PREVENTING SPECIFIC ADVERSE OUTCOMES — Living facilities and hospitalization for the older adult patient can result in unintended adverse consequences from interventions meant to be therapeutic. Bed rest, polypharmacy, tethering devices (eg, intravenous lines, urinary catheters, telemetry, restraints), sensory deprivation, disruption of usual sleep patterns, and lack of proper nutrition all contribute to functional, physical, and cognitive decline. Since many older adults live on the brink between independence and functional dependence, even a small decline in function during hospitalization can place them in a position of newly acquired dependence.

Some decline may be unavoidable due to the effects of the acute illness. However, many of the harmful effects of hospitalization can be avoided or minimized by addressing specific risks that predispose to a poor clinical outcome.

Functional decline — Bed rest and lack of mobility combine to hasten physical deconditioning and muscle weakness . Immobility is associated with increased risk for falls, delirium, skin breakdown, and venous thromboembolic disease. Improved mobility during hospitalization has been linked to decreased risk of death at two years.

Although a few conditions require absolute bedrest (eg, unstable fractures and certain critical illnesses), most medical conditions do not necessitate immobility. Activity orders for bed rest should be avoided unless absolutely medically required. Staff should attempt to get patients out of bed to a chair with meals, which also decreases risk of aspiration  and, when possible, encourage patients to walk several times daily.

Patients who have difficulty ambulating on their own or who pose a significant fall risk may need supervision by trained staff (eg, physical therapy) or referral to a specialized mobility program. Increased activity during hospitalization can mitigate functional decline so that patients can transition optimally outside the hospital setting.

Falls — Older hospitalized adults are at great risk of falling due to the effects of the acute illness compounded by an unfamiliar environment and side effects of treatments. The etiology of a fall is often multifactorial. Many of the interventions needed to address the acute illness can increase the risk of falling. As an example, interventions to treat an older adult in heart failure (eg, antihypertensive medications, diuretics, telemetry, and an indwelling urinary catheter) all combine to increase the patient’s propensity to fall.

Several strategies can help prevent falls in the hospital setting.

●The risks and benefits of medications with significant psychotropic and anticholinergic effects (eg, opioid analgesics, benadryl) should be carefully weighed.

●Patients should be monitored when prescribed drugs that might increase the risk of falls (eg, when diuretics are prescribed, blood pressure and volume status should be monitored closely to avoid orthostatic hypotension).

●Patients at higher fall risk may need supervision with ambulation.

●Time out of bed throughout the day should be encouraged, whether walking or sitting in a chair, to prevent orthostatic hypotension associated with prolonged immobility.

●Intravenous lines and urinary catheters should be discontinued as early as possible.

●Restraints should be avoided since restraints, either physical or pharmacologic (eg, antipsychotics, benzodiazepines), may increase the risk of falling.

Nonetheless, it is likely that the majority of falls that occur in the hospital setting may not actually be preventable. Bed alarms have not been demonstrated to be effective at reducing falls and may increase the risk of alarm fatigue, be distressing to patients, and lead to a false sense of security. In the United States, Medicare does not reimburse hospitals for complications or extended length of stay related to falls that occur during the course of hospitalization. It is important that institutions not adopt potentially deleterious practices, such as increased use of strict bed rest orders, restraints or restraint-like chairs or other devices, in an effort to decrease their revenue losses.

Delirium — Delirium is acute brain failure characterized by inattention and a fluctuating course. The Confusion Assessment Method is frequently used to diagnose delirium. An altered level of consciousness and/or disorganized thinking are usual components of delirium. Early recognition of delirium is important in ensuring prompt delivery of appropriate care.

Many aspects of hospitalization inherently promote delirium for the older patient. The change in environment from the comfort of home to a hospital room is disruptive to the patient’s daily routine. An older patient, particularly someone with preexisting cognitive impairment, is prone to developing delirium. Pain, interruption in sleep patterns, and several classes of medications are also important risk factors for delirium. Confusional states can be worsened when sensory input is affected, such as occurs when a patient lacks access to eyeglasses or hearing aids.

