Patient Relations: No More, ‘Oh, By the Way…’

You’ve interviewed the patient, assessed the problem, and prescribed an effective course of treatment. Exam over. You quickly glance at your watch while reaching for the door - you’re already late for your next appointment. That’s when you hear it, those four little words that will no doubt consume the next 30 minutes of your life: “Oh, by the way…”

“It’s the bane of every doctor’s existence,” says Meryl Luallin, a partner with Sullivan/Luallin, a physician consulting group in San Diego. “The doctors focus on the presenting problem, they complete their exam, and then the patient whips out a list of new questions.”

All physicians are regularly blindsided by patients who walk in with an unfocused agenda, making it difficult for doctors to gather the information needed for the most serious concerns, let alone prevent a waiting room pile-up. While doctors are quick to place blame on their voluble patients, Luallin believes physicians should be pointing their fingers at themselves. Many, she notes, simply lack the communication skills to manage patient interviews. That means asking the right questions, keeping the conversation on course, and letting the patient feel heard without conceding the floor. It is, indeed, an art form.

Fortunately, there are numerous ways to control the process, from giving and interpreting verbal and visual cues to high-tech handholding.

Let them speak

Judith Chamberlain, a family physician for nearly 30 years in Brunswick, Maine, notes that doctors can eliminate many of the most common exam room hang-ups by simply giving the patient time to talk. “When you walk into the exam room, let the patient talk for the first two minutes of the interview without interrupting,” she recommends. “That’s a long time. It’s not something we’re used to doing. But more often than not, they’ll tell you everything you need to know.”

Luallin agrees. She believes - to the detriment of patients - that medical schools teach doctors to focus only on a patient’s presenting problem. “The way doctors are trained has a big impact on how they come across in the exam room,” she explains. “The reason they get frustrated is that, based on their training, they’ve focused too narrowly from the get go.”

Taking a few extra minutes at the outset of the exam, she says, can reduce the length of the overall interview significantly - and prevent the dreaded “hand-on-the-door” questions. After hearing the patient’s first concern, doctors should immediately offer empathy and ask if there’s anything else going on they’d like to discuss. “They should say this at least three times,” recommends Luallin. “From the beginning, the physician needs to be sure he or she has a sense of what the patient is expecting to get out of the visit.”

For patients who identify a laundry list of concerns, Luallin suggests the doctor politely let them know that there’s not enough time to address everything that day. “Ask that patient which issue is most important to them, and tell them which ones you are more concerned about,” she says, adding that the doctor should indicate she’s making a note in the patient’s chart to address the other concerns at their next visit. “Now the doctor has a list of the patient’s agenda items, and she’s negotiated with the patient what they’ll have time to discuss,” explains Luallin. “It all has to do with staying on time.”

The group dynamic

To that end, Rick Kellerman, a family physician in Wichita, Kan., and president of the American Association of Family Practitioners (AAFP) notes one way to free up more time for individual patient visits is to utilize group workshops. For example, diabetic patients in his practice get invited to an hour-long question and answer session in which specialists are brought in to hold educational seminars.

As a result, individual visits with those patients are more productive and less repetitive. “We’re using this a lot for patients with common health problems, like diabetes,” Kellerman says. “You also have to meet with those patients individually, of course, but this helps them better manage their disease, and it reduces the number of questions they [bring to the exam room].”

Kellerman says that group health workshops have been well received by his patients, providing an unexpected benefit. “Meeting together as a group has been shown to decrease the use of emergency room visits and provide better ongoing care and more information for the patient,” he explains. “But it also becomes a kind of support group for them.”

Body language

It should go without saying, but doctors ought to give patients their undivided attention. Staying focused, using patients’ names, and making eye contact makes patients feel heard, giving them the confidence they need to get right to the point. It also helps the doctor pick up on nonverbal cues such as gestures or facial expressions, which can be equally telling.

“If you bury your nose in your chart or stare at a computer screen, patients don’t think you’re listening to them, and you’re probably not,” says Chamberlain. “These are the same communication skills we use with our families and kids.”

One strategy that works for Chamberlain: “Studies have shown that patients in a hospital will perceive you’ve spent twice as much time with them if you sit down,” she explains. “It’s such a little thing, but it says a lot. It says you’re settling in and paying attention.”

