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.
Sample Action Plan
- Something I WANT to do: Get
- How: With friend
- Where: From apartment to corner
- What: Walk
- Frequency: Once a day, 3x week
- When: After morning TV show
- Barriers: Forgetting
- Plans to overcome barriers:
Put a note by remote control
- Confidence rating (1-10):
- Followup plan: Nurse will
call me next week
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:
- An opening sequence such
as "Good morning, Mrs S. Today we have 15 minutes
to discuss your concerns. How can I help you?"
- This is followed by a patient
statement of concerns.
- 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.
AND EMAIL CARE
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.
is a senior dermatology resident in Edmonton.
information visit www.ihi.org