Doctor Patient Communication - Stop the "Oh By the Way ..."

Doctor Patient Communication - how to stop "Oh, by the way ..." at the end of the visit and build patient satisfaction at the same time.

You know the visit ... 

You work hard helping your patient adjust the three meds she takes for diabetes and heart failure. You are 20 minutes into this visit, feeling like you have done a good job ... wondering when you will get the chance to write your note because now you are a full 30 minutes behind.

As you are neatly wrapping things up, your patient smiles at you and says, "Oh .. by the way doctor ..." and rummages around in her purse, eventually pulling out "THE LIST".

You sigh, your shoulders slump, it feels as if the wind has been knocked out of you. You didn't see it coming and you just fell into the Tiger Trap of "Oh .. by the way" at what should have been the end of this patient encounter. You would give anything to have been able to prevent this happening ... again.

In this post, let me show you how to fill this hole in your doctor patient communication skill set. When you learn to actually ask for the list up front, your energy and patient satisfaction ratings will go way up.

Three steps to stop , "Oh ... by the way"

Realize why the typical patient makes a list in the first place

They write things down simply so they don't forget.
Just like you do sometimes. Patients don't come and see the doctor every day. This is a significant event in their week. They make their list so that they remember to relay these issues to you for your expert opinion. The list is so they don't forget anything. It is not typically a demand that you deal with all of the issues on the list today.

They make a list because they are told to.
Here in the age of the web savvy patient, every website that dispenses advice on how to get the most out of your doctor visit actively encourages patients to make a written list of their concerns and bring it to the appointment.

It is not uncommon to feel that the patient's list is an instrument tailor made to frustrate you and knock you further behind schedule. I assure you that is not the case. They are not sitting at home calculating how to most efficiently mess up your day. Honest they are not. If you really feel that way, I want you to know that attitude is a sign of burnout. This flavor of Compassion Fatigue shows up most commonly in doctor patient communication.

The exception proves the rule

You will have the occasionally hostile patient who wants to get their money's worth out of their co-pay and insists you deal with their 7 issues in a 10 minute work-in visit. That is rare however - probably less than 15% of the patients who bring in a list for you.

That patient is in need of some boundaries and if it is a repeated behavior might benefit from finding another physician. See the end of this post for specific recommendations on how to deal with this type of patient interaction.

To stop, "Oh ... by the way", Ask for the list up front

It is important to open your visit with a specific CONTEXT. Establish that you are here to answer ALL of their problems first thing in your conversation. You must let them know this up front rather than sprinting off in pursuit of the first symptom they mention to you.

- You want to do a good job with everything on the list

- It won't all happen today AND you want to get to them all

When you follow this doctor patient communication style you will see the patient visibly relax. You can focus your visit on prioritizing the list rather than cramming everything in to this next 15 minutes and doing a substandard job on each and every one.

Let me show you a sample conversation below.
After you see the full interaction, we will go over the steps to this successful encounter.

It could go like this:

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You: "Hello Mavis. What can I do for you today?"

Mavis talks for 70 seconds until she takes a break

You: "Anything else?"

Mavis says, "Not that I can think of doctor."

You reply: "You know Mavis, sometimes folks bring in a list to the doctor so they don't forget anything. If you have a list like that I would love to see it so I can make sure I know everything that is going on."

Mavis: "Well now that you mention it doctor, I did write a few things down." She fishes in her purse.

You: "Great. Let's have a look."

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At this point I can guarantee you will NOT have an "Oh ... by the way" at the end of this visit.

You have the list, now take turns prioritizing 

Once you have the list in hand, step two is prioritizing. You each take a turn picking the issue you will deal with today. 

Start by reassuring her you will get to everything.

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You: "Mavis, I want you to know we will get to everything on this list AND I want to do a really good job with each one. We can't do all of this today, so which one of these problems is the most important to you?"

Mavis: "Can you do something about the rash on my ankle?"

You: "You bet we can. And as I look at this list, I am most concerned about the fainting spells you put on the list. (you are not acutely concerned about any other items on the list) Let's take a look at your rash and deal with the fainting spells and set up another appointment to get to the rest of the list. That way I can give them my full attention and we can get to the bottom of each one of them."

Mavis rolls up her pant leg to show you her flea bites. You diagnose mild orthostatic hypotension with out loss of consciousness as her "fainting problem" and adjust her diuretics. She will weigh herself every morning and call your nurse with the results.

You: "Mavis, let me hold on to this list for you. Which one do you want us to work on next time?"

Mavis: "I suppose the arthritis in my right wrist."

You: "Great, let's set you up for an appointment early next week and take care of that."

Mavis pats you on the hand and grins. You tell your nurse what to schedule as you move on to the next room.

You are happier and less stressed. Your patient satisfaction rating with Mavis just went up. You have more energy and are less behind in your schedule. Nice work!