Effective measures to prevent delirium include orientation protocols, environmental modification, nonpharmacologic sleep aids (eg, warm milk or herbal tea offered at bedtime, relaxing music, soft lighting, massage), early and frequent mobilization, minimizing use of physical restraints, use of visual and hearing aids, adequate pain treatment, and reduction in polypharmacy (particularly psychoactive drugs).

Some hospitals have found that patients with delirium benefit from specialized care delivered in a dedicated room for disoriented patients. This room supports multidisciplinary care that avoids the use of restraints and reduces use of psychoactive drugs. These “delirium rooms” can offer a useful option for caring for delirious patients, using the T-A-DA method (Tolerate, Anticipate, and Don’t Agitate) to guide the approach to caring for delirious patients.

Sleeplessness/sleep deprivation — Multiple factors contribute to sleep deprivation during hospitalization, including an unfamiliar sleep setting, conditions related to illness (eg, shortness of breath, pain), environmental factors (eg, noise, light), and the logistics of providing care (eg, phlebotomy, medication schedules). Inadequate sleep, whether it is too short in duration, of poor quality, or interrupted, may contribute to a host of complications.

The link between poor sleep and delirium remains elusive. However, older hospitalized adults who received a multicomponent intervention, including protocols to address sleep deprivation, had a decreased risk for developing delirium. Strategies such as bundling care at night (eg, vital sign monitoring, dispensing medications, toileting) and creating a conducive environment for sleep with low light and quiet surroundings may help achieve improved sleep for patients receiving care in the hospital and decrease the risk for delirium and other adverse events.

Tethers — Some tethering medical devices, such as urinary catheters, intravascular lines, cardiac telemetry leads, and restraints, may be necessary to provide optimal care. However, tethering devices make it more difficult to mobilize patients safely and are associated with increased rates of delirium, infection, and falls, and the devices can contribute to sleepless nights and distress from ringing alarms. Tethers are commonly ordered when not absolutely indicated and, even when initially appropriate, may remain in place when no longer needed. As an example, despite the well-publicized risks of indwelling urinary catheters, their use and associated complications have not declined over several decades.

Clinicians should weigh the risks and benefits of each tethering device and initiate use only when the likelihood of benefit is significant and in keeping with the patient’s preferred intensity of care, and there is no effective alternative. As an example, if a patient prefers not to be resuscitated in the event of a cardiac arrest, the benefit of continuous cardiac telemetry should be questioned.

There may be options to reduce the total tether burden, such as the use of fluid boluses rather than continuous intravenous fluids. In most cases, urinary catheters should not be used as a treatment for incontinence or as a substitute for getting the patient up to the bathroom.

Infections — Underlying health conditions, poor nutritional status, and greater severity of illness contribute to increased rates of hospital-acquired (or nosocomial) infections in older patients. Heightened clinical suspicion is necessary to identify infection in older patients as they may demonstrate only atypical symptoms, including delirium. Fever may not be present in older patients with an active infection.

Infections commonly seen in older hospitalized patients include:

●Clostridioides (formerly Clostridium) difficile-associated diarrhea – C. difficile is the most frequent cause of nosocomial diarrhea and a significant cause of morbidity and mortality among hospitalized older patients. The incidence of C. difficile infection continues to rise.

Contact precautions help to prevent spread of C. difficile spores and should be used in patients who have suspected or proven C. difficile infection.

●Pneumonia – Hospital-acquired pneumonia (HAP) is pneumonia that is not associated with mechanical ventilation and that develops 48 hours or more after admission.

Patients with advanced dementia, severe Parkinson disease, or other neurologic conditions are at high risk for aspiration pneumonia. Older patients treated with antipsychotics are also at increased risk for developing aspiration pneumonia.

HAP prevention measures include avoiding acid-blocking medications, attending to oral hygiene, and feeding only at times when the patient is alert and able to sit upright. Patients who cough when swallowing may be showing signs of swallowing dysfunction and aspiration. Offering increased assistance with feeding, modified consistency of foods, and a formal swallowing assessment may be warranted.

