The patient encounter: asking difficult questions

Doctor-patient communication makes the national news! NPR All Things Considered 6/27/06 ory/story.php?storyId=

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 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

Copyright ©2005 BMJ Publishing Group Ltd. Lill, M. M et al. BMJ 2005;331: Fig 2 Patients' 95% CIs of scores for female doctors' items

Copyright ©2005 BMJ Publishing Group Ltd. Lill, M. M et al. BMJ 2005;331: Fig 3 Patients' 95% CIs of scores for male doctors' items

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 decision- maker 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 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? 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 % “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 African- American 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 $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? 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