Dr.Paul’s Clinic: Effective Strategies

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 21st 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.



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