●Urinary tract infections – Urinary tract infections associated with urinary catheters are the leading cause of secondary nosocomial bacteremia, which is associated with high mortality. Patients with indwelling catheters often do not experience typical signs of urinary tract infection. Blood and urine cultures should be obtained when patients develop fever or otherwise unexplained systemic manifestations compatible with infection (eg, altered mental status, fall in blood pressure, metabolic acidosis, and respiratory alkalosis).

The most effective strategies to reduce urinary infections are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated.

●Intravascular catheter-related infections – Intravascular catheter infections are an important cause of morbidity and mortality.

Several preventive measures, such as wiping access sites with antiseptic and connecting only to sterile devices, can markedly reduce the rate of intravascular catheter infections.

Infection control programs aim to prevent and reduce rates of nosocomial infections. Major components of infection control are :

●Standard (universal) precautions

●Isolation precautions when appropriate, with recognition that isolation may increase the risk of delirium in older adults

●Environmental cleaning

●Surveillance

Standard precautions are recommended in the care of all hospitalized patients to reduce the risk of infection transmission between patients and health care workers, even when the presence of an infectious agent is not apparent. Precautions include hand hygiene before and after every patient contact; use of gloves, gowns, and eye protection for situations in which exposure to body fluids is possible; and safe disposal of sharp instruments in impervious containers.

Malnutrition — Poor nutrition for older hospitalized patients may result from several factors:

●Impaired cognition or delirium

●Poor appetite, nausea, or constipation (due to underlying illness or as side effects of medications)

●Restriction of movement

●No access to dentures

●Difficulty in self-feeding

●Severely restricted diet orders (eg, “nothing by mouth”)

Evaluation for malnutrition includes a history of changes in weight, dietary intake, and physical examination, as well as select laboratory and radiologic studies.

Simple interventions such as getting an older patient out of bed at mealtime and providing assistance with feeding can improve nutritional intake during hospitalization. Inpatient assessment by a nutritionist can identify nutritional deficiencies in older patients and, combined with subsequent nutritional follow-up in the community after discharge, may decrease mortality. Patients should be allowed to eat unless medically required to be maintained “nothing by mouth.” Generally, restricted diets are not required for older patients and when ordered may further limit the nutritional intake of older patients. Even patients with heart failure may be allowed access to an unrestricted diet without adverse impact during hospitalization.

Nutritional repletion may be provided to restore the patient to a target weight, with recognition that weight correction in the older population is less readily accomplished than in younger people.

Pressure ulcers — Several host and environmental factors increase the risk of developing pressure ulcers during hospitalization in older patients, including :

●Poor nutritional status

●Incontinence, causing a moist environment

●Immobility

●Neurologic impairment

Optimizing nutritional status and limiting time spent in one position can help prevent pressure ulcers. Patients who are bed-bound should be repositioned at least every two hours, with proper repositioning techniques to minimize shear forces. Pressure-reducing products for patients at increased risk of ulcers should also be used. Clinical risk assessment and preventive interventions are discussed in detail separately.

Venous thromboembolism — Hospitalization is a significant risk factor for developing venous thromboembolism. The use of prophylaxis for venous thromboembolic disease, including pharmacologic or mechanical methods, depends on the individual risk of thrombosis and bleeding. Prophylactic anticoagulation is generally recommended for most patients >75 years of age who are hospitalized for an acute illness and who do not have risk factors for increased bleeding.

Adverse drug events — Serious adverse drug events include delirium, urinary retention, orthostasis, metabolic derangements, bleeding from anticoagulation, and hypoglycemia related to medications for diabetes. Gastrointestinal side effects, including nausea, anorexia, dysphagia, and constipation, are common. Adverse drug events increase the length of stay and costs of care.

Several high-risk drugs are commonly associated with adverse drug events in hospitalized patients. Multiple medications, often new to the patient during hospitalization, potentiate the risk of nutritional, functional, and cognitive decline in older adults during hospitalization, as well as increase the risk of overall mortality. With physiologic decreases in liver and kidney function, older patients have a higher incidence of adverse drug events than younger patients.

