Tuesday, September 25, 2007

Communicating With Your Physicians - Part 2

In part one, I addressed the importance of effective written and verbal communication when communicating with a Primary Care Physician or Specialist. I gave examples of various situations that often arise and the type(s) of communication I normally choose to utilize for those situations. Additionally, I outlined some of the benefits and protections that the patient gains through effective verbal communication, and to a greater degree through written communication.

In part two I am going to offer suggestions on how a patient can be more effective in both verbal and written communication. Keep in mind that effective communication is only beneficial if the patient has a patient friendly physician.

Verbal Communication

I will outline below the key elements of verbal communication that are particularly important when communicating with physicians, and I will include examples.

1. Prior to any visit with a physician, the patient should make a list of all issues that he / she wants to address during the visit. Example: new symptoms, changes in existing symptoms, medication changes, alternative treatment options, etc. This will insure that the patient does not leave anything out due to faulty memory. Obviously, there will not be effective communication at all, if the patient cannot remember what he / she wanted to discuss.

2. Listen to what the physician is communicating, more than how he / she is communicating. Example: A physician may speak in a tone that may give the impression that the physician is skeptical of or not interested in a patient’s medical situation. That may be the case, or it may be just the way that the physician speaks, and is not a reflection on his / her actual opinion. If a patient moves into a defensive mode because of the manner of speaking, he / she may miss the information that the physician is trying to provide. Rather than concentrating on “how the words” are spoken, the patient needs to maintain his / her focus “on the words” that are being spoken.

3. The patient needs to make sure that he / she fully understands what the physician is communicating. Example: If the patient is unclear of something the physician just said, the patient can repeat back to the physician (paraphrase) what the physician just said. The patient should then ask, “Is that correct?” Once the physician confirms that the words the patient repeated back to him / her are correct, the patient can ask additional questions if further clarification is necessary.

4. The patient must be willing to state his / her position or opinion in a polite but firm manner, even if it is not in agreement with the physician’s position or opinion. Example: The physician tells the patient that it is not necessary to order an MRI of the lower back, although the patient has had radiating back pain for over a year. An X-ray two months prior did not produce the cause. This patient has done research and now understands that the type of pain he / she has been experiencing could be caused by a herniated disc or some other soft tissue injury, which will can not be seen on standard X-rays. The patient should communicate to the physician the information he / she believes to be relevent, remind the physician of the duration of time the pain has been present, and firmly state that it is his / her understanding that an MRI of the lower back is the best way to determine the source of the symptoms. By making a firm, educated statement, the physician is now obligated to provide specific reasons for his / her position. On the other hand, the physician may now concur with the patient’s educated statements and request the MRI. (I have had both scenarios occur.)

5. The patient must communicate in a clear, descriptive, and detailed manner. Example: A patient is seeing his / her Primary Care Physician for an abdominal problem and says, “My stomach hurts when I eat, but it does not hurt every time I eat”. Although a physician should ask multiple questions in response to this vague statement, this may not happen. This vague statement leaves the option open for a physician, especially one who is running behind schedule, to make a quick diagnosis of convenience, rather than take the time to extract more information from the patient.

The patient with the abdominal problems must clearly communicate the following information:

1. Type of pain (burning, stabbing, constant, intermittent, etc.)
2. The specific portion of the abdominal area affected by this pain
3. When the pain occurs (after meals, before meals, before bed, etc.)
4. How often the pain occurs (after every meal, daily, weekly, etc.)
5. Conditions that contribute to the pain (types of food, time of day, exercise after a meal, exercise prior to a meal, etc.)

By providing clear, descriptive, and detailed information, the patient enables the
physician to offer a more accurate initial differential diagnosis. It also provides enough information for the physician to quickly determine what type of diagnostic tests should be done, as well as a possible initial treatment plan to ease symptoms. Communicating in this manner saves time during the visit by limiting the number of back and forth questions and answers. This is especially important when dealing with a physician who is running behind schedule and is trying to limit the time spent with each patient in order to catch up.

