Our smart colleagues have published in JGIM (Journal of General Internal Medicine) and have updated the classic study: how long does it take for a doctor to interrupt the patient at the beginning of the interview, when patients begin their opening statement about “why I am here today.”
In years past, we found that the time it takes for a doctor to interrupt the patient used to be …
18 seconds! Then 23 seconds (hey! we’re getting better!) and now … 11 seconds?!?! That is, IF the doctor asked an open-ended question AT ALL. Yikes.
Seriously disappointing. But, are we surprised? The time pressures on doctors have increased over time. More regulation. More required elements in the documentation. Meaningful Use requirements of Electronic Health Records. Decreasing reimbursement. Not sufficient time or effort dedicated to redesigning the exam room, or to redesigning teamwork so that doctors can be doctors and not clerical workers.
Beyond that, we have an internal clinician retraining program at UCHealth to improve communication in healthcare encounters between patients and physicians, we call Excellence In Communication. Led by our inimitable Patrick Kneeland, executive for Patient and Provider Experience, and a team of a dozen physician coaches (myself included), we are teaching our docs highly effective communication strategies. In a four hour workshop, we can improve clinician experience, patient experience, and reduce physician burnout. Who doesn’t want that?
Of the many techniques and tips, here’s a trio that work particularly well:
- Open ended inquiry “How can I help you today?”, and then WAITING UNTIL the patient is done with their opening statement. The published data on this indicated that the vast majority of patients complete their opening statement in far less than a minute, and the exception will go up to maybe 3 minutes, if uninterrupted. The trouble is that docs feel like they’re under so much pressure that every second of listening is excruciating, and the other parts of their brain are already; categorizing, creating a list of possible diagnoses, worrying about completing checklists, wondering about quality metrics, and are too “full” to be present in the moment. We train docs to practice listening for up to 2 full minutes to a colleague’s statement and committing to trying this in an exam room with a patient. Simple, but the behavior change is IMMENSELY challenging and yet IMMENSELY rewarding when done well.
- The second technique is “What else?” That’s it. Just keep asking “what else” until the patient runs out of stuff. This, of course is the petrifying fear that docs have: “But that opens Pandora’s box and I’ll never get it shut ever again!” and “But then they’ll bring up stuff that I can’t help them with!” and “OMIGOD this will be 75 things and we’ll be here all day and night!” Yes well, we also know that the FIRST thing that patients bring up with their doctor is only 10% to 50% of the time, the most important thing they want to talk about. So, guess what, if we RUN with the first thing patients say, we’re going to be wrong 50 to 90% of the time. So there.
- Finally, and this is the piece-de-resistance, say: “Well, we have discussed quite a few things so far. Which of these topics would you like to cover today in the time that we have? I would like to discuss A, and sounds like B is also important to you. How does that sound?” Negotiating the agenda is a critical skill, and makes items 1 and 2 really useful, creates a win-win agreement between patient and physician, and EVEN SAVES TIME. Imagine: a tool that increases patient and physician satisfaction, and saves time.
Notice that this has NOTHING to do with the EHR being for good or for evil. This works regardless of what you have in the exam room, as long as you have the presence of mind to remember to practice and use the tools.
In this, the winter of our discontent, when everything seems to be going in the wrong direction, when all of our institutions are under attack, and public courtesy and discourse seems to have gone awry, and everyone has a complaint, it seems that so few have ideas to help us climb out of this morass.
These tools could be a glimmer of hope.
CMIO’s take? Use these three tools in the exam room (or the meeting room, the board room, any professional or personal setting where important conversations occur), see what transpires. They are EASY TO understand, but require discipline and hard work to make them work for you. Persist, and they will pay off in large ways for you and for your patients.