Minimizing the use of nonessential medications can reduce the risk that an older patient will suffer from an adverse drug event. Avoiding potentially inappropriate medication and starting with the smallest possible therapeutic dose can similarly help avoid adverse drug events. Older patients who have impaired renal or hepatic function should have dosage of medications (eg, antibiotics) adjusted appropriately.

References 

https://www.uptodate.com/contents/hospital-management-of-older-adults?search=medical%20errors&source=search_result&selectedTitle=10~28&usage_type=default&display_rank=10#H25046739

At Dr.Paul’s Clinic we take every precaution to prevent drug complications in all patients, especially older adults, who are more vulnerable to drug side-effects and interactions.

The possibility of an adverse drug event (ADE) should always be borne in mind when evaluating an older adult; any new symptom should be considered drug-related until proven otherwise. Pharmacokinetic changes lead to increased plasma drug concentrations and pharmacodynamic changes lead to increased drug sensitivity in older adults.

●Clinicians must be alert to the use of herbal and dietary supplements by older patients, who may not volunteer this information and are prone to drug-drug interactions related to these supplements.

●Various criteria sets exist identifying medications that should not be prescribed, or should be prescribed with great caution, in older adults. However, clinicians need to consider each patient’s individual situation, and they should use their best clinical judgment rather than strictly adhere to prescribing guidelines when making prescribing decisions.

●Clinicians also under-prescribe medications, such as statins, that could provide benefit for older adults. Clinicians may be better at avoiding overprescribing of inappropriate drug therapies than at prescribing indicated drug therapies. Patient financial constraints and unavailability of prescribed doses may contribute to medication underutilization.

●ADEs result in four times as many hospitalizations in older, compared with younger, adults. Prescribing cascades, drug-drug interactions, and inappropriate drug doses are causes of preventable ADEs.

●ADEs are a particular problem for nursing home residents; atypical antipsychotic medications and warfarin  are the most common drugs involved in ADEs in this population.

●A stepwise approach to prescribing for older adults should include: periodic review of current drug therapy; discontinuing unnecessary medications; considering nonpharmacologic alternative strategies; considering safer alternative medications; using the lowest possible effective dose; including all necessary beneficial medications.

If you feel you have a drug interaction issue with one of the medications prescribed at our office, please call Dr.Paul’s Clinic immediately. Thank you for your cooperation.

PROFESSIONAL VALUES — Dr. Francis W. Peabody’s often-quoted address on “The Care of the Patient” speaks eloquently to the value of clinicians’ respect for humanity and the value of the clinician-patient relationship to treatment itself. “The significance of the intimate personal relationship between clinician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both the diagnosis and the treatment are directly dependent on it. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is caring for the patient” . Carl Rogers studied and taught about the beneficial outcomes for learning and health that result from approaching a learner/patient with unconditional positive regard.

The American Board of Internal Medicine has placed increasing importance on humanistic qualities as it considers candidates for its examination. It requires program directors to evaluate residents’ personal integrity and their respect and compassion for patients. The Pew-Fetzer Task Force on Advancing Psychosocial Health Education carefully considers areas of knowledge, skills, and values that support effective patient-practitioner relationships. They emphasize the following values: importance of self-awareness, self-care, and self-growth; appreciation of the patient’s life story and the meaning of the health-illness condition; respect for the patient’s dignity, uniqueness, and integrity (mind-body-spirit unity); respect for self-determination; respect for a person’s own power and self-healing processes; and the importance of being open and nonjudgmental.

In addition to the above observations, we would highlight the importance of ascribing value to several other features of clinician-patient interactions:

●Clinical curiosity

●Attention to decision-making preferences

●Attention to cultural issues

●Attention to accountability

●Attention to professionalism

Clinical curiosity — Respectful curiosity about the person in front of you and about medicine brings energy, vitality, salience, and meaningfulness to medical visits. It is healthy for the encounter and critically important to the sustenance of the clinician’s dedication to his/her work.

