The Internal Medicine Work-Up (Patient Encounters)

Introduction

These were tabulated using Health Care Financing Administration relative value units and converted to dollars using the Medicare schedule. Prescription costs were based on either Health Care Financing Administration rates or generics when available. Predictors of difficulty were evaluated using logistic regression. In addition, potential confounding or interactive effects of other variables were explored. For example, functional status was adjusted for well-described confounders such as mental disorders and age. Because of the clustered sampling technique, the Huber formula was used to produce robust confidence intervals.

Difficulty was analyzed as a dichotomous variable using a score of 30 or greater as indicative of difficulty. Data exploration using various cut points for difficulty confirmed the previously held cut point of 30 as functionally identifying a unique subgroup of patients. An attempt to use DDPRQ scores to categorize patients into 3 groups, "difficult," "average," and "satisfying," after the suggested hierarchy of Lin et al 19 was not successful.

A cut point of 70 on a scale of was used as indicative of "poor" physician psychosocial attitude score for several reasons. First, dichotomization was necessary because the Physician's Belief Scale score was not linear over the logit function. Second, preliminary evidence suggests that a cut point of 70 may discriminate among physician specialties that differ in the degree of their biopsychosocial orientation. These data were collected as part of a clinical trial of providing previsit information to clinicians on patient symptom-related expectations and mental disorders.

The Internal Medicine Work-up

Since one outcome of the intervention 36 was a reduction in the frequency that patient encounters were labeled as difficult, adjustment for study group was made in all analyses. Five hundred twenty-eight adults were invited to participate. The participants were similar to nonparticipants in terms of age, race, sex, and type of symptom.

Study patients were seen by 38 physicians with no physician contributing more than 34 patients. Patients had a mean age of A depressive or anxiety disorder was present in Major depression was present in 8. Among 38 participating physicians, 35 were general internists and 3 were family practitioners.

Majors Books : Patient Encounters: The Internal Medicine Work-Up

Sixteen were faculty members and 22 were house staff. The mean age of participating clinicians was Encounter difficulty was not associated with patient sex, age, ethnicity, educational level, or marital status Table 1. Previsit expectations of care, including desiring an explanation of the symptom's cause, a prescription, an estimate of likely symptom duration, and subspecialty referral, did not differ between difficult and not-difficult patient encounters. There was no relationship between the duration of the presenting symptom or patient report of recent stress and difficulty.

Patients in difficult encounters were more likely to have an underlying mood or anxiety disorder, were worried that their symptom might represent a serious illness, reported greater symptom severity, and had higher rates of somatization Table 1. Patients from difficult encounters had lower functioning on all domains of function assessed overall health, physical, pain, role, social, and emotion , although the difference in emotional functioning was eliminated after adjusting for age and the presence of mood or anxiety disorders Figure 1.

There was no relationship between the type or number of mental disorders and physician-perceived difficulty. No specific type of presenting physical symptom was associated with difficulty. Physician age, sex, ethnicity, house staff vs staff status, and the number of years of practice were not associated with the likelihood of rating patient encounters as difficult.

There was no interaction between patient or physician age, sex, or ethnicity with regard to difficulty ratings. Individual questions from the DDPRQ were also analyzed, using responses of 4 to 6 as indicative of difficulty. Follow-up data were available on all patients immediately after the visit, on There were no differences between respondents and nonrespondents at any time, including the proportion of encounters considered difficult.

There were no differences in visit costs or in the likelihood that a patient would receive a specific intervention from the physician, including a diagnostic test, prescription, or subspecialty referral. Patients from difficult encounters had no increase in the number of previsit expectations for care and were neither more nor less likely to receive desired interventions. Despite this, patients from difficult encounters were more likely to have unmet expectations for care both immediately after the visit and at 2 weeks.

Patients from difficult encounters were less likely to be satisfied overall with the care they had received immediately after the visit and at 2 weeks, and were more critical of all aspects of the physician-patient encounter measured. Patients also experienced significantly improved functioning in all 6 domains by 2 weeks after which functional status did not change appreciably over the ensuing several months.

