How to maximize face-to-face time with patients
The average time of a consultation in primary care rose from 15.56 minutes in 1993 to 21.07 minutes in 2012, research recently published in BMJ found.
Though the amount time a primary care physician spends with a patient has improved, less than a half hour may not always be enough time to sufficiently discuss all necessary topics during a patient visit.
Compounding the time constraints are the litany of conditions considered to be a top priority by various guidelines, recommendations and commentaries and the need to document the appointment in an EHR.
Even when sufficient time exists to discuss a patient’s concerns, the issue of how much the patient has truly understood often needs to be addressed.
This concern was underscored in a recent HHS survey that showed only 12% of U.S. adults had proficient health literacy, to complete tasks such as calculating an employee's share of health insurance costs for a year with the help of a chart, while 35% of patients would have problems with tasks such as following directions on a prescription drug label or adhering to a standard childhood immunization schedule.
Healio Family Medicine interviewed American Academy of Family Physician members and other health care professionals to discuss strategies to maximize face-to-face time with patients.
Discourage patient passiveness
A patient’s demeanor may make a difference in how they are treated, a study suggested.
“Research has shown that the differences between physicians with regard to the amount of prescribed drugs, the number of referrals and the conduct of surgical procedures are not so much determined by differences in the nature and seriousness of the complaints presented but by the varying manners in which the physicians address and cope with the complaints and preferences presented to them,” Hans Peter Jung, MD, PhD, GP, of the Centre for Quality of Care Research at the Universities of Nijmegen and Maastricht in The Netherlands, and colleagues wrote in Health Expectations.
Familydoctor.org, an AAFP-affiliated website, recommends that clinicians encourage patients to be active, such as by having the patient take notes or use a recording device during the appointment. Clinicians should also try to solicit questions from patients, such as what their symptoms mean, if a test would be appropriate, and, at diagnosis, how serious their condition is, what their treatment options are and what their prognosis could be.
Visual aids can help some patients make decisions that have potentially important health consequences, Barry G. Saver, MD, MPH, of the University of Massachusetts Medical School said.
He led a team of researchers that recorded vignettes of physician-patient discussions about prostate cancer screening and mammography. They also created illustrative slides, based on previously published principles regarding these two medical procedures, including USPSTF recommendations.
“We have an obligation to help our patients make the best decisions for their health that we can. For preference-sensitive or controversial decisions, simply telling them what to do or even providing unbiased information, such as with many traditional decision aids, frequently fails to achieve that goal,” he told Healio Family Medicine.
Saver and colleagues found that at baseline, 31% of surveyed men were unsure if they wanted prostate cancer screening, while 69% of surveyed women were unsure if they wanted breast cancer screening. After seeing the slides, these percentages dropped to 11% and 20% respectively.
“We feel our results show that we helped patients overcome their biases as screening preferences of substantial proportions of patients changed, with a majority of men not desiring screening and nearly half of women either unsure or not desiring screening,” Saver said in an interview. “That is a substantial change in stated preferences that other cancer screening decision aids of which I am aware have not produced — typical is a modest increase in knowledge and little or no change in screening preferences.”
Employ universal health literacy precautions
Using universal health literacy precautions often makes a difference in whether or not a patient understands what a clinician has told them.
“You have to consider the possibility that all individuals will have limited comprehension, even when it’s not obvious, and then check to ensure the patient understands,” Michael Cooper Jr., MD, of the department of pediatrics at the University of Oklahoma Health Sciences Center, told Healio Family Medicine.
According to Lauren Hersh, MD, of Thomas Jefferson University in Philadelphia and colleagues, such precautions in written communication include:
- Utilizing materials that are at a 5th- to 6th-grade reading level or lower;
- Utilizing short, simple sentences;
- Stopping use of words of more than two syllables;
- Confining content to important/most relevant information;
- Limiting medical jargon, and define terms;
- Combining information into clearly marked sections;
- Bulleted lists are better than blocks of text;
- Reviewing health education materials with the patient, and underline or circle important points;
- Using check boxes instead of asking patients to write answers on forms;
- Providing “don’t know” options on forms; and
- Bolding important words on forms.
- When using spoken communications, precautions to take include:
- Utilizing plain, nonmedical language;
- Utilizing common words and/or words the patient when talking to you;
- Talking clearly and at a moderate pace;
- Reiterating important points; and
- Confirming if the patient understands the information given.
“Even patients categorized as having intermediate health literacy may have difficulty accomplishing tasks essential for managing their health (e.g., correctly determining from instructions on a prescription bottle what time to take the medication based on mealtimes),” Hersh and colleagues wrote in American Family Physician.
Utilizing interpersonal skills
There are a multitude of benefits to having open conversations and establishing rapport with your patients, according to a study in BMC Family Practice written by Kimberley Lee, MD, of the general internal medicine division at the Johns Hopkins University School of Medicine, and colleagues.