Explicit attention to decision-making preferences — Patients vary in the degree to which they want to share in medical decision-making. Many older patients prefer the clinician to hold most of the authority, while younger patients are apt to want to play an active role in shaping diagnostic and therapeutic plans. No rules hold, however, so the operative value needs to be one of respecting each individual’s preference for the extent to which decision-making is shared, and the operative behavior must be to check explicitly about that preference.

Attention to cultural issues — We have alluded to the importance of knowledge about cultural differences between patients and clinicians. For this knowledge to be of real use, to effect medical outcomes of care, the clinician must move beyond cognition of cultural differences to truly valuing and respecting the beliefs of each patient to whom s/he provides care.

Attention to accountability — Much of medical training inculcates clinicians with a strong sense of responsibility. “The buck stops here” is a feeling well known by every intern. While this can greatly benefit patients when the clinician is personally executing every aspect of care, that is now rarely the case. It is not an effective point of view when the clinician is part of a team. Clinician arrogance about “who knows best” is unfortunately another well-known phenomenon. The clinician must hold responsibility for his/her part in the team’s work but must also appreciate each team member’s role and skills. All team members are responsible for respectful collaboration in the work and participation in a system that monitors outcomes of care and provides clear and timely feedback about each team member’s performance.

Attention to professionalism — Effective interactions between each clinician and patient depend, at their core, on mutual trust. Survey data show that the levels of trust and respect that were formerly extended to the profession of medicine have substantially eroded over the past 40 years. Societal skepticism about the trustworthiness of medicine has many legitimate sources and is a cause for concern.

What can we do to restore the public’s trust in our chosen profession? While there is no straightforward solution, we can begin by being aware of this challenging situation and mindful of the foundational values that can guide our behavior with each patient we approach.

●We must learn to use and balance our values when navigating particularly difficult situations with patients (eg, breaking bad news, withholding an unnecessary and costly technology/test).

●We must openly reveal to our patients (and students) the basis for the professional judgments we are making.

●We must actively take patients’ preferences into consideration and be prepared to change our opinions when new information becomes available, including the basis for patients’ opinions.

Only by making this “juggling act” explicit will we regain trust and avoid perpetuating some of the most damaging situations of all, ones in which we contribute to racial, ethnic, and other disparities through our implicit processes of stereotyping and misperceptions.

CONTINUOUS LEARNING — As Hippocrates observed, art is long and life is short. No one of us truly “masters” skillful approaches to all patients in all situations. We mature, grow in our professional experience, and hope to improve our capacity for this most fundamental of clinical tasks.

We owe it to our patients and ourselves to continue to reflect and improve our interactions.

Dr.Paul’s Clinic Approach to Medical Interview: The medical interview is the medium through which the patient’s needs and requests are made known, the human connections are established, and almost all the work of doctoring is conducted. Many diagnoses can be made based on the patient’s history alone.

Three functions of the medical interview have been identified :

●Data-gathering

●Relationship-building

●Patient education

The three functions of the interview are interwoven throughout the dialogue of the clinician and patient.

Data-gathering — Data-gathering enables the clinician to establish a diagnosis or recommend further diagnostic procedures, suggest courses of treatment, and predict the nature of the illness. The tasks of this function are to:

●Acquire the appropriate knowledge base of diseases and disorders

●Acquire the knowledge base of psychosocial issues that contribute to the patient’s illness behavior

●Bring the data that have been elicited into focus

●Generate and test multiple hypotheses during the course of the interview

The verbal skills that facilitate accomplishing these tasks include asking open-ended questions (and waiting for the answers); active listening; making facilitative utterances (“uh-huh, tell me more… yes… go on…”); making orienting remarks (“I will ask you about x, and then we will do y…”); asking focusing questions when needed (“Where was the pain? What made it worse?”); eliciting and prioritizing the patient’s agenda for the visit (“What should we be certain to get done today?”); checking for understanding; and summarizing what the clinician has heard (“Let me be sure I have this right. You felt fine until you started shoveling snow, then you felt dizzy and thought you might faint,” etc) .

