer

5. D: Acknowledge.

Acknowledge and discuss similarities and differences. This helps clarify

understanding and allows you to understand how to proceed.


Questions

6. In the ‘LEARN’ model of patient communication, the ‘R’ stands for:

A. RepeatB. RationalizeC. RecommendD. Routine


Answer

6. C: Recommend.

You can now make recommendations for treatment based on your

knowledge of the patient and of the disease.


Questions

7. In the ‘LEARN’ model of patient communication, the letter ‘N’ stands for:

A. Nuances B. Next steps C. Negotiate D. Navigate the system


Answer

7. C: Negotiate.

The first 4 steps of the LEARN model may identify differences and

similarities in your desired approaches to care. At this point you are ready to

negotiate any differences to achieve a clear plan.


Questions

8. You are having difficulty communicating with a patient regarding a medication request and state “I understand that you are concerned about whether this medication will be effective in controlling your symptoms.” This statement demonstrates what technique of conflict resolution?

A. Negative Assertion B. Negative Inquiry C. Fogging D. Repetition


Answer

8. A: Negative Assertion.

Using this technique a provider is acknowledging the patient’s negative

comment or concern. This could be a criticism of the treatment plan or the

healthcare system, for example. Discussion should move on to address this

specific concern.


Questions9. In conflict resolution, the technique of ‘fogging’ refers to:

A. Acknowledging a patient’s negative comment or concern. B. Prompting a patient to reflect on a specific aspect of the conflict in

discussion. C. Agreeing with patients in principle without actually supporting specific

points. D. Repeating a point until the patient compromises or raises a different issue

or question.


Answer

9. C: Agreeing with patients in principle without actually supporting

specific points.

This technique works through settling tense moments without providing any

new source of conflict. However, prescribers must be careful not to appear

patronizing when using this technique.


Questions10. In conflict resolution, the technique of ‘negative inquiry’ refers to:

A. Acknowledging a patient’s negative comment or concern. B. Prompting a patient to reflect on a specific aspect of the conflict in

discussion. C. Agreeing with patients in principle without actually supporting specific

points. D. Repeating a point until the patient compromises or raises a different issue

or question.


Answer

10. B: Prompting a patient to reflect on a specific aspect of the conflict

in discussion.

For example, you might respond to your patient by asking “I’m not sure I

understand why you think that medication would be better for you.”


Questions

Patient: “I have a coupon for this new sleeping medicine. Can you please sign it so I can get samples?”

11. How might you respond to this patient?


Questions

Patient: “The pharmacy filled my prescription with a generic. I just don’t feel like it’s working as well.”

12. How might you respond to this patient?


Questions

13. Did completing this module help you to describe the value of a shared decision-making model in challenging prescribing situations ?

A. Yes, definitely B. Yes, probably C. Probably notD. Definitely notE. Not sure

14. Would you recommend this training module to a colleague?A. Yes, definitely B. Yes, probably C. Probably notD. Definitely notE. Not sure


Questions

15. Will you do anything differently in your practice as a result of this training module?

A. Yes, definitely B. Yes, probably C. Probably notD. Definitely notE. Not sure

16. Please tell us about any changes you are considering or planning:

umass medical school meyers primary care institute the following presentation contains some items...

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questions patient

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