What To Do After The History And Physical Exam

Front 1

What is empathy?

Back 1

Entering the world of your patient and letting them know you noticed something important about their world.

Front 2

What is the role of the physician?

Back 2

IS TO BE A:
1. Partner
2. Co-expert
3. Facilitator
4. Coach

Front 3

What is NOT the role of the physician?

Back 3

NOT TO BE A:
1. Parent
2. Expert
3. Lecturer
4. Judge

Front 4

What are the steps in acting with empathy?

Back 4

Step 1: Enter the patients world b/c there are TWO experts in that room: You are the expert in medicine; they are the expert on their own body.
Step 2: Be on their side - it is not you against them, it is you against what CONCERNS them, which may be different from what concerns you.

Front 5

What is the goal of the doctor patient relationship?

Back 5

To develop a collaborative partnership that maximizes the chance that your patient will receive benefit.

It is NOT the main goal to get the right dx or treatment or have them like you.

Front 6

How can you know you successfully established a collaborative partnership w/ a pt?

Back 6

You build a beneficial treatment plan that is agreed upon and they follow it.

Front 7

Why would a pt trust your treatment plan?

Back 7

They need to TRUST you: they need to believe you care and that you are capable.

Front 8

Why would a pt believe you care and how do you communicate caring?

Back 8

1. use reflective listening
2. make empathic comments

Front 9

What is reflective listening?

Back 9

Making comments that reflect back to the pt what they are telling you, this shows you care enough to understand.

Front 10

What is so great about empathic comments?

Back 10

They show you care enough to notice and to meaningfully step into a part of their existence.

Front 11

What is the most important and powerful way you can communicate to your patients that you are fully listening to and caring about them?

Back 11

Using empathic comments

Front 12

Is an empathic response a feeling? what is it?

Back 12

NO it is NOT a feeling it is a technique it is NOT necessary to:
1. be experiencing the same thing as the pt.
2. agree w/ the pts view
3. be certain about what the pt is feeling.

Front 13

T/F: an empathic comment is not about what emotion the pt is having? what is it?

Back 13

True; it is about their situation rather than their emotion:
*"this has all been very tough to deal w/"
*"this must have come as quite a shock"
*"the uncertainty is hard to cope w/"

Front 14

What words can you use that are not emotion-specific but still communicate empathy?

Back 14

tough, upsetting, unpleasant, awful shock, knocking you sideways, distressing

Front 15

What are the steps to meaningful empathic comments?

Back 15

1. Look at what the pt is going through
2. comment on it.

Front 16

What two things can you do to show a pt you capable-ness?

Back 16

1. how your dx relates to their Sys
2. how your treatment plan relates to their dx.

Front 17

How can you explain to a pt how the dx relates to their Sys?

Back 17

1. Use English not Medicalese: explain it in a way that makes sense to them
2. Show how the dx explains their Sys ("when your heart cannot keep up w/ its work fluid backs up into your lungs")
3. After you explained the dx to the pt in English, then use medicalese and write it down for them.

Front 18

What do you do if the pt has a very different explanation for their problem than you and does not accept your explanation?

Back 18

1. you CANNOT move forward until you agree so search for common ground. This starts w/:
>Listening: active, non-patronizing, non-judgemental
> Reflect back to them your understanding of their explanation.
2. Where you go from here depends on the sit. This is a common issue in cross-cultural medicine.

Front 19

What is the SPIKES system to delivering bad news?

Back 19

S= setting
P= perception
I= invitation
K= Knowledge
E= Empathise
S= strategy and summary

Front 20

How can you make the setting appropriate for delivering bad news?

Back 20

Make the physical setting and interactional setting optimal by using ALL of your listening and facilitating skills.

Front 21

How can you ascertain the pts perception of their problem?

Back 21

By asking how serious does he/she think it is? Do this by:
1. listening to the pts level of comprehension - which gives you how much you need to explain.
2. Listen to the pts vocabulary - start at their vocabulary level.