The nonverbal skills that facilitate good data collection start with “clearing the clinician’s mental and physical slate” before entering the room with the patient. Important and often neglected nonverbal skills also include being aware of and consciously shaping how the clinician’s appearance, body language, voice qualities (eg, tone, volume, pace), and the spatial arrangements of furniture and people in the room affect the interactions. As health care providers increasingly use electronic medical records (EMRs), they must master the skills needed to use the computer to assist effective data-gathering and -sharing and the skills needed to avoid allowing the computer to become a barrier between the patient and the provider .

Relationship-building — Relationship-building seeks to ensure the patient’s willingness to provide diagnostic and other important information, to relieve the patient’s physical and psychosocial distress, to ensure the patient’s willingness to accept the treatment plan or a process of negotiation, and to ensure both the patient’s and clinician’s satisfaction with work well-done. The tasks of this function are to:

●Define the nature of the relationship

●Communicate professional expertise

●Communicate interest, respect, support, and empathy

●Recognize and resolve various relational barriers to patient/clinician communication

●Elicit the patient’s perspective

The skills of effective relationship building are both verbal and nonverbal. The power and importance of nonverbal communication cannot be overstated. Consider, for example, the effect of nonverbal empathy when the clinician gently touches the shoulder of the newly widowed woman. All behavior is communication. Patients are reading nonverbal messages from clinicians consciously or unconsciously throughout each visit . Does the clinician lean towards or away from the patient? Is there appropriate eye contact and head nodding to indicate listening? The clinician and patient assess whether the unspoken messages match the words. When they match, the veracity of the words is likely. A mismatch suggests need for some explicit checking (eg, patient says “OK, I’ll fill the prescription” but looks absently out the window). The skillful clinician is consciously monitoring and controlling his/her own nonverbal messages to the patient while reading the nonverbal communication from the patient.

The skillful clinician is also evaluating his/her own thoughts and emotions and how these affect verbal and nonverbal responses to the patient and even influence clinical judgment. Is a growing sense of irritation in the clinician during an interview related to actions of the patient, or unrelated issues (eg, that second cup of coffee, air conditioning problems, or a disagreement at home the previous night?). Awareness of the effects of our own mental processes on our relationships with patients is often referred to as “mindful practice” and has been described as “cultivation of the observing self in the midst of the complexity and chaos of everyday work” . Through mindful practice, clinicians improve their attention and ability to sense subtleties, reduce bias and premature categorization, and enhance openness to new ideas and actions.

The appropriate use of language is also a crucial aspect of relationship building. Both what is said and how it is said are important. Verbal relationship building skills include statements of partnership, empathy, apology, respect, legitimation, and support (PEARLS) . Empathy is most easily conveyed by the use of reflection. Communication of understanding of emotion through reflective statements such as “that was tough for you” or even “gosh!” can deepen the therapeutic relationship and improve patient satisfaction. Legitimation refers to voicing acceptance or validation of the emotions or reactions of the patient. A simple “I’d be upset by that too” can be reassuring to an anxious or angry patient and turn a difficult encounter into a productive one.

Patient education — Patient education seeks to ensure the patient’s understanding of the illness, to suggest diagnostic procedures and treatment possibilities, to foster consensus between clinician and patient, and to create a firm foundation for informed consent, improved coping mechanisms, and the promotion of healthy lifestyle change. Providing appropriate patient education to foster consensus and allow full informed consent is one way that clinicians show respect for their patients.

The tasks of this function are to:

●Determine the areas of differences (potential conflict) between the clinician and patient, and promote negotiation to resolve the differences

●Communicate about the diagnostic significance of the problem(s)

●Recommend the appropriate diagnostic procedures and treatment, including appropriate preventive measures and lifestyle changes

●Enhance coping ability by understanding and working with the social and psychosocial consequences of the disease and treatment

The skills of patient education involve asking questions to discover what the patient knows about the illness, how s/he feels about it, what s/he believes about it, what meanings s/heattaches to it, and what s/he expects to happen because of the illness and/or its treatment. The two keys to successful patient education are the use of comprehensible language and avoidance of “too much, too soon, too fast.”

