Good communication—in 15 minutes?
By Paula S. Katz
Dealing with noncompliant patients or end-of-life decisions can challenge doctor-patient communication. Now try working through one of those issues in a 15-minute office visit.
Those scenarios were the subjects of role plays using standardized patients during a the first part of a course on "Challenges in Doctor-Patient Communication." Suggestions from panelists on how to best handle such patient encounters were met by skepticism from audience members, who questioned how they can squeeze all the right questions into the tight schedules demanded by managed care.
"It helps if you've known the patient a while so you can do this effectively in 15 minutes," said Timothy E. Quill, FACP, of The Genessee Hospital in Rochester, N.Y. He acknowledged, however, that 15 minutes is a "severe limit if it's a new patient."
Dr. Quill played the role of the physician during a scenario in which a 68-year-old man asked to end life-sustaining hemodialysis. Dr. Quill recommended that physicians consider such requests a "cry for help" and that they thoroughly screen for depression, pain and psychosocial distress. He said that physicians should also consider the interests of family members and consider consulting experts in palliative care, psychiatry and ethics. He noted, however, that patients have a right to refuse life-sustaining therapy and that 10% to 15% of dialysis patients do so.
During what may be only 15 minutes, explained Dr. Quill, physicians should ask patients what they hope to accomplish during the visit, focus on one or two of those issues and schedule an appointment to handle the other issues later.
Even if physicians' time is limited, they should at least acknowledge the patients' concerns, said Peter Rudd, FACP, professor of medicine at Stanford University Medical Center. At the presentation, Dr. Rudd worked with a standardized patient who was having trouble remembering to take her blood pressure medicine. By using questioning that was nonconfrontational yet probing, he was able to discern that the patient was leading a hectic life of working while taking care of her sick husband—and that she was possibly illiterate.
Dr. Rudd's solution was to ask the patient to bring her medications to the next visit and consider what he could do to help her get her medicine and remember the schedule. He noted that working with noncompliant patients "isn't easy or always successful," particularly in a short visit. "But it's part of our job."
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