6. A patient should communicate with emotion and feeling, but should not react emotionally. (This is easier said than done.) Example: If the patient is told something by a physician that he / she disagrees with, the patient can verbally respond in a passionate manner in order to get a point across or for emphasis on that topic. However, if the patient becomes visibly angry or bursts into tears, this can be very detrimental, especially if the patient is being told that his / her physical symptoms are being caused by a mental health disorder. These types of emotional reactions or outbursts will only serve to strengthen the physician’s opinion that the symptoms are mental health related rather than being caused by a physical medical condition. Even if mental health is not in question, a physician may be less inclined to want to work with the patient, if the patient is unable to keep emotional outbursts under control.

7. Before allowing a visit to end, the patient needs to inquire and understand the follow-up protocol, as well as a date for the follow-up. Example: A patient is trying a new treatment for a chronic condition. Any new treatment should include a follow-up appointment, especially if associated with a chronic condition. The patient should not allow for an open-ended statement such as, “Try this and call me if there are any problems”. Because the patient has a chronic condition, there should already be regularly scheduled follow-up visits in place. If this is not the case, the patient should insist on a follow-up visit, including the date the follow-up would take place. Depending on circumstances, at the bare minimum, a telephone follow-up should at least be scheduled.

8. Prior to any appointment, a patient should research medical terminologies associated with the chronic condition, as well as the medical terminologies often associated with the field of medicine that the chronic condition falls under – Example: A patient has been given a differential diagnosis of Parkinson’s Disease and is seeing a Movement Disorder Specialist. During the visit the patient should use the most accurate medical terminologies when discussing
symptoms, previous diagnostic testing, medications, etc. This will allow the physician to get a more accurate picture of what the patient has been or is currently experiencing. The greatest benefit of using and understanding the correct medical terminologies is that it demonstrates to the physician that you have a firm understanding of not only the differential diagnosis, but of other associated conditions. Because the patient has educated himself, it makes it more difficult for a physician to offer a diagnosis of convenience or statements contrary to known facts about the condition.

Written Communication

I will outline below the key elements of written communication that are particularly important when communicating with physicians, and I will include a sample written correspondence.

1. If the written correspondence is in letterform, which is my preference, always include the date, name of physician, physician’s address, subject of correspondence, and correspondence delivery method.

2. In the opening paragraph, provide a short, detailed summary that includes the purpose for the correspondence. If it is a summary being sent to the patient’s Primary Care Physician, in reference to a visit with a specialist, include the specialist’s name, location, and the date of the visit. Likewise, if it is in reference to concerns with or changes in a patient’s medical condition, the date of the patient’s previous visit and the specific concerns or changes since that visit should be included.

3. In the body of the correspondence, provide the details clearly. It is particularly important to use appropriate medical terminologies when corresponding in writing. Each paragraph should be limited to one subject, concern, symptom change, etc. Too many subject matters in one paragraph can cause confusion and may promote a less clear picture of the patient’s purpose for addressing the subjects.

4. Once all individual subjects have been addressed, the next paragraph should include either a summarization, if known, of future visits with a specialist, treatments, goals, or a question on how the physician would like to proceed based on the information in the correspondence.

5. The final paragraph should include a statement of thanks to the physician. A sentence that states that the patient looks forward to hearing from the physician should be included. This type of statement lets the physician know that you expect some form of response to the correspondence.

Sample: Written Correspondence to Primary Care Physician

September 24, 2007

Dr. Physician’s Name
1111 Any Street. Suite 1
Any City, Any State, Zip

Re: Patient’s Name – New Symptoms and Medication Concerns

Via Facsimile: xxx-xxx-xxxx

Dear Dr. Physician’s Name

Since my last visit with you on July 1, 2007, I have had two new symptoms develop, that I believe relate to my condition. I am now experiencing insomnia and multiple awakenings during the night. Additionally, the medications I am taking for this condition are not controlling my symptoms as well as they were. As you may recall, I am taking medication A and medication B for the last six months with positive results up until two weeks ago.

