doctor-patient communications

Now Available Webinar Recording Achieving Effective Patient-Provider Communication with Dr. Drossman

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One of the greatest problems that emerges with continually decreasing amounts of time that clinicians can spend with patients include the inability to:

1) obtain sufficient high quality information about the illness and

2) have quality time to establish an effective patient-provider relationship.

This can result in inaccurate diagnoses and treatments as well as patient and physician dissatisfaction with each other and the very process of care.

This webinar is specifically designed for patients and features Douglas A. Drossman, MD, MACG, and one of his patients, Katie Errico, who recently published her health journey in The American Journal of Gastroenterology.

Dr. Drossman and Katie will discuss her case as an example of effective patient-provider communication and provide guidance, tips and insights on what you can do to better understand your symptoms and how best to communicate with your doctor on how they are impacting your quality of life so you can effectively work together to achieve symptom relief.

Objectives:

1. To learn methods that help to optimize a visit to a physician

2. To learn ways to self manage chronic pain and functional GI symptoms

3. To understand how effective communication improves the patient-provider relationship through presentation of a case history


 

About Katie Errico:

I am a 31 year old special education teacher, tennis enthusiast and lover of dogs.  I am also a type one diabetic, diagnosed at 22, and looking back have had symptoms of IBS since my early teen years.  However, I did not know this until I met Dr. Drossman just after my 29th birthday, who also discovered that I have functional dyspepsia, atrophic gastritis and pernicious anemia.  I’m not going to lie, this was no easy road to travel and I still hit some bumps every now and again, but I can honestly say for the first time in a long time, I’m really enjoying my life 

Related Resources

Katie: A Patient’s Perspective Katie Errico Am J Gastroenterol 2017; 112:528–529; doi: 10.1038/ajg.2017.26; published online 21 February 2017

Katie: The Physician’s Perspective of a Young Woman’s Illness Experience Douglas A. Drossman , MD 1 Am J Gastroenterol 2017; 112:525–527; doi: 10.1038/ajg.2017.23; published online 21 February 2017


Are You a Patient’s “Dream Doctor”? July 2016

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2016-07-12_21-02-14A recent article, A Doctor that Every Patient Would Want, by Suneel Dhand, MD, highlights much of what I have been writing and speaking on for many years–the importance nurturing the doctor-patient relationship. It is encouraging to read Dr. Dhand’s words and his call for us to get back to basics, put the patient first and refocus our attention on the humanity of medicine despite a healthcare system that by design often loses sight of the patients’ needs.

Much of what I have championed in my career and in with my work as a mentor and teacher at the Drossman Center, embodies what Dr. Dhand says here in this excerpt from his article:

“The doctor-patient interaction is sacred and those precious few minutes transcend everything else and should be every doctor’s “zone”. That is something that no mandate, administrator or information technology can ever touch. They are what the patients and families will remember and judge you on. Patients simply cannot just be an afterthought in a real healthcare system.”

I encourage my colleagues to read Dr. Dhand’s latest article and then ask themselves if they are a patient’s “dream doctor.”  If not, then it is time to put the patient first and take the necessary steps to make the patient’s “dream doctor” a reality.

Douglas A. Drossman, MD

Related Drossman Center Resources

 


How the Internet Can Hinder the Doctor-Patient Relationship March 2015

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IDoctor And Patient Teamt is no surprise that many patients take to the internet to search for health information, find support from other people who share similar health conditions or experiences and research doctors and other healthcare providers via online review sites often basing their decision on who to seek care from on the number of stars or the content contained in the review.

