We admit it. We’ve fallen into the same trap in our columns
that we fall into every day in the office or hospital. All our columns on the
impact of interruptions and distractions have focused on interruptions to
healthcare workers. Now a new “Piece of My Mind” in JAMA reminds us about the
impact of interruptions on our patients
(Mauksch 2017).
For several decades now, when teaching students and
residents about listening skills, we have quoted from a study by Beckman and
Frankel that physicians interrupt their patients on an average of 18 seconds (Beckman
1984). Actually, the timeframe might be even shorter. A study of resident
interactions with patients showed the interruption occurred on an average of 12
seconds (Rhoades
2001).
But in the recent piece Larry Mauksch
points out that the interruptions are not always negative and provides some
great examples of how to interrupt your patient tactfully so that you do not
appear rude yet help focus on things that are important to the patient. He
notes that some interruptions may build rapport, offer support, and express
cooperation.
He suggests adhering to “The Triple E” when interrupting
patients:
Mauksch suggests the following
script for redirecting patients who have a tendency to jump from one
symptom/topic to another: “Excuse me, your back pain sounds distressing, but we
were only part way through addressing your asthma. How about we finish the
asthma and then see if there is time for your back pain?”
We all have a few patients who tend to move from topic to
topic and are difficult to get to focus on key points. Most of us have learned
that, to be fair to both those patients and other patients we are seeing the
same day, thoughtful scheduling is important. If we schedule such patients
early in an office/clinic session we will always be pressured by time and workload
and all patients get short-changed. So we tend to schedule the more
“loquacious” patients toward the end of an office/clinic session.
But what if you are a patient? When we do our patient safety
for patients courses we tell our audience they should have a checklist of the
symptoms/topics they hope to discuss with their physician or other healthcare
provider. The items should be roughly prioritized with those the patient
considers most important near the top of the list. Giving the physician a copy
of the checklist at the beginning of the session may also help him/her get an
idea about time allocation.
Mauksch also points out that the
physician can also do agenda setting early in a session to help avoid late “oh,
by the way” issues. For example, he suggests the following script: “Excuse me
for a moment. Your knee has been painful. Before we talk further about this
pain, I’d like to know if you have something else important to address today.
This way you and I can figure out how to make the best use of our time.”
Read Mauksch’s article. It’s short
but to the point. And his suggestions are valuable not only for your patient
interactions but apply equally to many of the everyday interactions you have
with multiple other people! They are an important part of treating individuals
with respect and you’ll find in the long run that will make your life easier.
Actually, another group of clinicians recently took agenda
setting to a new level: collaborative agenda setting in the electronic visit
note. Anderson et al. (Anderson
2017) had patients attending a large primary care safety-net clinic type
their agendas into the electronic visit note before seeing their clinicians.
Patients and clinicians agreed that the agendas improved patient-clinician
communication (patients 79%, clinician 74%), and wanted to continue having
patients type agendas in the future (73%, 82%).
Are there implications for patient safety? You bet! One of
the examples provided by Anderson et al. was a patient typing on his agenda
“lumps on my lungs”. The clinician explained that a pulmonary nodule had been identified
on a CT scan on an ER visit that the clinician might have missed if the patient
had not put it on his agenda.
Prior Patient Safety
Tips of the Week dealing with interruptions and distractions:
References:
Mauksch LB. Questioning a Taboo. Physicians’
Interruptions During Interactions With Patients. JAMA
2017; 317(10): 1021-1022
http://jamanetwork.com/journals/jama/fullarticle/2610340
Beckman HB, Frankel RM. The effect of physician behavior on
the collection of data. Ann Intern Med 1984; 101(5): 692-696
http://annals.org/aim/article/699136/effect-physician-behavior-collection-data
Rhoades DR, McFarland KF, Finch WH, Johnson AO. Speaking and
interruptions during primary care office visits. Fam
Med 2001; 33(7): 528-532
http://www.stfm.org/FamilyMedicine/Vol33Issue7/Rhoades528
Anderson MO, Jackson SL, Oster NV, et al. Patients Typing
Their Own Visit Agendas Into an Electronic Medical Record: Pilot in a
Safety-Net Clinic. Ann Fam Med 2017; 15(2): 158-161
http://www.annfammed.org/content/15/2/158.full
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