The skillful clinician’s questions probe the patient’s “need to know” in each of these areas. S/he then calibrates responses in both content and tone to exactly what the patient wants to know. If the clinician senses resistance to learning about something that is important from her/his perspective, this resistance must be explored. Invariably, such an exploration will uncover important patient concerns, fears, prior adverse experience, or serious misunderstanding of what the clinician is saying. In summary, the content of effective patient education rests upon the clinician’s knowledge, but that is not enough. Its implementation requires an open, trusting clinician-patient relationship. Patient education is best accomplished in a true conversation between clinician and patient, not through a clinician monologue.

If you ever feel, we have not listened to you well, please call us back 814 424 2095 and we will take more time to listen to you. Thanks 

EFFECTIVE CLINICIAN STRATEGIES — Four general categories of clinician behaviors lead to effective patient care:

●Cognitive strategies (knowledge-related)

●Affective strategies (emotion-related)

●Behavioral change strategies

●Social strategies (invoking group mechanisms beyond the individual)

Cognitive strategies — The effective clinician negotiates patient priorities and expectations explicitly at the beginning of the relationship, as well as at subsequent critical junctures of decision making. S/he gives a complete explanation of the patient’s condition and treatment options, encouraging questions that expand the patient’s understanding. Through this dialogue, the clinician brings the patient to a “decision crossroads” at which s/he is ready to make informed choices about treatment. The clinician also educates the patient about difficulties s/he might have with her/his condition or its management, and offers a prognosis of what may be expected to happen.

Cognitive strategies that the cost-conscious clinician employs prior to recommending specific diagnostic testing or treatments include asking the questions: Why order this test or treatment? What makes it appropriate and cost-effective in this patient’s care? What will I do with the test results? Will the test results affect my management of this patient’s care?.

Affective strategies — The effective clinician conveys his/her genuine empathy for the patient in many ways. These include facilitating full expression of the emotional content of the patient’s experience, providing encouragement and reassurance when needed and suitable, touching the patient appropriately; and taking actions that sustain hope. The clinician also facilitates patient self-forgiveness, in anticipation of or after failure in the face of a challenge.

Behavioral change strategies — The effective clinician discovers a patient’s readiness to change any particular unhealthy behavior. One group has described stages of behavior change as precontemplation, contemplation, preparation, action, and then either maintenance of the new, healthier behavior or relapse into the old, unhealthy behavior. Understanding the patient’s readiness to change and then matching the clinician’s strategy to that stage may lead to successful change efforts.

Patients in precontemplation may need to hear clearly from the clinician that the behavior is likely to have unhealthy consequences. Others may be aware of the consequences but need a supportive and nonjudgmental atmosphere in which to wrestle with their ambivalence about behavior change.

Patients in contemplation often need help from the clinician to explore the pros and cons of continuing versus stopping the unhealthy behavior. Exploring the pros of the unhealthy behavior (eg “What do you like about smoking?”) as an initial step can often reduce defensiveness and open conversation. Reviewing past attempts at change may be helpful. Emphasis should be placed on past successes (“You were able to quit for an entire week!”), leading to increased self-efficacy and hope.

Patients in preparation may need the clinician’s help in planning a specific behavior change strategy, and patients in action may benefit from the prescription of specific treatments that can support the change (eg, alternative nicotine delivery systems to aid in smoking cessation). The clinician must explain clearly the goals of any specific treatment and the means of achieving them, emphasizing the benefits and necessity of the patient’s active participation in the program of care. S/he provides regular, positive feedback for patient adherence to the program and, when needed, suggests alternative courses if the original path proves impossible.

Motivational Interviewing is a patient counseling method for encouraging behavioral changes to improve health outcomes. While motivational interviewing is most associated with substance use disorders, and is often used in counseling patients regarding alcohol and tobacco use, meta-analyses have indicated effectiveness in medical care settings for a range of important outcome measures including blood pressure, cholesterol level, sedentary behavior, body weight, HIV viral load, patient confidence, intention to change, engagement in treatment, and even death rate. Combining the active ingredients of a supportive relationship and a conversation that promotes positive change statements, motivational interviewing may be a useful strategy for a number of common problems.