But while the internet has an important role to play in healthcare, empowering patients to take a more active role in their health, the internet can also do more harm than good especially when there is an endless amount of information available to patients online, making it difficult for them to ascertain among other things, which sources are credible, whether the information is based on scientific evidence and whether or not the information is relevant and accurate for their (or their loved one’s)particular health condition.

bigstockphoto_Hand_Type_Computer_369004Let’s consider some of the scenarios where a patient’s online hunt for information can impact both the patient and the provider in challenging ways:

  1. Googling for Answers: People who search using very common symptoms (i.e., diarrhea, constipation, nausea, abdominal pain) without much other qualification. This gives a very large number of possibilities that really take medical knowledge to sort out.
  2. Self-diagnosis: To make things worse patients are vulnerable to “med student syndrome”. When a medical student has a symptom and they look it up – what do they focus on? The worst possibility. When I was a 4th year med student I took an elective in Denver Colorado for a month. I was on hematology (specialty of blood diseases). Two weeks in I took my own blood smear and looked under the microscope. Based on all my new knowledge, I found these unusually large cells. I checked the photographs in the books and sure enough they looked like the cells seen in acute leukemia. As it turned out these were reactive lymphocytes, which became larger in response to the high altitude. But how would I know that with my limited knowledge?
  3. Information overload: Some patients may run the risk of going to the doctor armed with their new information from the internet and then put the physician in a defensive position. “How do you know this isn’t pain from pancreatic cancer? I just read about it and have those symptoms!” The physician may practice defensive medicine and order tests just to satisfy the patient when it’s not really indicated, or conversely may stand ground and appear confrontational to the patient. It’s also possible that the doctor might not even have thought of the possibility. A good doctor would say “let me look into that and get back to you”. But beware of the doctor who strongly argues the case; egos may be hurt.

On the positive side, with a good patient-provider relationship (as we seek to promote in our practice) the relationship is a partnership not a confrontation. The patient can bring ideas from the internet and the provider can put it in perspective. Here are some examples of how a doctor might respond in a positive manner: “Yes you have pain that seems like pancreatic cancer, but a year ago the CT was negative; if you had pain from cancer it would have been seen then. Let’s move on now to managing your functional GI pain” or if the physician is not sure, “let’s consider this and other possibilities further.”

Watch this video demonstration, “Doctor, I want a CT scan,” where I respectfully approach a delicate and common situation when a patient is pressing, despite medical advice, for additional testing to uncover the cause of certain symptoms.

From the physician side there are problems as well. Consider the following:

  1. Doctors are forced to spend more and more time online with the electronic medical record (EMR) which I believe is more for billing purposes than to help the patient. Too much attention to the computer during the office visit can take away from good communication.  See my blog post on the EMR
  2. Many doctors in practice need to maintain their practices through referrals. With specialties at major medical centers it may come from other specialists or primary care. But for community doctors they also need to rely on their patients’ recommendations: “Dr. Jones….he’s the best! He really takes the time to listen.” Now there are patient evaluation sites like Health Grades, Vitals, etc. where patient evaluations of their doctors can be compiled. The good news is that if a provider consistently gets glowing reviews you can expect a good clinical interaction with your appointment. And, for the most part people like to give good reviews. However, you don’t need more than one angry patient to make a doctor look like an ogre. So one or two bad reviews doesn’t necessarily mean there is a problem. Be aware that there really is no good way to judge the quality of the doctor’s technical skills in diagnosis or treatment from the patient perspective; for the most part what the patient is judging is their interpersonal skills. For technical competence and good knowledge, check their training credentials and the hospitals where they work. Ideally you want both features.
  3. Some doctors may try to encourage good comments. There are examples of doctors who might prescribe medications e.g., opioids to satisfy some patients with pain when it might not be medically indicated.

Yes, the Internet is rapidly changing the doctor-patient relationship by giving patients the opportunity to assume much more responsibility for their own health care—and there is no doubt this increased empowerment of patients is challenging the traditional role of the physician in providing care. I urge patients to also recognize the ways in which the Internet can hinder their relationship with their physicians and potentially impact the delivery of care. Additionally, I encourage healthcare providers to be mindful of the ways patients are using the Internet in relation to their health—and learn how the vital role of effective communications can help foster a collaborative physician-patient relationship that achieves quality delivery of care.

