American College of Physicians: Internal Medicine — Doctors for Adults ®

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Strategies to make the most of patient appointments

Active listening, the right questions and collaborative decision-making can save time in the long run

From the June 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Atlanta—Are you constantly running behind in your appointments as visits stretch far past their allotted time? Do your patients leave the office with lists of questions, only to call you after hours? Do they bring up their most disturbing symptom just as you are about to leave the exam room?

Then it’s time to try using new communication techniques to make your patient visits more efficient. During an Annual Session presentation on enhancing the efficiency and quality of office visits, a physician panel gave tips on how to do just that by actively listening, asking good questions and involving patients in treatment decisions.

“The idea behind all these techniques is that you’re accomplishing at least two or three things simultaneously,” said panelist David J. Gullen, MACP, a general internist practicing in Phoenix and a former College Regent. In the long run, the panelists said, the strategies can save time for you and your patients.

Opening the interview

Panelist Wendy S. Levinson, FACP, professor of medicine at the University of Chicago Pritzker School of Medicine, urged physicians to take a moment to prepare for each patient. Before walking into the exam room, she said, quickly review the patient’s chart or lab tests and free your mind of any distractions—a hospitalized patient or a billing problem, for example—that could cause your attention to wander.

Dr. Levinson (right) works through a role-playing exercise in which a patient doesn’t want to take her diuretic. She and other panelists negotiated a solution so the woman would continue to take her medicine.

Dr. Levinson explained that the most important component of the patient interview is “active listening.” Through careful attention, she said, physicians can better focus on what patients are saying, what they may be omitting and what nonverbal clues—such as anxiety or fatigue—they are presenting. Active listening also demonstrates concern and respect, she said, and leads to a much more efficient interview.

“Studies show that most patients finish their narrative in 60 seconds, and almost none take more than 90,” Dr. Levinson pointed out. “Yet physicians interrupt patients after only 18 seconds.” If you keep interrupting patients, she noted, you might end up concentrating on less relevant parts of their stories.

She said she suggests physicians use nonverbal communication like head nods or hand gestures to encourage patients to keep talking. When you do need to ask questions, she said, use open-ended queries like “Then what happened?” instead of simply asking, “Where does it hurt?”

After the patient describes each problem or symptom, delve further by asking “What else?” Dr. Levinson said that primary care patients have, on average, three separate problems they want to discuss at each visit. Often, they don’t bring up the one they’re most concerned about—like sexual dysfunction or depression—until they’ve established some rapport.

While Dr. Levinson admitted that she sometimes feels panicked when patients list symptom after symptom in response to her prompts, she said it is nevertheless crucial to get a full snapshot of patient concerns. Hearing about all symptoms helps you form a diagnosis and decide which problems to tackle first.

Encourage patients to bring a written list of issues they want to discuss. These lists help them remember what they want to say and give you a chance to see their concerns at a glance.

Expectations and beliefs

Once patients have presented their problems, elicit their priorities. Dr. Gullen said physicians should avoid assumptions and ask, “Of the problems you just mentioned, what bothers you most?”

Next, ascertain patients’ beliefs about the cause of their health problems, treatments that will or won’t work and the risks and benefits of various tests. This approach can build rapport and help you determine a course of action that will satisfy the patient.

Patients’ beliefs may be cultural, religious or drawn from the media or experience of others. “Perhaps they’ve had a friend with similar symptoms who had a bad diagnosis, so they’re sure what these symptoms mean,” Dr. Gullen explained. “Or they’re convinced they need an ECG, even though their symptoms clearly point to reflux esophagitis.”

Dr. Gullen said that patients typically don’t divulge their beliefs and fears, although such feelings strongly influence patient compliance and satisfaction. He recommended a direct approach, such as asking patients, “What do you think may be causing this problem?” or “What’s your worst fear?”

You then need to state your own priorities and expectations for the visit, he said. If your views are in harmony with the patient’s, you can discuss treatments.

If the patient’s list of symptoms is too long to address in one visit, Dr. Gullen advised, say so. Make sure you reinforce your desire to address the patient’s most pressing concerns in the current visit.

If an impasse develops between what the patient wants to accomplish and your own expectations, you need to negotiate. “Reiterate the patient’s perspective to make sure you have it right, review your own perspective and find a common goal,” Dr. Gullen said.

Collaborative decision-making

Medical decision-making is usually a condensed process, explained panelist Mack Lipkin Jr., MD, professor of clinical medicine at New York University School of Medicine. Physicians often reel off a list of interventions that patients find disorienting and difficult to keep track of.

Instead, physicians should engage patients in collaborative decision-making. Start by asking patients about their ideas concerning therapy, then discuss treatment options, giving both the pros and cons of each option. Bring patients’ ideas into the decision-making process and find a solution that encompasses their preferences and your own.

In a role-playing session, Dr. Lipkin presented an example where a patient with congestive heart failure admits that she is not taking her diuretic. The reason? Frequent urination makes it hard for her to enjoy outings with her friends.

Dr. Lipkin explained why the patient can’t stop the therapy, but together they decide on a schedule she can live with. She will break up her diuretic dosage. Instead of taking it all before she goes out, she can wait until the afternoon to begin taking it.

“In patient satisfaction surveys, patients most frequently complain, ‘My doctor doesn’t listen to me,’ and ‘My doctor doesn’t discuss options or give me choices,’ ” Dr. Lipkin said. “Because patients usually won’t push their treatment preferences, it’s up to the physician to bring them into the discussion.”

Closure

The panel suggested tips to close the encounter. First, ask the patient to repeat the steps of your agreed-upon treatment plan. That allows you to hear what the patient has learned, including misconceptions that you can address immediately.

Clarify the next steps in the process: The patient needs to make another appointment, for example, or have blood drawn. Ask patients where they anticipate problems with the treatment you’ve agreed upon, and help them come up with strategies to overcome those hurdles.

Encourage them to write down steps of their treatment. For complex situations like initiating care for diabetes or cancer, making an audiotape of the session for the patient can help improve recall and compliance.

Taping patient encounters is also an excellent exercise for physicians, the panelists said. By listening to tapes, physicians can hear how often they interrupt, use complex medical jargon or insist on treatment options that patients seem reluctant to take.

Using those clues can help physicians avoid those mistakes during future patient encounters—and lead to the more efficient use of time for themselves and their patients.

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