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Strategies for Successful Patient/Provider Communication Erin E. Krebs, MD, MPH Minneapolis VA Health Care System November 16, 2012 “They come in here and they wanna talk about my cholesterol and my blood pressure or my mammogram and a colonoscopy and everything, which, to me, I just do that really kind of to appease them ‘cause I’m not interested in it…I mean, what affects every single day, every single waking moment and half the time my nights, is this constant pain.” Experience of chronic pain care Patient perspectives Desire for validation of experience and suffering Worries about cause and future implications of pain Fears of being mistrusted or not believed Feelings of frustration and powerlessness Physician/provider perspectives Concerns about patient motivations Uncertainty about legitimacy and etiology of pain Worries about pressure to provide tests/treatments Feelings of frustration and powerlessness US prescription opioid sales, 1997-2007 800 700 600 500 400 300 200 100 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Figure adapted from CDC Grand Rounds, 2/17/11; data source DEA ARCOS Primary care frustration? 800 700 600 500 400 300 200 100 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Role of opioids in chronic pain American Pain Society/American Academy of Pain Medicine guidelines for opioid therapy in chronic pain 25 recommendations: none based on strong evidence; 4 on moderate evidence “At a minimum, this deficit will result in continued uncertainty regarding best practices, and at worst these deficiencies could contribute to unnecessary harms.” Chou R et al, J Pain 2009;10(2): 113-130; Chou R et al, J Pain 2009;10(2): 147-159 Balancing benefits and harms Pain relief Abuse/ addiction Balancing benefits and harms Symptoms Dependence Social role Mood Tolerance Abuse/ Uncertain addiction Pain relief Uncertain Injuries benefits risks Work Hypogonadism Physical Sleep activity disorders Pain hypersensitivity The other side of the coin… Effective communication is a powerful intervention Patients with pain describe positive provider behaviors Listening and expressing empathy Seeing patient as an individual Acknowledging patients’ experiences with treatments Providing options and sharing decision making Being available between visits (email, phone) Working with a care team (nurses, other providers) Effective medical interviewing Quick survey How many received advanced interview skills training during medical school or residency? How many received advanced interviewing training after your formal medical education was complete? “Self-help” books Four Habits Model Habits = organized ways of thinking and acting during clinical encounter Synthesizes evidence about effective interviewing strategies into a framework for clinic visits Implemented extensively within Kaiser Permanente Frankel RM and Stein, T Permanente Journal, 1999:3(3), available at http://xnet.kp.org/permanentejournal/fall99pj/habits.html Four Habits Model 1. Invest in the beginning Typical visits fail to identify patients’ concerns Physicians solicit at least one concern in 75% of visits Physicians interrupt patients’ initial statement of concerns after an average of 23 seconds 76% interrupted after first concern Late complaints occur more than twice as often when initial concerns not solicited (35% vs. 15%) Most common complaint among patients with pain is that doctors don’t want to listen Beckman HB, et al. JAMA. 1999;281(3):283-287 1. Invest in the beginning Elicit the full spectrum of patient concerns “What would you like help with today?” “Anything else?” “Anything else?” “ Anything else?” Plan the visit Repeat concerns to confirm understanding Set expectations for visit, put your concerns on the table “I want to focus on your back pain today, but I also want to make sure we’ve got you up to date on your cancer screenings...” 2. Elicit the patient’s perspective Physicians often fail to accurately identify patient expectations When patients expect information, physicians often believe they expect tests, medications, or referrals Addressing patient expectations improves patient and physician satisfaction Understanding effects of pain on valued activities is a foundation for functional goal setting Rao JK, Weinberger M, Kroenke K. Arch Fam Med. 2000;9:1148-1155 2. Elicit the patient’s perspective Assess patient’s point of view Identify patient requests Explanatory model—“What have you been thinking about the cause of this pain?” Serious illness worries— “What concerns you most about this pain?” “Is there anything in particular you were hoping I would do for you today?” Explore implications of pain “Tell me about how things have been going for you” “What is a typical day like for you?” “How has this pain affected your life?” 3. Demonstrate empathy Empathy = “appreciation, understanding, and acceptance of someone else’s emotional situation” Patients hope for a good outcome, but expect caring Perceived caring is associated with patient satisfaction Perceived lack of caring is associated with malpractice Beckman HB, et al. Arch Intern Med 1994;154:1365-70. 3. Demonstrate empathy Identify emotions Make eye contact Encourage patient to express emotions (pause, “go on”) “How are you feeling about that?” Express empathetic statement Reflect—“I see you’re feeling worried about…” Legitimate—“I understand why you would feel angry” Support—“I want to help you get through this” Cohen-Cole SA. The medical interview. St Louis, MO: Mosby Year Book;1991 4. Invest in the end Deliver diagnostic information, framed by patient concerns Provide an explanation for pain, even if work up is “negative” Involve patient in decision making about treatment Provide a rationale for recommendations Explore patient preferences and barriers to adherence Probe patient comprehension Express intention to work with patient over time Setting limits around opioids Difficult conversations Saying no to opioid initiation Introducing opioid monitoring Addressing abnormal drug screens, aberrant behavior Tapering high-risk or ineffective opioids Specific strategies Take the time you need Focus on benefits/harms of the drug Develop a standardized monitoring approach Ally with patient, share concerns and uncertainties Prioritize safety, share decision-making for non-safety issues