 

Douglas A. Drossman, MD


Why We Need to Evaluate Doctors for Their Empathy, Not Just Their Technical Skills January 2015

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Patient EducationI’m still thinking about an article I read in the New York Times a few weeks ago by Nirmal Joshi, MD, who illuminated a significant challenge in our healthcare delivery system – the failure of the clinician to embrace a more effective way of communicating with their patients that is based on a biopsychosocial approach and hinges on the doctor’s ability to listen, explain, and empathize.

In the article, “Doctor, Shut Up and Listen,” Dr. Joshi describes the case of a patient who had seen a number of physicians for a “rapid heartbeat” and “feeling stressed.” She was referred to psychological counseling for an anxiety disorder after extensive testing was inconclusive. It was the counselor who finally “asked” her the necessary questions to get the patient to reveal that she was taking an over-the-counter weight loss product that contained ephedrine.

According to the article, “when she stopped taking the remedy, her symptoms also stopped. Asked why she hadn’t mentioned this information before, she said she’d “never been asked.” Until then, her providers would sooner order tests than take the time to talk with her about the problem.”

I have spent the majority of my career writing and speaking about how poor communication between physicians and their patients is detrimental to the delivery of quality patient care and the health care system in general. In 2012 I founded the Drossman Center for Education and Practice of Biopsychosocial Care, fulfilling a passion of mine to improve doctor-patient relationships in a way that ultimately improves health care delivery and outcomes by achieving physician and patient satisfaction and reducing unnecessary health care costs.  Since that time we have had visitors from all over the US, Asia, and Latin America, have given workshops at national and international meetings and d have integrated these methods at medical centers as well.

Learn more about Rome AGA Workshop

Watch Simulated Patient Interview

Watch 12 Gurus Game Changing Presentation on Doctor-Patient Communication

Read “Helping Your Patients by Helping Yourself: How to Improve the Patient-Physician Relationship.” The full article was published in the April issue of the American Journal of Gastroenterology.

I applaud Dr. Joshi for bringing attention to this issue with his recent article that also noted that a review of reports by the Joint Commission, a nonprofit that provides accreditation to health care organizations, found that communication “failure (rather than a provider’s lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes in hospitals.”

This is alarming. Now whether this failure is based on a lack of communication skills or understanding of the biopsychosocial approach to care, time constraints or overt refusal to listen, one thing is clear, we need to evaluate doctors for their ability to actively listen, empathize and engage in patient centered care, not just for their technical skills.

Why?

Because as Dr. Joshi writes and I agree, “a doctor’s ability to explain, listen and empathize has a profound impact on a patient’s care.” Yet, as he points out, one survey found, two out of every three patients are discharged from the hospital without even knowing their diagnosis; while another study found that in over 60 percent of cases, “patients misunderstood directions after a visit to their doctor’s office. And on average, physicians wait just 18 seconds before interrupting patients’ narratives of their symptoms.”

Yes, Dr. Joshi, we do have a long way to go.

What we are trying to do at the Drossman Center is to communicate the basics of good communication skills to clinicians and patients so that a higher quality of information is obtained and is done in a fashion that builds and strengthens the relationship. It’s not what you do (in the amount of time available) but how you do it that makes the difference. Through our preceptorship and mentoring programs clinicians at all stages of practice from GI fellows to senior clinicians are able to observe at our center methods and skills they can bring back to their practice.   I encourage physicians to contact the Drossman Center to learn more about how our customized educational programs, resources and expertise can help their practices, medical centers and hospitals increase their efficiency, improve patient satisfaction and increase external funding for their health care programs.

Douglas A. Drossman, MD


Suffering with Chronic GI Symptoms? Here’s How to Make the Most of Your Doctor Visit July 2014

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Patient EducationMost would agree that good communication skills are the cornerstone of an effective patient-provider relationship. In a previous post, I offered tips to help physicians achieve effective relationships with their patients. But patients also share some of the responsibility for developing and nurturing an effective relationship with their doctor, and one of the ways patients can foster a better relationship is by taking steps to make the most out of their doctor visit, especially if they are suffering from chronic GI symptoms, like abdominal pain, diarrhea or constipation.

