[No SPF Record] Re: [IMPROVEDX] This is NOT good news for Patient Engagement

Swerlick, Robert A rswerli at EMORY.EDU
Sun Aug 5 20:20:22 UTC 2018


In my mind, the issue is not that the clinician does not elicit the patient agenda or interrupts the patient so frequently during the encounter, it is that the patient agenda is not systematically collected ahead of time as the default. We train clinicians to walk into rooms consistently unprepared. We as teachers model this behavior for our trainees every single day and we are blissfully unaware just how dysfunctional this is.


Our schedules in the (ambulatory world) amount to days filled with agenda-less meetings with unrealistic expectations of both patients and care givers. A visit agenda set before the office visit would go far in establishing appropriate expectations. Patients don't consistently even know how long their visits are scheduled for!  Imagine any other industry where those meeting have no clear idea of how much time they have and what items will be discussed prior to the meeting. It is amazing that it works as well as it does in healthcare.


Interruptions are a necessary evil given the time constraints and the lack of information collected ahead of time. The primary goal of those practicing is to get through the day, not get too far behind, and not have a mountain of unfinished notes.


Our information systems are not capable of generating a shared visit agenda ahead of the office visit. I have tried to implement such tools at Emory but collecting information from patients before visits and integrating this into the EHR has not been a priority of the system or most of the clinicians.  There does not appear to be great tools widely available which will allow for patient information to be written into EHRs. There may be exceptions  but they are few and far between and there has been no major push from clinicians to create clear agendas before clinic visits.


While robust information collection ahead of office visits and artful display of information may not be a panacea,  I think it will go a long way in helping patients be heard. Without better preparation (by all parties) prior to visits, aspirations of real patient engagement are simply a pipe dream.


Bob


Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
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From: Tom Benzoni <benzonit at GMAIL.COM>
Sent: Saturday, August 4, 2018 12:24:03 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [No SPF Record] Re: [IMPROVEDX] This is NOT good news for Patient Engagement

We deal directly with this in SPAL teaching at our school.

However, I wonder why it's done. Like many observations, we each ascribe a reason. We do so without knowing and thus commit attribution bias.

"Why" would be a very good study for the group to undertake.

Tom Benzoni

On Fri, Aug 3, 2018, 22:02 ROBERT M BELL <0000000296e45ec4-dmarc-request at list.improvediagnosis.org<mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:
Is there any medical school in the world that deals with this in training?

Would simulators help?

Rob Bell
On Aug 3, 2018, at 3:51 PM, Rory Jaffe <rjaffe at CHPSO.ORG<mailto:rjaffe at CHPSO.ORG>> wrote:

Interviewing patients is a real art—the only way I could see an accurate evaluation of good vs bad interruption is to videotape the interviews, then have a panel of patient advocates and clinicians score each interruption for its value.

Because you can over-redirect—including premature focus on a particular aspect of the story, which may indicate that the clinician is jumping to a conclusion.

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From: HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>>
Sent: Friday, August 03, 2018 2:26 PM
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Subject: [No SPF Record] Re: [IMPROVEDX] This is NOT good news for Patient Engagement

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
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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
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