Social strategies — In all of these activities, when appropriate, the effective clinician employs social group strategies to improve health outcomes. These include obtaining permission from the patient to inform and involve family members in the patient’s care, as well as collaboration with appropriate community organizations. The clinician explicitly creates coherent teamwork for patient care, sharing information about his/her own care activities with other members of the health professions team.

The first decades of the 21^st century are seeing social strategies to improve health and healthcare adopted as a new “way of doing business” by many leading academic and community hospitals. Referred to as “patient- and family-centered care,” this approach brings thoughtful patients and family members into the administrative decision-making practices of hospitals and office practices. Patients and family members offer their insights into how health care delivery can be made more “user-friendly” and efficient. The four core concepts of patient- and family-centered care are:

●Dignity and Respect – Listen to and honor patient and family perspectives and choices

●Information Sharing – Communicate and share complete information with patients and families in ways that are affirming and useful

●Participation – Patients and families are encouraged and supported in participating in care and decision making at the level they choose

●Collaboration – Patients, families, and health care practitioners and leaders collaborate in policy and program development, implementation and evaluation, facility design, and professional education as well as in delivery of care

The potential for patient- and family-centered care to improve patient safety and satisfaction, the cost of care, and provider satisfaction is substantial and is becoming an important research topic.

DESIRABLE CLINICIAN BEHAVIORS — Patients’ descriptions of desirable clinician behaviors can be grouped into three major dimensions:

●Behaviors expected of clinicians because they are professionals

●Clinician behaviors understood by patients to be respectful

●Clinician behaviors understood by patients to be supportive

Patients expect clinicians to groom and dress appropriately, minimize frustrations from prior visits with other patients that carry over into subsequent visits, be punctual, treat them like an equal, engage in the courteous behaviors expected among equals (eg, shaking hands, calling patients by the names they prefer, sitting down with them, etc), and engage in activities that establish a relaxed atmosphere in spite of patients’ anxiety. These help to get the visit off to the right start.

Clinicians should prepare in advance for the visit, minimize interruptions during the visit (eg, unnecessary phone use), listen actively and seek to understand fully the patient’s illness history, explain elements of the physical examination as it proceeds, take all the patient’s complaints seriously even if they are not medically plausible, and express concern for the effects of the illness in the patient’s daily life. Critical professional behaviors when talking about a diagnosis and its possible therapy include clear and complete explanations of the problem and treatment, and the clinician’s knowing his/her own limitations, referring when necessary for consultation.

Respectful clinician behaviors when talking about a problem and its treatment include involving the patient in making treatment choices and being honest under all circumstances. Supportive actions on the part of the clinician include taking time to talk no matter how busy and encouraging patient and family questions. In follow-up activities, the clinician provides the patient with ready access to care, including cross-coverage when s/he is away, and follows through on all promises made to the patient. The respectful clinician involves the patient in management and is conscious of the financial implications of the patient’s illness. Finally, the supportive clinician remains active in helping patients throughout the process by connecting them with additional resources, being available between appointments, and, when possible and appropriate, checking on them at home.

The overarching task for clinicians is to appreciate and act upon patient preferences for better integrated conversations in medical visits and for greater attention to psychosocial issues and affect-loaded problems. The ultimate challenge is not a cognitive one, but a behavioral one: to stay in close touch with the clinician’s own humanity, no matter how harried the day, and to connect with the patient. The growing prevalence of burnout among physicians may add difficulty to being emotionally present in the moment with patients . When burnout is recognized as a problem, specific interventions, especially those that are organizationally directed, have shown important benefits.

This behavioral task of making a good connection with each patient must be realistically considered within the context of time-limited office and hospital visits. Research demonstrates that expressly attending to affect-loaded problems can in fact improve efficiency as well as improve patient and provider satisfaction. Approaches that have been proven to save time include allowing patients to offer and finish their opening statements, negotiating a consensually prioritized agenda for the visit, responding to patients’ reactions and concerns with empathy, and offering patients orientation to the events of the visit.

References 

https://www.uptodate.com/contents/approach-to-the-patient?search=medical%20records&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1