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

Stefanie Lee stefanieylee at GMAIL.COM
Tue Sep 4 19:30:00 UTC 2018


from  this week's AHRQ Perspectives in Safety:
https://www.opennotes.org/news/the-next-step-for-opennotes-is-ournotes/
https://psnet.ahrq.gov/perspectives/perspective/257
"...the most promising approach for OurNotes is to contact patients before
an upcoming visit and ask them to review previous notes, provide an
interval history, and list what they hope to address at the visit."

On Sun, 5 Aug 2018 at 21:35, Swerlick, Robert A <rswerli at emory.edu> wrote:

> 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
> ------------------------------
> *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> 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> 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.
>
> Rory Jaffe, MD MBA, Executive Director, CHPSO <http://www.chpso.org/>
> 1215 K Street, Suite 930
> Sacramento, CA 95814
> rjaffe at chpso.org
> (916) 552-2600
>
> <image002.jpg> <http://chpso.org/>
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> *From:* HM Epstein <hmepstein at GMAIL.COM>
> *Sent:* Friday, August 03, 2018 2:26 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *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
>
> Website
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>
> On Aug 3, 2018, at 4:28 PM, Joe Graedon <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> 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
>
>
>
> *David E. Newman-Toker, MD PhD*
> Professor of Neurology, Ophthalmology, & Otolaryngology
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> *From:* Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
> *Sent:* Friday, August 3, 2018 2:46 PM
> *To:* 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
> <image002.jpg>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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