Patient Talk 101: Tips for Effective and Efficient Patient Communication

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Patient Talk 101Tips 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

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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.

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The Ambulatory Visit

• Information Gathering
• Physical Exam
• Assessment Presentation
• Instruction Giving/Intervention

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I) Information Gathering

• 1. Attend to the setting
• 2. Identify the person with the problem
• 3. Clarify the patients agenda

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Agenda Setting

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

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So what? Why do I need to find out the patients
agenda?

• Door-knob questions By the way, Ive 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

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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.

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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.

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This is a short list of my main symptoms in the
last week.
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Agenda Card

• Main reason for todays 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.

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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

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Am I asking it correctly?

• The leading question
• Double negatives
• of questions
• Closed-ended questions
• Summarize and ask for clarification
• Use patients descriptions

• No chest pain, shortness of breath, or nausea,
  right?
• Not been suicidal, right?
• So youve had squeezing here for 2 days?

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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
• Patients perception that physician listened
  carefully enough that both agreed upon problem
  was more highly associated with improvement than
  tests, treatment, charting, HP
• Bass et all, 1986, University of Western
  Ontario

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Agenda Setting Establishes Focus

• Determine the patients complete agenda at the
  beginning of the interview.
• Prioritize if patient has multiple agenda
  concerns.
• Continue until patient responds Thats about
  it.

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II) Physical Exam

• After clarified agenda,
• Negotiated priorities for visit, and
• Provided structure for visit
• Use transitional statements
• Let me wash my hands and Ill take a look

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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 youre waiting for me to come back?
• Now Ill step out and go over your information

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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 Id like to be sure I explained myself
  clearly. Please tell me what you heard

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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.

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Active Listening

• Mirror patients body language
• Acknowledge the concerns
• Normalize so the patient does not feel foolish
• Im 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.

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Empathy Focus on Patients feelings

• Reflection and Validation increase satisfaction
• That must be frustrating for you.
• I can see why youd 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.

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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

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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.

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Instructions, continued

• 6. Transition As we wrap up today, lets make
  sure we are on the same page.
• 7. Can you help me remember what weve 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.

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Provider Problem Discussed Plan 1. 2. 3.
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Difficult interactions

• The Angry Patient
• The Noncompliant Patient
• The Heart-Sink Patient

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• René Descartes

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BATHE  A Useful Mnemonic for Eliciting the
Psychosocial Context

• Background What is going on in your life? Tell
  me more
• Affect Whats 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.

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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
• Todays visit

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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

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• Recommended resources
• Platt Gordon (2004) Field Guide to the
  Difficult Patient Interview. NY Lippincott,
  Williams, Wilkins.
• sperryj_at_wvuh.com