Initial functional status differences between difficult and not-difficult groups Figure 1 were no longer present at either 2-week or 3-month follow-up. Also, the greater dissatisfaction with the index visit that the difficult group expressed immediately after the index visit and persisting out to 2 weeks was no longer apparent at 3 months. Fifteen percent of encounters involving walk-in patients presenting with physical symptoms to a walk-in clinic were experienced as difficult by the clinician.

Patient characteristics associated with difficult encounters included the presence of depressive or anxiety disorders, more somatic symptoms, and greater symptom severity. Poor physician psychosocial attitude was strongly predictive of experiencing more encounters as difficult. Adverse outcomes associated with difficult encounters included more unmet expectations, higher utilization rates, and greater dissatisfaction with the overall care received as well as with all aspects of the physician-patient relationship.

Several of our findings are similar to those seen previously. A relationship between difficult encounters and the presence of mental disorders, 1 , 2 , 16 - 19 , 37 greater somatization, 2 , 19 , 37 and higher health care utilization 2 , 10 , 19 have been reported. Similar to previous reports, the relationship between patient functional status and difficulty disappeared when adjusted for the other patient characteristics. We are also the first to report on the lack of impact of "difficulty" on symptom or functional status improvement or on visit-specific costs.

For example, Lin et al 19 used a single question asking physicians to rate their experience with high users of ambulatory services as "satisfying," "average," or "frustrating. Walker et al 37 used the DDPRQ as a continuous variable in asking rheumatologists to rate the difficulty of 68 patient encounters with fibromyalgia or rheumatoid arthritis. Hahn et al 2 used the DDPRQ as both a continuous and categorical measure in a study of patients presenting for primary care. All 3 studies corroborated our own findings of more psychopathology among patient encounters rated as difficult or frustrating.

We found no interaction between physician and patient sex, age, or ethnicity and the likelihood difficult ratings, similar to a previous report. Their finding was limited by clinician interest measurement based on responses to a single, nonvalidated question. Physicians with an interest in managing patients with psychosocial disorders tend to accumulate such patients in their practice. A higher interest in psychosocial disorders may result in a clinic population with a higher proportion of patients with such disorders. In our study of physicians seeing new, arbitrarily assigned walk-in patients, a item validated measure of psychosocial interest found that clinicians with better psychosocial attitudes experienced significantly fewer patient encounters as difficult.

The Physician's Belief Scale used in our study has been found by other investigators to correlate with better physician communication skills and with a higher proportion of time spent discussing psychosocial issues. It is possible that difficulty could be reduced by recognizing and treating mental disorders and by improving physician skills or attitudes toward addressing psychosocial problems or patient's serious illness concerns.

Specific training in caring for "difficult" patients has also been found to help trainees gain understanding and empathy for such patients, rendering them less difficult. Most reports suggesting approaches to managing difficult patients have focused on patient-physician communication. By 3 months, the relationship between encounter difficulty and patient dissatisfaction had faded. However, after 3 months, the intensity of patient dissatisfaction is likely to shift to more recent clinical encounters.

Most patients had at least 1 interim follow-up visit, usually with a different clinician than seen in the index visit, and patients from difficult encounters averaged more than 7 follow-up visits. The patient's recall for the index encounter may be limited.

Reports of dissatisfaction may be more likely to reflect attitudes about recent visits or symptom outcome. Indeed, in this study, symptom resolution by 3 months was the strongest correlate with 3-month satisfaction. Our study has several limitations. First, because the sample consisted of walk-in patients seeing new physicians, one should be cautious in generalizing these findings to established clinician-patient relationships.

How can Doctors Improve their Communication Skills?

One study found that new patients were less likely to be considered difficult than those that were "somewhat known" or "well known. A second limitation was the inclusion of patients with a variety of physical complaints rather than 1 specific symptom. Although this may limit conclusions regarding individual symptoms, it does more broadly reflect the range of symptoms presenting in primary care. If it is an old case, greet him and ask him how he is. Put the patient at ease. Some patients may be nervous, so begin with a general non-medical inquiry in order to develop a comfortable scenario for the patient.

