Transcript The patient encounter: asking difficult questions and involving

The patient encounter:
asking difficult questions
Doctor-patient
communication makes the
national news!
• NPR All Things Considered
6/27/06
• http://www.npr.org/templates/sto
ry/story.php?storyId=5515753
Goals for today
• To understand the importance of
good communication in supporting
the patient-doctor relationship
• To understand basic elements of
communication, and where we may
“go wrong” during patient
encounters
• To explore areas that may be more
difficult for doctors and patients to
discuss, and to learn optimal ways
to communicate about them
Elements of
communication
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Build a relationship
Open the discussion
Gather information
Understand the patient’s perspective
Share information
Reach agreement on problems and
plans
• Provide closure
Entering the room
• How do patients like us to
introduce ourselves? (New
Zealand study, Lill 2003)
• Wear a name badge (76%)
• “Dr. First Last” (46%)
• How do patients like us to look?
• Smiling face helped in all dress
categories
Fig 2 Patients' 95% CIs of scores for female doctors' items
Lill, M. M et al. BMJ 2005;331:1524-1527
Copyright ©2005 BMJ Publishing Group Ltd.
Fig 3 Patients' 95% CIs of scores for male doctors' items
Copyright ©2005 BMJ Publishing Group Ltd.
Lill, M. M et al. BMJ 2005;331:1524-1527
Build a relationship
• “A strong, therapeutic, and effective
relationship is the sine qua non of
[essential to] physician-patient
communication.”
• Patient-centered approach focuses on the
patient’s disease/symptoms as well as the
patient’s experience of it/them
• The relationship is a partnership
• The patient is an active participant and decisionmaker
• If the patient is unable to fulfill this role, then we
must also build a relationship with the surrogate
decision-maker
Open the discussion
• Allow the patient to complete his or
her opening statement
• Elicit the patient’s full set of
concerns
• Use open-ended questions:
• What’s on your list for me today?
• Oh, really? What’s going on?
• Establish/maintain a personal
connection
• Eye contact
• Good body language
Gathering information:
difficult areas
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Sex
Intimate partner/domestic violence
Mood
Memory
Substance use/abuse
Finances
Culturally-sensitive questions
Scenario 1:
A 20-year old patient with
vaginal discharge
Scenario 1: What went
wrong?
• “Her immediate assumption that I was
straight and my reticence to reveal the
truth prevented the development of a
productive doctor-patient relationship and
resulted in inappropriate care.”
Scenario 1: What went
wrong?
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Build a relationship
Open the discussion
Gather information
Understand the patient’s perspective
Share information
Reach agreement on problems and
plans
• Provide closure
Sex
• Accurate sexual history is
important for all patients
• Avoid labels, mirror the
patient’s terminology
• See handout
Intimate partner
violence
• USPSTF found insufficient evidence to recommend
for or against routine screening (2004)
• Routine screening recommended by ACOG
• Physicians are typically reluctant, uncomfortable
• “Expert” physicians were consulted regarding best
screening methods
• Include with other safety questions
• Phrase generally: “this is a real problem in our
society…I want all my patients to know how to get
help…”
• Have a high index of suspicion when a patient’s story
doesn’t fit with her/his exam
• See handout
Mood
• Psychiatric illness common in
primary care
• 43% of women and 33% of men in
primary care clinics had evidence
of a psychiatric illness
• 31% of women and 19% of men
had evidence of a mood disorder
Mood-depression
• USPSTF recommends screening for
depression (2002)
• Point prevalence of major depression in
primary care is 4.8-8.6%
• “usual care” without formal screening misses
30-50% of depressed patients
• Many well-validated screening tools
• “Over the past 2 weeks, have you felt down,
depressed or hopeless?”
• “Over the past 2 weeks, have you felt little
interest or pleasure in doing things?”
Mood—special
considerations
• In a study of international medical
graduates in a family medicine
residency (2006), mental health
questions were not routine in earlier
training/practice
• Fear of offending patients
• Not viewed as “medical problems”
• Difficulty in finding the language to
explore emotional concerns
Substance use/abuse-alcohol
• USPSTF recommends screening
to reduce alcohol misuse (2004)
• “risky”
• 7 drinks per week/3 drinks per event
for women
• 14 drinks per week/4 drinks per event
for men
• Several screening tools
available—see handout
Memory
• USPSTF found insufficient evidence to recommend
for or against dementia screening (2002)
• Approximately half of primary care patients older
than 65 with dementia are undiagnosed
• Though screening is helpful in identifying people
with dementia, evidence that such identification
modifies morbidity or mortality is limited
• MMSE has sensitivity of 71-92%, and negative
predictive value of 95-99%
• Must be adjusted for age and educational level
• See handout
Substance use/abuse—
other drugs
• USPSTF is currently reviewing
screening for drug use/abuse
• Missouri Board of Healing Arts
states assessment of prior
substance abuse is a
requirement prior to
prescription of medications for
pain
Scenario 2:
A 78-year-old AfricanAmerican woman with
poorly controlled blood
pressure
Scenario 2: What went
wrong?
• Patients may be reluctant to discuss their
financial limitations
• When patients are not responding to
treatments as hoped/planned, we must be
sure the patient is taking the
medication/treatment recommended.
• If not…why? How can we help?
Treatment adherence
• Adherence to prescribed
medications typically 50%
• 43% of patients with annual income
< $10K, >$100/mo in drug costs and
minority ethnicity reported
restricting medications due to cost
• In a survey of 4055 patients older
than 50 who used medications for
chronic health conditions, 18%
reported cost-related medication
underuse over the past year
Treatment adherence
• Counseling patients about the
importance of adherence is helpful
• Patients show selectivity with regards
to which medications they restrict due
to cost
• The physician-patient relationship is
a tool that reinforces adherence
• In a VA study looking at patients who
restrict medications due to cost
pressures, those with higher levels of
trust in their physicians were less likely
to restrict
Scenario 2: What went
wrong?
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Build a relationship
Open the discussion
Gather information
Understand the patient’s perspective
Share information
Reach agreement on problems and
plans
• Provide closure
Culturally-sensitive
questions
• The first barriers to overcome are
your own cultural barriers to asking
difficult questions
• Cultural biases/misperceptions “at
best lead to continued discomfort on
the part of physicians and patients,
and at worst lead to potential
serious misdiagnoses, or diagnoses
missed altogether.” (Whelan 2006)
Involving patients in
goal-setting
• Patients are most participatory in
the treatment plan presented by
their provider when they are
satisfied with the provider-patient
relationship (Lipkin 1996)
• Trust
• Perception of competence
• Partnership
Summary
• It is important that we gather all medically
relevant information about our patients, in
the context of a patient-centered
therapeutic relationship
• Learning nonjudgmental ways to explore
sensitive topics with patients, as
discussed above, will help you to gather
this information and to ensure good
communication
• Good patient-physician communication
also improves patient outcomes by
improving patients’ treatment plan
participation and medication adherence