MAY 15, 2005

Interact with patients, improve your practice

Recent IHI teleconference offers a crash course on shooting
the breeze, effectively

Sample Action Plan

  1. Something I WANT to do: Get more activity
  2. Describe
    - How: With friend
    - Where: From apartment to corner
    - What: Walk
    - Frequency: Once a day, 3x week
    - When: After morning TV show
  3. Barriers: Forgetting
  4. Plans to overcome barriers: Put a note by remote control
  5. Confidence rating (1-10): 7
  6. Followup plan: Nurse will call me next week

I recently attended, or I suppose listened in on would be more apt, a teleconference called "Interaction: Every Patient Is the Only Patient" from the US-based Institute for Healthcare Improvement (IHI). American healthcare researchers have done a great deal of work delineating a better understanding of healthcare practices, with a marked focus on quality and system improvements. Whether this has been incorporated into broader American healthcare policy for the betterment of the health of the entire nation is another story.

The teleconference offered a timely overview of some very useful doctor-patient communication techniques. Below is a run-through of some of the key tenets that were raised.

The teleconference, presented by Dr Susan Baumgaertel of The Polyclinic and Connie Davis of the MacColl Institute for Healthcare Innovation in Seattle, summarized much of the healthcare research that has been done over the past 50 years on the subject. An important British study by Di Blasi et al published in The Lancet in 2001 noted that outcomes are influenced by practitioners who form warm, friendly relationships with patients, and who reassure them that they will improve. The patient-physician interaction pre-1990 was summarized as being physician-patient focused, with an emphasis on medication taking, risk reduction (eg, smoking, STIs), rational thinking and skill building (eg, taking up exercising). This was felt by many to be a concrete, but limited view.

When researchers started looking into the matter, significant problems with communication were found to exist. A study by Roter from 1989 found 50% of patients left their visit not understanding instructions they were given. Waitzkin in 1984, in a study of over 300 medical encounters, noted that physicians spent an average of 1.3 minutes giving information and 88% of the time it was given using technical language. Clearly there was a problem.

As physicians, we need to listen to our patients better. Another much-quoted study, published in 1999 in the Journal of the American Medical Association, showed that physicians interrupted patients within 28 seconds of their encounter. Only 25% of patients were able to express all of their concerns during the visit, and 25% of patients were never asked their concerns at all. When explored further, 80% of patients only needed one minute to explain their problem, and 100% of patients finish describing their problem in two minutes. The bottom line: allow your patients to speak their minds to get your relationship on a good footing; it doesn't actually take that long for them to explain themselves (it just seems painfully long sometimes!).

Recently there's been a move toward so-called 'patient-centred' goals, including productive interactions between informed, activated patients (and caregivers) and prepared provider teams. The agenda should be clarified in advance, there should be participatory decisions and shared decision making, support for health behaviour change and the use of different modalities (phone, email) for followup.

Agenda setting involves three components:

  1. An opening sequence such as "Good morning, Mrs S. Today we have 15 minutes to discuss your concerns. How can I help you?"
  2. This is followed by a patient statement of concerns.
  3. And finally, negotiation such as "I see that you have five concerns today. Because of time pressure, let's pick the one or two problems that bother you the most."

Participatory relationships can enhance your agenda setting. Research has shown that participatory relationships promote healthy behaviours, and patient participation in decisions promotes concordance, understanding of physician recommendations and improves self-efficacy. However, for patients to adequately participate in decision making, visits need to be at least 20 minutes in length.

Another technique discussed at the teleconference is called closing the loop. This one involves summarizing or restating the events of the appointment visit. Studies have shown that physicians 'closed the loop' just 12% of the time, and when asked to restate what they had heard, patients responded correctly only 53% of the time. Bottom-line: it is valuable to either have the patient restate their understanding of the discussion (and doctor clarifies any misperceptions) or the doctor makes a point of clarifying and restating the events of the appointment at the end of the session.

Several studies have shown the efficacy of telephone care either as followup or to substitute for face-to-face visits. As far as email interaction with patients, which many of us have been slow to adopt, systems promoting email have been shown to suffer very little abuse, increase patient satisfaction and free up the physician from often time-consuming phone calls. Still, some of the medico-legal issues that have prevented many of us from adopting email interactions need to be ironed out.

With chronic problems like poor exercise habits and obesity, patients should be encouraged to develop a personal action plan as outlined in the sidebar, left. They can develop it at home and bring it to their next doctor visit. Then it's up to us physicians to assist the patient in overcoming barriers, ensuring that the plan is realistic and followed up on.

Dr Barankin is a senior dermatology resident in Edmonton.
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