Simply writing a prescription has got no value and is actually wastage of time and energy unless and until it is adequately honoured by patients. It is extremely important, especially in cases with chronic illness, where good communication skill is useful in allaying anxiety and motivating the patient for good compliance regarding advices. The interview should be patient centric rather than disease centric [ 21 ].

Some of the very important practical advices are listed below [ 18 - 20 ]:. Pay attention to both the verbal and non-verbal clues from the patient and explore whenever there is any discrepancy 2between the two. Meanwhile, the physician too should be alert about his own non-verbal clues like body language, gestures, eye-contact.

Discuss nature, course and prognosis both short term and long term of the disease, treatment options available and necessity of the investigations. Discuss in detail regarding necessity and feasibility of expensive investigations and drugs and their effect on main course and outcome of disease. Involve the patient in the decision making.

Put additional efforts in motivating patients regarding adherence to lifestyle modifications. Always comprehend details in simple language. The use of medical jargons and abbreviations can have a negative effect. This scenario usually comes when a doctor is treating an indoor patient. Attendants are apprehensive and at times full of doubts and queries. Communicating with the attendants assumes great importance especially when patient is critically ill or admitted in ICU.

Most of the attendants surfs internet and gather lots of information. Try to satisfy their queries by giving better references. Always explain the dynamic nature of disease. This is especially important for critically ill patients. Second opinion should be sought proactively. One will be more convinced and ready to accept bad outcome if the same fact is explained by more than one consultants.

Try to convince that all efforts are being made to bring situation under control or will be controlled. Consent taking is very important part of counselling. Never neglect this and give it to paramedical staffs or interns who may fail to explain convincingly. Junior doctors including postgraduate students, fellows and interns along with nursing and supportive staffs are part of the team. It is important to keep them united and motivated. Following principles should be followed [ 24 ]:. Never talk low about your colleagues or scold residents, fellows or other students in front of patients or attendants.

One should be extremely cautious while asking questions from Junior Residents on rounds. Patient may feel insecure in absence of senior consultants who may not present at all the time. This may also create doubts in the minds of patients even if Junior Residents prescribe drugs for common complaints.

Greatest courtesy should be displayed for all staffs including nurses, paramedical staffs and other supporting staffs. Make them realise that they are a part of the team and their role and responsibility is also important. A system with effective teamwork can improve the quality of patient care and reduce workload among healthcare professionals [ 25 ]. Lead by setting examples.

Supporting staff will never work with full sincerity unless and until they appreciate the hard work and ability of doctor. Try to teach them the basics and the principles of management of commonly encountered diseases in your ward. This will keep them motivated. Audit and regular feedback improves in professional practice. Never delay to give appreciation and dare to give positive criticism [ 26 ]. It is worth noting that difficult encounters may be consequent to a combination of factors related to doctor, patient and even the circumstances.

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It is precipitated by an imbalance between the expectations, perceptions and the conduct of the doctor and the patient involved [ 28 ]. Difficult encounters may occur when a doctor deals with a patient having multifarious medical ailments that are exacerbated by complex social issues. At times, a patient may present with misleading information from internet and pose challenging situation leading to professional burnout of the physician [ 29 , 30 ].

Besides, poor communication skills and psychosocial attitudes along with lesser job satisfaction among the doctors may also be contributory [ 28 , 31 ]. It may be a rather taxing situation for the doctor to tackle the dependent, argumentative and manipulative patients or patients with certain behavioural issues.

Difficult encounters, also, occur due to circumstances like language, cultural and time barriers. A clinician should always be ready to deal with these challenges. Whatever may be the factor s responsible for difficult encounter, the doctor has both ethical and professional obligations to treat the patients of their ailments. Following strategies have been found to be useful in maintaining a healthy therapeutic relationship with specific type of patients [ 31 - 33 ].

Dependent patients- Such patients are vexed with the idea of being deserted. Hence, they demand more of the personal time from the doctor making him resentful. Thus, it is essential to maintain a professional demeanour with well established boundary. Many a times, involving the patient in decision making is helpful.