In a paper titled, “Tips on Building Doctor/Patient Relations,” the AAFP offers a few other suggestions for managing the patient interview. Physicians, they note, should never look down at their chart or EMR when a patient is speaking.

Doctors should also minimize distractions by silencing pagers and closing the door. Showing empathy during the interview - using phrases like “that must be difficult” - can also help establish trust, making patients less likely to repeat themselves or continue talking in circles. Finally, the AAFP suggests doctors be deliberate about their own nonverbal cues. Lean forward during the interview, nod appropriately, and never cross your arms.

Bill Ventres, a long-time family physician with the Multnomah County Health Department in Portland, Ore., notes that patients appreciate ongoing communication. “As you’re doing an exam, talk to the patient about how their heart sounds or how their ears look so they’re included in your thinking and you don’t have to go over that later on,” he recommends.

High-tech help

Ventres says that in some ways, high-tech tools like tablet notebooks, Pocket PCs, and other mobile digital devices have actually made the doctor-patient interview process more difficult, creating an impersonal atmosphere in the exam room. Typing notes during the exam or focusing on a screen makes the patient feel excluded. “When patients feel like they’re not being listened to, they may not be as open about sharing important things until they’re panicked because time is up and they still haven’t shared this important piece of information,” says Ventres, who co-authored an article titled, “EHR In the Exam Room: Tips on Patient-Centered Care.”

His suggestion: shy away from large, fixed monitors in the corner of the exam room and invest instead in either a flat-screen monitor on adjustable arms, a tablet computer, or a laptop computer, all of which offer some mobility.

“It may help to ask the patients if they’d mind if you typed a few notes during the exam,” says Ventres. Better yet, show them the screen and use it to keep the conversation moving forward: “You can use your computer to actually draw wayward patients back in. Tell them what you’re typing and why.”

Ventres also recommends showing patients updates to their charts based on your discussion, and asking if there’s anything else they’d like to add. If your laptop allows, you can also use a pointer to show them digital lab examinations and reports.

With the growing use of EMRs in the exam room, doctors are losing an important visual cue that helps bring conversations to a close. “It used to be you could simply close the chart as a symbol that you were done,” says Chamberlain. Today, it helps to rely on summary statements that encapsulate the patient’s concern. Reviewing the patient’s symptoms out loud sends an equally poignant message that the interview, or that part of the interview, is over.

Prep work

One of the best ways to make the most of each patient visit is to update and review patient charts before exams take place. Luallin recommends that medical assistants (MAs) prepare charts in advance, making sure all pertinent documents, referrals, and test results are on file. “You’d think doctors would automatically know to do this, but many don’t require their medical assistants to be all they can be,” she says, noting that flipping through patient files during an exam can distract patients. “There are a variety of things that should be prepared by the MA, and one of them is making sure everything needed for the visit is in the chart.”

Doctors should also consider asking office staff members or MAs to run screening checks and update patient charts on a routine basis - perhaps quarterly. Computer programs and EMRs now allow medical groups to scan its patient base for all diabetics, for example, flagging those who have not kept current on their eye exams, flu shots, or regular check-ups. “Computers can be helpful in identifying preventive health targets, so it eliminates something the doctors commonly have to do in the exam room,” says Ventres. “It doesn’t have to intrude on the visit itself, and it frees up time to focus more on that patient.”

Through different eyes

Body language and group seminars aside, Chamberlain insists physicians must also learn to alter their perspective during exams, stepping back to let patients be patients. “We as doctors think our patients are not focused because they’re not giving us the information in the order we want it,” she says. “We’re thinking about chief complaints, medical history and treatment regimens, the things we were taught in medical school. But that’s not how the patient thinks. It’s not how you tell a story.”

Ventres agrees. At the end of the day, he notes, it’s all about taking time to meet your patients’ needs. “The biggest mistake physicians make is that they spend a vast majority of their time in the medical world, and they don’t communicate to patients in a way they understand,” he explains. “Regardless of the work we do, if a patient has no idea what we’re talking about, they may leave confused and that makes them less likely to follow the plan of action you’ve laid out.”

Shelly K. Schwartz is a freelance writer in Maplewood, NJ, who has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNN/Money.com, Bankrate.com, and Healthy Family magazine. She can be reached via editor@physicianspractice.com.
This article originally appeared in the January 2007 issue of Physicians Practice.