This is NOT good news for Patient Engagement

Michael H. Kanter Michael.H.Kanter at KP.ORG
Sat Aug 4 00:17:18 UTC 2018


So I think the bigger issue is not the interruptions as they could be either useful and appropriate or not so.  The real issue in this paper is that the patient’s agenda was not elicited over about 2/3 of cases.

From: Elias Peter <pheski69 at GMAIL.COM>
Sent: Friday, August 3, 2018 3:14 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] This is NOT good news for Patient Engagement


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A ‘clarifying’ question that turns the patient narrative into a series of yes/no or checklist questions would be an interruption. However, the following clarifying questions would not be:

  *   Hmmm. I’m not sure I understand. Could you tell me more?
  *   How was that for you?
  *   What did you think that meant?

Peter
On 2018.08.03, at 5:26 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>> wrote:

The question is whether the term “interruption” is the patient’s term or the researcher’s. If my doctor asks me a clarifying question, I do not consider that an interruption but if they redirect me with an question unrelated to what I’m describing I do. This is one more example why we need engaged patients and/or patient advocates involved in the design of every research project.
Best,
Helene
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On Aug 3, 2018, at 4:28 PM, Joe Graedon <jgraedon at GMAIL.COM<mailto:jgraedon at GMAIL.COM>> wrote:
Great point David,

So how would we 1) distinguish between “good interruption” and “don’t care interruption”?

and

How can we drill deeper into this issue so that we would have meaningful data?

Joe


On Aug 3, 2018, at 3:50 PM, David Newman-Toker <toker at JHU.EDU<mailto:toker at JHU.EDU>> wrote:

I guess I’ll push back a little on this, Mark. I have always been a little concerned that people spontaneously equate “interrupting” with “not listening,” or, worse yet, “not caring.” I can see the logic of these ideas being associated, and I’m sure that some clinicians interrupt their patients thoughtlessly because they have their own agenda and don’t care what the patient is interested in telling them. However, I’m not sure this concept really applies when it comes to good diagnosis. A typical diagnostic encounter in my clinical domain goes something like this…

DNT (asks an open ended question): “So, tell me what happened when you first got your dizziness symptoms?”

Patient: “Well, I was at home this morning. I got dizzy, so my husband called 911. Then the ambulance arrived, and they put me in the back, and then they put in an IV, and gave me some fluids. Then I arrived at the emergency room and Dr. Smith told me I had an ear infection. He gave me a medicine… I can’t remember the name, but I think it started with an ‘M’. Then they admitted me to the hospital because I was too sick to go home….”

DNT (interrupting after ~10-20 seconds of the patient’s story above): “Ok, hold on a minute. Let’s go back a bit to the part where you first got dizzy… Where were you? What were you doing?” … (waits for answers) … “Did you feel unsteady on your feet? How did you get from the hall to the kitchen… Did you crawl? Hold on to the wall?” … (waits for answers)… “Were you sick to your stomach? Did you vomit?” … and so on …

I just think that active listening to the patient’s story means redirecting them to the information that is most pertinent diagnostically… and that often means interrupting frequently with more narrowly-focused or closed-ended questions than the ones you began with. In my view, this is what patients should be looking for in a caring, thoughtful diagnostician. That’s because it is very rare for a (lay) patient to be able to so cogently and concisely tell their illness history that it simply rolls out perfectly over 5-10 minutes while the clinicians politely takes notes for the record in complete silence. I just think there is another side to this issue of “patient engagement” and dialogue.

For what it’s worth, patients can readily tell the difference between someone who interrupts because they want to understand what happened… and someone who interrupts because they don’t care what the patient has to say.

Best,
David



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From: Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>
Sent: Friday, August 3, 2018 2:46 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] This is NOT good news for Patient Engagement

There have been earlier studies showing that clinicians tend to interrupt the patient at the start of the encounter.  At a time when patient engagement and partnership are strongly being endorsed, one would have thought we’d be doing better by now.  I guess not !

Here’s a quote from a new study, attached:  “The patient’s agenda was elicited in 36% of the clinical encounters. Among those in which the agenda was elicited, patients were interrupted seven out of ten times, with a median time to interruption of 11 s.”

Mark

Mark L Graber, MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University, NY
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