Demanding patients- They are often aggressive, intimidating and do not want to go through the stepwise assessments or treatment. In such a situation the doctor should avoid judgemental approach and empathetically ensure the patient that he will get the best medical care and there is no need to show anger. However, the doctor in such circumstances should be empathetic and listen to his problems attentively while sharing frustration over poor outcomes.

The doctor must reformulate the treatment plan with the patient after having set limitations over expectations. Self-destructive patients — Some patients with an underlying anxiety or depression are often hopeless about their ailment and fear failures. The health problem persists despite adequate counselling and management. The doctor should set realistic expectations and recognize the fact that complete resolution is limited.

The doctor should try to delve into the reasons for non-adherence to therapy money, time or family support and offer or arrange for psychological support. The doctor must identify all the contributing factors and approach the patient with non-judgemental and caring attitude. Any underlying psychological condition must be identified and appropriately treated.

Involving the patients by asking them the possible cause of poor outcome and potential solution would foster a more collaborative relationship leading to therapeutic success. Disclosing bad news is a complex communication art that not only involves verbal component of actual news breaking but also includes empathetic response of the doctor to tackle the reaction. Studies have demonstrated that many doctors lack competence as well as confidence in their ability to divulge bad news and there is necessity to provide didactic training [ 35 ].

Several protocols have been devised to guide the doctors for imparting this skill [ 36 - 38 ]. Following the key communication skills like maintaining privacy, sitting relaxed with the patient, maintaining constant eye-to-eye contact and avoiding any time pressure and interruptions allow an undistracted and focussed discussion. If the patient wishes someone else to be with them, allow the patient to choose among the relatives or friends.

Such information makes it easy for the doctor to reveal the information according to the patient desire. Actual breaking of bad news- It is better to plan an agenda with the patients including diagnosis, treatment, prognosis and support or coping. An initial warning may decrease the shock that can follow the disclosure of bad news.

Use of simple and non-technical words, giving information in small portions and periodic assessment of the impact are some of the communication tools that can be extremely useful. Moving closer to the patient, holding the hands, and using empathic statements help the physician to not only support the patient but also to acknowledge their own sadness and emotion. Validating responses help the patient to overcome and accept the reality. Sometimes when the patient becomes silent or tearful, allow them time to recover.

Those who are having a definite plan of action are less likely to get anxious or panic. Summarizing the whole discussions in the last is extremely useful and helps in assessing if patient has understood the facts correctly or not. To conclude, good communication skills among the doctors is crucial in building a trustworthy doctor-patient relationship that not only helps in therapeutic success by providing holistic care to the patient but also leads to job satisfaction among the doctors.

Not many doctors are naturally blessed to have good communication skills and there is necessity of formal training in this. National Center for Biotechnology Information , U. J Clin Diagn Res. Published online Mar 1. Find articles by Piyush Ranjan. Find articles by Archana Kumari. Find articles by Avinash Chakrawarty. Author information Article notes Copyright and License information Disclaimer. Piyush Ranjan, Room No. This article has been cited by other articles in PMC. Abstract The process of curing a patient requires a holistic approach which involves considerations beyond treating a disease.

Breaking bad news, Doctor patients conflict, Verbal component. Introduction Good communication skill has been considered extremely important for medical practitioners in the western world since decades. Benefits of good communication skills The practice of good communication skills in the medical profession is integral for the development of meaningful and trustworthy relationship between the doctors and patients and, thus, is beneficial to both of them. Components of communication Effective communication has three basic components-Verbal, non- verbal and paraverbal.

Barriers to good communications There are several barriers to effective communication between patients and doctors [ 13 ]. Learn to listen to the patients patiently The importance of listening, extends far beyond the academic and professional settings and is extremely important in creating a trustworthy doctor-patient relationship which is a prerequisite for therapeutic success [ 14 , 15 ]. Some of the communication strategies that may help the doctor to improve listening skills are listed below [ 15 , 18 ]: While concluding, one must ask the patient if he would like to add something more.

Some of the practice points are listed below [ 19 , 20 ]: Establish eye contact and maintain it at reasonable intervals.