“Giving patients the opportunity to share their stories and perspectives, through active listening, improves trust, adherence, and some biophysical outcomes. Empirical research has shown lower blood pressures, better control of [HbA1c], and faster symptom resolution when patients are encouraged to share their illness narratives,” they wrote. “Patient-centered communication has been shown to transcend race and gender concordance, thereby allowing for additional dimensions of commonality.”
Lee and colleagues also found that PCPs who are empathetic and focused on the patient, rather than the disease, have seen improved patient outcomes.
“Share the care”
A group of researchers, led by Christine A. Sinisky, MD, Medical Associates Clinic and Health Plans, Dubuque, Iowa, visited nearly two dozen primary care practices they considered “high-functioning” to identify best practices that could be shared. Their report, which appeared in Annals of Family Medicine included what they called “share the care.”
“Improving access and increasing adherence to clinical guidelines requires building additional capacity into the practice. Many sites accomplished capacity-building by transforming the roles of medical assistants, licensed practical nurses, registered nurses, and health coaches so that they assume partial responsibility for elements of care,” Sinisky and colleagues wrote to explain the concept.
“In addition, some practices have an extended care team of social workers, behavioralists, nutritionists, and pharmacists, usually working with several clinician–medical assistant teamlets,” they added.
Other ways to increase face-to-face time
Other staff members can perform functions that can increase the primary care physician and family medicine doctor’s face time with patients, according to Ada Stewart, MD, of Eau Claire Cooperative Health Center in South Carolina and AAFP board member.
“If the patient is there for an annual wellness visit, I ask a nurse to make sure the patient has their mammograms, pap-smears, and other preventive measures and annual exams up to date,” she said. “This allows me to spend my time with the patient addressing issues he or she has.”
Sinisky et al. explained another way members of the team can pitch in, thus giving the doctor more time to spend with the patient.
“The nurse or medical assistant filters all the electronic and paper information, passing on to the physician only that information which specifically requires a physician’s level of expertise. In addition, replacing asynchronous electronic messaging with verbal messaging reduces the volume of in-box messages.”
Recognize that follow-up work, appointments may be necessary
Offering follow up visits, phone calls or mailings to ensure that everything that the patient wants to discuss during the appointment is addressed is an important step, Stewart said.
“There is so much we're trying to do, so many boxes we have to click and so many metrics we have to meet, but you can’t let the patient get lost in all that. Before the patient walks out of that door, I make sure there is nothing they have not at least mentioned to me, whether we are able to address it that day or not.”
Clinicians also be attuned to signs of other problems that may be become apparent during a visit and require another appointment, added Heidi Combs, MD, an associate professor at the University of Washington.
“Tell your patients that in talking with them, you are starting to wonder if there’s something else wrong,” she said in an interview. “Tell them you’d like to talk next time they come in and the you’d like to be talking more about what’s going on with them as far as coping with the stresses that they have, how their mood’s doing, how their anxiety level and their stress level is.”
Learn for a lifetime
Lee and colleagues found that for patients to see the greatest benefit, and to be a good physician, learning can never stop.
“Knowledge may be considered to be the cornerstone of clinical excellence,” they wrote. “The early part of medical school is devoted primarily to the acquisition of medical knowledge, and this quest as a lifelong learner never ends for the clinically excellent physician. The domains of diagnostic acumen and scholarly approach to the practice of medicine rest on the foundation of knowledge; or at the very least, an understanding of what knowledge is required to solve a clinical problem and the ability to find, interpret, and apply this information.”
Lee and colleagues also acknowledged that medical knowledge frequently changes — a treatment that may have stood a long test of time may suddenly be replaced by a more effective option — and physicians must be willing to adjust.
“Medical information is constantly evolving, and clinically excellent primary care doctors remain abreast of discoveries,” they wrote. “Further, after critically appraising newly published studies, they extract the relevant clinical material and apply it effectively in caring for patients.”
Tomorrow, Healio Family Medicine offers recommendations from experts on how clinicians can better ensure proper reimbursement for office visits. – by Janel Miller
Familydoctor. Getting the most out of your doctor appointment. https://familydoctor.org/tips-for-talking-to-your-doctor/. Accessed July 27, 2018.
Familydoctor. Understanding health information. https://familydoctor.org/understanding-health-information-health-literacy/. Accessed July 27, 2018.
Hersh L, et al. Am Fam Physician. 2015 Jul 15;92(2):118-24.
Health and Human Services. America's Health Literacy: Why We Need Accessible Health Information. https://health.gov/communication/literacy/issuebrief/. Accessed Sept. 7, 2018.
Jung HP, et al. Health Expect. 2003;doi:10.1046/j.1369-6513.2003.00221.x.
Lee K, et al. BMC Fam Pract. 2016;doi:10.1186/s12875-016-0569-x.
Sinisky CA, et al. Ann Fam Med. 2013;doi:10.1370/afm.1531.
Disclosures: Healio Family Medicine was unable to determine relevant financial disclosures prior to publication.