Front 22

How can you find out how much the pt wants to know about their dx? (ie how much detail they want)

Back 22

By asking "are you the sort of person who would like the full details?" and accept the pts right to not know, but offer to talk to a relative or friend and to answer questions as the pt wishes later.

Front 23

How should you deliver knowledge about a pts dx?

Back 23

Do it in chunks to make sure the pt is understanding and respond to the pts reactions as they occur. Do this step simultaneously w/ empathy and as you talk listen and acknowledge and respond.

Front 24

What is the strategy and summary stage of delivering bad news?

Back 24

Propose a strategy and close by summarizing the ground that has been covered and making a clear contract for what the next steps will be.

Front 25

How can you answer the question "how long have I got to live?"

Back 25

Strive to be reasonably accurate and honest while making clear the uncertainties of the situation so give a range instead of a precise figure.

Front 26

How can you tell someone their loved-one died?

Back 26

1. introduce yourself clearly
2. use a brief narrative to place the event in a context and provide an explanation
3. make simple, empathic response
4. assess the relatives immediate sources of support.

Front 27

Besides making sense to the pt what other quality must a good treatment plan have?

Back 27

It must be something the pt can live with.

Front 28

What factors enhance the carrying out of a treatment plan?

Back 28

1. the regimen is simple
2. instructions are understandable and easy to remember
3. length of treatment is brief
4. doctors listen non-judgementally to the difficulties involved in adhering to the regimen.

Front 29

What roles should you adopt to enhance a pts adherence to a treatment plan?

Back 29

Adopt the role of advocate, coach and cheerleader NOT judge/authoritarian/adversary.

Front 30

How can you encourage a partnership w/ a pt?

Back 30

By actively soliciting feedback:
1. do NOT ask: "does that sound OK to you?" (few pts have the chutzpah to look a doc in the eye and say 'no that's not okay;)
2. DO say "now, tell me what you think of that plan".

Front 31

What should your treatment plan take into account?

Back 31

The pt's concerns, objections and desires.

Front 32

What should you openly discuss w/ the patient when discussing adherence to a treatment plan?

Back 32

1. the difficulties of adherence
2. the reality of the pts autonomy - "The decision about the medication is yours - my job is to help it to be a well-educated decision"
3. the two-fold goal: (1) have the pt take primary responsibility responsibility for managing the illness w/ the MD as a partner (2) find a treatment regimen that is effective that the pt can live w/
4. discuss that the agenda will be a standing agenda item in subsequent visits
5. the need for honesty about adherence and that the lack of adherence will not lead to anger/upset on your part

Front 33

How can you communicate the need for honesty about adherence to a treatment plan?

Back 33

"I am not going to slap your wrist if you don't take the medication - but I DO need to know about it. That way we can both look at what is making it hard, and we can work to find a treatment you can live with and that works for you".

Front 34

What should you do in subsequent visits about adherence to a treatment plan?

Back 34

1. inquire non-judgementally about side-effects, missed doses and troubles w/ taking the treatment
2. w/ empathic comments and reflective listening explore difficulties that arise
3. let the pt have the first crack at coming up w/ solutions to difficulties "what do you think might help you do better w/ this?"
4. Renegotiate a new plan

Front 35

What is one of the strongest correlates w/ poor adherence to a treatment plan?

Back 35

Depression; a key feature of depression is a lack of motivation.

Front 36

How can you include questions about alternative medicine in the treatment plan?

Back 36

1. inquire about it - help the pt see that you feel their use of it is relevant and not going to result in a demeaning response
2. assess it - why do they use it? why do they believe it is helpful and step back into your own world (could this be harmful?)
3. discuss pros and cons
4. partner together/negotiate around its place in the treatment plan.

Front 37

How can you determine whether alternative medicine is harmful?

Back 37

1. adverse physiologic effects/drug interactions
2. adverse economic impact
3. adverse time impact (steals away time and energy from approaches that have a greater likelihood of being helpful)