The Issue: Between 30 and 80 percent of patients' expectations are not met in routine primary care visits, in part because of inadequate communication between doctor and patient. In some cases, patients are not given enough time to express their concerns, or doctors are not involving their patients in treatment and other decisions. In other cases, physicians are not expressing empathy toward their patients. All of these problems can contribute to low adherence to treatment, conflicting agendas and expectations, and patient confusion.
Target Audience: Primary care and family physicians.
The Intervention: A Commonwealth Fund-supported article in the March 2008 issue of Family Practice Management outlines the elements of patient-centered communication and offers guidance on how physicians can help establish a patient-centered medical encounter without lengthening the visit.
In the article, "Have You Really Addressed Your Patient's Concerns?," authors Ronald M. Epstein, M.D., Larry Mauksch, M.Ed., Jennifer Carroll, M.D., M.P.H., and Carlos Roberto Jaén, M.D., Ph.D., provide three useful tables that compare physician interaction styles. The first features snippets from transcripts from a physician-dominated encounter, while the second two give examples of patient-centered medical encounters.
In the physician-dominated encounter, the patient expresses a concern about back pain but the physician never gives the patient the chance to elaborate. Instead, the doctor changes the topic, asking the patient about his occupation and last physical exam. In the patient-centered encounter with explicit agenda-setting, the physician elicits all of the patient's concerns—which include back pain, tiredness, and feeling down—and then invites the patient to prioritize those issues.The authors also describe a series of steps known as the 'Establishing Focus Protocol,' which helps physicians set an agenda at the beginning of the visit with input from the patient. The protocol has been shown to increase patients' satisfaction without increasing the length of visits. Its basic components are:
- Inquire into all of the patient's concerns.
- Develop a working agenda together.
- Sort through the patient's concerns.
- Structure the office visit accordingly.
Other tips include helping patients prepare for the visit by providing written or online forms asking patients to list their concerns or consider their agendas in advance, or asking patients to prepare questions for the visit ahead of time; the Agency for Healthcare Research and Quality's "Question Builder" tool is one example.
The article also presents other ways to increase patient involvement, such as using trained patient-coaches or applying the "teamlet" model of care, in which medical assistants are trained to assist in agenda-setting and coaching.
For Further Information: See the article (subscription required): R. M. Epstein, L. Mauksch, J. Carroll, and C. R. Jaén, "Have You Really Addressed Your Patient's Concerns?" Family Practice Management, March 2008 15(3):35–40.