Last month I gave a presentation at patient education event in Washington, DC, sponsored by the UNC Center for Functional GI and Motility Disorders. My talk, “How to Make the Most of Your Visit to the Doctor,” touched on several important areas related to the doctor-patient relationship and what patients can do to make it more effective. What follows is a summary of that presentation.

Before I offer some suggestions for making the most of your doctor’s visit, it is important to understand the patient mindset and perspective when it comes to talking about their functional GI symptoms and how they impact their quality of life. Often patients dismiss, overlook, forget or are too embarrassed to share and describe all of their symptoms to the doctor or his staff. From my practice experience patients have many concerns that evolve from their experiences with their GI disorder and their health care providers but are reluctant to discuss them. Here are some statements that they will mention to me.

  • “Doctor’s don’t believe me”
  • “There MUST be something wrong”
  • “I know it’s real”
  • “I just want you to open me up and find out the problem”
  • “You don’t think it’s in my head do you?”
  • “Sometimes I feel like I’m going crazy
  • “Nobody really knows what I’m going through”
  • “I feel like I’m not the person I used to be”
  • “I feel so alone with this”
  • “I feel like such a burden to my family”
  • “I have no control over this”
  • “ I feel I may have caused some damage”
  • “I feel like a failure”
  • “I feel ashamed”

 

Functional gastrointestinal disorders are especially challenging to manage as patients often struggle to explain their condition during an office visit. A focus group assessment of patient perspectives on moderate to severe IBS and illness severity found the following:

  • IBS is experienced not only as symptoms (primarily pain) but as it affects daily function, thoughts, feelings and behaviors
  • Having IBS permeates life and is experienced even when not having symptoms
  • Core perceptions: uncertainty, unpredictability, loss of freedom, spontaneity and of social contacts
  • Core feelings: fearfulness, shame, embarrassment, social isolation
  • Core behaviors: avoidance of activities, changes in routine to regain sense of control
  • Patients felt stigmatized by a lack of understanding by family, friends and physicians, of the effects of IBS (e.g. needing to rush to bathroom), and that their emotions (e.g. feeling shame) are not being legitimized
  • Comments by others (e.g., “relax” “think of something else”) was perceived as a lack of understanding and a minimization of their IBS; this was ameliorated when patients felt truly understood

(Source: Drossman DA et al. Dig Dis Sci 2009; 54:1532)  Read Full Article: IBS Patient Focus Group_DD 2009

Why are these beliefs so commonly held?

All of these are valid thoughts and feelings that are commonly shared by patients with FGIDs, due to misunderstandings and misconceptions about FGIDs in Western Society. To answer this question, we must understand the history and limitations of Biomedical (reductionistic) thinking and replace it with a more effective Biopsychosocial model.

The concept of the separation of mind and body is dominant and pervasive in western thinking. This has had profound negative effects on research, patient care and the patient-physician relationship.

As Plato said in 400 BC, “The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.”

Realities of FGIDs –And Why Patients Need to Understand What They Have

Plato’s words are especially profound in our dealing with FGIDs since they are REAL medical conditions even though they are not defined by x-ray or endoscopy and exist as dysregulation of neuroenteric functioning and altered mucosal immune function. Despite common misperception, stress doesn’t alone cause FGIDs, but is an enabling factor as for all illness and disease. Efforts to understand FGIDs involve research in brain-gut interactions and to improve patient care involve using a biopsychosocial model.

FGIDs are disorders of altered gastrointestinal function (dysfunction) attributed to:

  • Motility abnormalities
  • Visceral or central hypersensitivity
  • Altered mucosal immune function
  • Altered gut bacteria composition
  • Brain-gut dysregulation

 

If patients understand that FGIDs involve both the mind and the body, they will be able to better explain their symptoms, impact of their symptoms on their daily life and not feel embarrassed about sharing this information with their healthcare provider.

Going to the Doctor: What do you expect in an effective -patient-provider relationship?