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Here is the structure of this conversation:

• Listen to the patient until they stop talking. 85% will do so in less than 90 seconds.
• Ask "Anything else?"
• Ask for the List
• Reassure them you will deal with everything on the list and that your focus is on doing a good job with everything
• Prioritize the issues you will deal with today - one for each of you (more if you have time)
• Deal with these two issues
• Prioritize what you will deal with next time
• Schedule a follow up visit

Do not make these mistakes:

a) Do not begin to ask diagnostic questions until you ask for the list.
You will be going down a random rat hole without knowing the big picture.

b) Do not tell the patient what you WON'T do.
As in, "Sheesh, there is no way I can deal with all of this today Mavis." If you do let that slip out ... please don't then go on to try and hammer through the whole list while you seeth and blow steam out your ears. That is classic victim behavior and your patients are exquisitely aware of your energy. If the list is impossible, prioritize and tell them what you WILL do with/for them.

c) Do not fall victim to your Perfectionist Programming.
There is a piece of you that is pointing out right now that "script" won't work on every single patient. That is true. It works on about 85%. Would you like to be more comfortable and effective with 85% of your patients, especially the ones who carry a list and end your visits with, "Oh ... by the way"? If so, don't let the one patient last week this would not have worked on prevent you from practicing and trying this technique out. 

Special Cases

The above scenario will work in approximately 85% of your normal patient encounters.

NOTE:
If the patient is either upset or angry at the start of your visit, make sure you use the structure of the Universal Upset Patient Protocol instead of this one.

Here are two common exceptions and some suggestions for deal with them.

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Please Note: 
The following examples concern a medically stable, unimpaired adult patient with no symptoms suggesting an acute, life threatening disorder. I am also assuming this patient has options available to you personally caring for them. If you are the only possible provider, are mandated to care for all patients who present to you or the patient is unstable or suffering from symptoms that could indicate a life threatening illness ... you will see them no matter what and do what you can despite their behavior. (I hate having to put in all those disclaimers and we are doctors so it is mandatory)

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1) The patient who does not stop talking

Occasionally a patient will talk beyond 90 seconds and show no signs of stopping. If this were a bar or a family get together, that might be appropriate. This is your office and you have certain time constraints that must be respected if you are going to do a quality job with this patient. Here are some samples of dialog you might use to interrupt the patient respectfully and understand what is most important to them today.

"Mavis, I am going to interrupt you here ... please forgive me. I want to understand something here so I can do a good job of taking care of you. What is the most important thing you want me to look at or deal with today?"

"Mavis, so sorry to interrupt and I am a little lost. Tell me what you want me to do for you today in just a sentence or two."

"Mavis, I am so sorry this is happening to you and I want to understand better. What is the thumbnail, headline, the most important thing you want me to look at today ... just one sentence."

2) The patient who becomes upset or angry and refuses to prioritize and/or schedule further visits

At some point you have a choice to continue to work with the patient by switching to the Universal Upset Patient Protocol or create a firm boundary. Which you choose will depend on the patient's energy, language and level of civility. 

If you choose to create a boundary around their behavior, I encourage you to continue to focus on what you are willing to do, rather than what you are not willing to do and simultaneously adopt a much more formal tone. Assuming the patient is stable and in no danger such that you must take action on one or more of their symptoms immediately - it could sound like this.

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You: "Mr. Leonard, please stop shouting. I notice you are quite upset. Let me tell you what I am willing to do here today. I am willing to look at your rash and deal with your ankle swelling here and now in this visit, today. I am happy to work on the rest of your list until we address them all, in future appointments. My commitment is to doing a good job with the most important issues here today. Is that acceptable to you?"

Mr. Leonard: "Looks like I don't have any choice."

You: "You have a choice Mr. Leonard. You can leave now and see a different physician at some other time. I do not think any of these issues are a threat to you at the moment. I would suggest you consult a doctor within the week. Would you like to stay and let me help you deal with these two issues .. or go? It is your choice"

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NOTE:
When the patient is rude, profane, shouting or threatening in such a way that you feel you or your staff are in danger, I encourage you to walk out of the room and call security and/or the police depending on the nature of their threats.

Finally ...

I believe that all patients deserve a "therapeutic relationship" with their doctor.

Not everyone is a good fit for me ... or you as their physician. If you and a patient are not a good fit, don't feel like you are forced to honor inappropriate requests or rude behavior.

If you end up calling the police on a patient and they are not capable of understanding that as a signal to find a different physician, it is our responsibility to draw that boundary for them. Each state has an established procedure for dismissing a patient. I suggest you dismiss threatening patients from your practice immediately. 

For the patients where you draw a boundary in a difficult conversation, sometimes you will become a solid working partnership. I am sure you can remember patients who were a real handful the first time you met them and they turned out to be one of your favorites.You have given them a healthy boundary for perhaps the first time in their life and you go on to form a very therapeutic relationship.

For others who are always pushing and snarling - at you or your staff - dismiss them as well. This gives them an opportunity to find a different doctor with whom they might click with more effectively. You showing them the door gives them that chance.

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PLEASE LEAVE A COMMENT:

What are some tools and phrases you use to 
- avoid the "Oh ... by the way"
- or deal with patients who bring in a list?