Within the last two weeks, I have had multiple episodes of insomnia. Most evenings I got to bed at 10:00 P.M. It usually takes no longer than twenty minutes to fall asleep. I have had difficulty falling asleep on ten of the last fourteen nights. On those evenings it has taken anywhere from two to four hours to fall asleep. I have had no recent lifestyle changes or stressors that could be contributing to this problem.

The multiple awakenings during the night began to occur at the same time as the insomnia. This now appears a nightly occurrence. On most nights, I wake up approximately six times per night. Of those awakenings, only one can be attributed to needing to use the bathroom. The rest appear to have no known cause. Again, I have no recent lifestyle changes or stressors that could be contributing to this problem.

For the last six months, medication A and medication B have been sufficiently controlling most of my symptoms. I have been taking both medications every four hours as directed. Two weeks ago, I noticed that my symptoms would return three hours after taking the previous dose. As a result, I now have one hour per every four-hour period that I must deal with the symptoms at their maximum levels. This has caused a great deal of hardship for my family and me. This change in effectiveness has been consistent throughout the entire two-week period.

At this time, I think it may be necessary to return to the specialist in order to address the new symptoms and medication issues. The onset of new symptoms appears to correspond with the onset of medication issues. Historically, it normally takes four to six weeks before an appointment is available with the specialist. If this is the case currently, should I make an appointment to see you in the interim? If you do not believe that an appointment with you is necessary at this time, then I would like to request that a prescription sleep aid be called in to my pharmacy. If it enables me to get a few more hours of sleep each night, I will be better able to handle the four to six week wait to see the specialist. I also believe I can handle dealing with my symptoms returning every four hours. Additionally, if it is possible, I would appreciate if your office could expedite the referral to the specialist.

Please let me know how you would like to proceed. I look forward to hearing from you. As always, thank you in advance for your assistance.


Patient With A Plan

This correspondence provides clear and accurate information to the Primary Care Physician with respect to the patient’s immediate concerns. Additionally, it provides a potential temporary solution for those concerns, until they can be addressed appropriately. In the manner written, this correspondence reflects the patient’s comfort level with the physician. The patient does not hesitate to state the need for a referral to a specialist, nor does the patient hesitate to offer input for an immediate course of action. A good doctor / patient relationship is evident, as well as the patient’s previous experience in dealing with the changes that can occur with a chronic condition.

Although personal information was not included, this correspondence represents my personal experience with this scenario. More often than not, my Primary Care Physician will call me, rather than have me come in for an appointment. This of course depends on the severity of the situation. Additionally, he has often been willing to call in prescriptions when situations warrant, as long as it does not pose a risk to my health. Again, because I have a good relationship with my Primary Care Physician, which was built through effective communication, there is a mutual understanding that my healthcare is a team effort.

The willingness to correspond directly with me outside of an office visit is something that is not common in the medical world today. In fact, this is the first Primary Care Physician that I have met, who goes above and beyond with respect to communication. There is no guarantee that a patient who communicates effectively will have the same exact results. However, the patient who communicates in an effective manner, both verbally and in writing, has a better chance of building a good relationship with his / her physician. That relationship, along with effective communication, provides the patient with the security that is essential when dealing with any chronic condition.


Patient on-line said...

Nicole, I have to admit, as much as I used written documentation in the school principal role I had when I worked,it has never occurred to me that the same makes sense in medical care situations. Thank you for pointing this important fact out. Also, your sample letters are very well written and clear. I thank you for guiding other patients. As a fellow Parkinsonism sufferer, I know how much this advice is able to be of benefit. Take care, Dan

Patient With A Plan said...

Dan, In the beginning I never realized how important that written documentation might be. Through trial and error I discovered how important it really is. Written communication leaves no room for the recipient to be able to deny receiving information.

As always, your support is very much appreciated. Thank you again.

God Bless,