Patients should expect that their doctor work with them to identify concerns; explain basis for symptoms; reassure them about their health concerns, management and outcomes; provide a cost-effective evaluation; involve the patient in decisions about treatment and ongoing management; provide continuity of care; and set realistic limits .

Here are the signs of effective physician-patient communications:

  • Doctor provides clear information
  • Mutually agreed upon goals
  • Active role for patients
  • Doctor provides positive effect, empathy, support

 

Ineffective comments by a healthcare provider include:

  • “Don’t worry; it’s nothing serious.”
  • “I’d like to order a few tests to be sure there’s no problem . . . But I believe they’ll be normal.”
  • “Your problem is due to stress

 

Tips for Making the Most of Your Doctor Visit

Once patients understand the genesis of FGIDs and the role of both the mind and the body, they should be better equipped to effectively communicate with their doctor and develop an effective relationship with better health outcomes.

  1. Know the Four Major Functions of the Interview
  • Information gathering
  • Education/Reassurance
  • Begin a therapeutic relationship
  • Implement treatment

 

  1. Be clear on your agenda (what you need to do to get what you expect)
  • Review and characterize your main complaint (s). This should include the location, quality (how it is affecting you): factors making it better or worse; time of onset and frequency/duration; why are you here now (if chronic); what are your worries and concerns.
  • Describe its impact on your quality of life (work, social, emotional, sexual, role) and its effect on your family.
  • Describe what you think you have
  • Raise any concerns and fears
  • If needed, ask to bring a family member or friend

 

Guidelines for Patient Centered Care

  1. Have realistic goals and objectives
    1. for the visit;
    2. for the clinical outcome (with chronic illness there is no “quick fix”);
    3. for your role in self care
  2. Your health care provider is a partner and advisor and the best outcome is when the patient shares in the clinical decision making. That is why it is vital that when communicating with your provider you:
  • Listen actively
  • Seek clarification if you don’t understand
  • Take responsibility to address your issues and concerns
  • Ask questions

 

After the visit: Begin to focus on strategies for self management; this is the key to a better health outcome

Step 1: Acceptance

  • Accept that your symptoms are there
  • Learn all you can about your condition and its management
  • Knowledge is therapeutic

 

Step 2: Get involved

  • Take an active role
  • Develop with your doctor a partnership in the care
  • Understand your doctor’s recommendations and maintain an open dialog

 

Step 3: Set Priorities

  • Look beyond your symptoms to the things important in your life
  • Do what is important
  • Eliminate or reduce what is not important

 

Step 4: Set Realistic Goals

  • Set goals within your power to accomplish
  • Break a larger goal into small manageable steps
  • Take the time to enjoy the success of reaching your goals

 

Step 5: Know Your Rights

  • … to be treated with respect
  • … to ask questions and voice your opinions
  • … to disagree as well as agree
  • … to say no without guilt

 

Step 6: Recognize and Accept Emotions

  • Mind and body are connected
  • Strong emotion affects pain, for better or worse
  • By acknowledging and dealing with your emotions you can reduce e stress and decrease the pain

 

Step 7: Relaxation

  • Stress lowers pain threshold and increases symptoms
  • Relaxation help reclaim control over your body and reduces pain
  • Relaxation options to consider:
  • Deep breathing
  • Relaxation response
  • Hypnosis
  • Yoga and meditation

 

Step 8: Exercise

  • … diverts attention from your symptoms
  • … increases one’s sense of control in life
  • … helps you feel better about yourself

 

Step 9: Refocus

  • With these steps your symptoms are no longer the center of your life
  • Focus on abilities not disabilities
  • You will then see you can live a more normal life

 

Step 10: Reach Out

  • Share your thoughts and feelings with your provider
  • Talk and interact with family and friends in healthy ways
  • Support others and seek support from them as well

 

 Douglas A. Drossman, MD

For further information on educational programs to teach patient centered care go to www.drossmancare.com

For information about Dr. Drossman’s patient practice go to www.drossmangastroenterology.com