Questions are the Answer

I have posted the second installment of my column on the MPD Chat listserve below. Though this column is written for members of the myeloproliferative disorders community, my suggestions apply across all conditions. A previoius post on this blog contains similarPlease leave a comment or offer your ideas for questions that patients might ask to enhance their participation in care.

June 23, 2011 – Number 2

The National Patient Safety Foundation's Ask Me 3 campaign (see: http://www.npsf.org/askme3/) encourages patients to ask 3 questions of their health card team to increase their understanding of their health conditions and what to do about them. The 3 questions are:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

Though these questions are good ones, I view the The Ask Me 3 questions as a minimalist approach for promoting clinician-patient communication, patient understanding and enhanced patient capacity to manage their conditions. These questions will help you get your clinicians' view of what you need to know, including their impression of what ails you (e.g., a diagnosis) and the options for managing your condition. Hopefully, if you ask the second question, you will learn not just about treatments, but also self-management options (i.e., what you can do to manage your condition). These questions hopefully will lead to a discussion and not just a lecture.

However, many clinicians do not have the inclination or skill to respond to these basic questions well. So, you may want to bring some additional questions. Here are a few others you might want to consider asking:

• "What else might be going on to explain my symptoms, examination and test results?" Ask "what else?" at least twice. Dr. Jerome Groopman, the noted oncologist and writer thinks "what else?" is one of THE most important questions you can ask. Asking "what else" actually helps clinicians to reflect and consider possibilities they might have prematurely rejected in their efforts to "make" a diagnoses.
• "What aspects of my presentation are not well explained by your diagnosis?" "Presentation"" is a word that clinicians use to convey the combination of symptoms, physical examination findings, and lab tests. They will be impressed if you use this word! Again, you are helping them to reflect and consider what doesn't fit their conceptualization.
• "How sure are you that this is my main problem?"
• "What tests would help you to be more sure?" For those of us with MPNs, you can get more specific and ask about JAK2 testing, bone marrow biopsies, imaging tests, etc.
• "How useful would it be to see another doctor who has more experience treating patient with my condition?" This is especially important question for us, since MPNs are relatively uncommon and only those who treat many MPN patients are aware of new and emerging treatments.
• "What are other treatment options?" This is similar to the "what else could it be?" question in helping the clinician expand his/her thinking about possible treatments.
• "What are the pros and cons of the treatment options?" Many clinicians minimize the down side - but it is important that you make fully informed choices that include an understanding of the risks and benefits.
• "What things can I do, (besides taking medication or undergoing other treatments) that will help me to manage my condition and have the best chance of maintaining my function?" Hopefully, this will lead to a discussion of strategies that may enhance your capacity to monitor you condition, maximize your well-being and function (e.g. eating well, being physically active, paciing oneself, etc.)
  

I realize that it may be challenging to ask ALL of these questions in a single visit...and some clinicians my bristle or balk if you pull out a list or ask too many questions. That kind of reaction is regrettable. After all, this is your life, your health, your condition! The doc may be the expert on the condition and treatment, but you are the expert about you!. Clinicians have the knowledge about what to prescribe. Yet, to effectively manage a condition, especially a MPN, you need to learn how to monitor, manage, cope and adapt.

I hope you will share your own favorite questions here....

Asking is the first step. As the US Agency for Healthcare Research and Qualtiy has said in their ads, "Questions are the Answer!" see: http://www.ahrq.gov/questionsaretheanswer/

Next column, I'll discuss what patients and caregivers can do if their clinician is reluctant to answer questions or hesitant to consider alternative diagnoses, treatments, referrals or self-management education.

Best wishes,
Michael

New Column on Communicating with Your Health Care Team

At the request of the moderator of an online support group for people with Myeloproliferative Neoplasms (MPNs) and their caregivers, I will be writing a regular column, "Communicating and Connecting", that focuses on helping patients and caregives communicate with members of the health care team. (As noted in my previious posts, I have a MPN, Polycythemia Vera, that is currently is being controlled with medication.)

"This is my first installment of this column, which I am very excited to humbly offer to the readers of MPD Chat. Thanks to Beverly for inviting me to share my thoughts about communicating with your health care team, a topic that has been a central focus of my entire 30+ professional career as a physician educator and part-time researcher.

I must start by apologizing for being tardy with this first offering, as I had promised Beverly I would send it to the group on Tuesday, and it is now past midnight on Thursday. I fell asleep at the computer on Tues eve. I am not the night owl I used to be, which I attribute to a combination of aging, my PV and the interferon I have been taking for more than 18 months.


In this first column, I thought it would be useful to share a little bit about me, so you have some context by which to judge my viewpoints, and associated bias. I am the grandson and son of physicians and grew up feeling awe and admiration for both my grandfather and dad. I actually began hanging out in my father's office, which was in my house, at the age of 4. (The office staff were convenient babysitters). When I became old enough to help out (by filing charts or stamping them with dates), my father would often invite me in to his consultation room to introduce me to grateful patients who were more than happy to share their stories or allow me to view their healing eye conditions (my dad was an ophthalmologist, an eye surgeon). My dad loved his work, and enjoyed his daily interaction with his patients. Sometimes, he would call me in just to have a patient retell the joke that she had just shared, or to introduce me to a valued member of our local community: the town librarian of 50 years; the former fire chief; or the nurse supervisor of the local hospital's operating room. He loved hearing their stories and it was clear they loved the extra attention and interest he showed in them. To him, they were more than just eye conditions, they were "whole people" who just happened to have an eye condition... and he loved caring for them. My grandfather, a family doctor for more than 60 years, was most proud of his opportunity to care for several generations of family members. I will never forget him telling me on the cusp of starting medical school that he knew I would become a good doctor because I had "a good mind....and even more importantly, a good heart".


So, I followed my grandfather's footsteps into primary care medicine, then pursued additional training in psychosomatic and behavioral medicine, and subsequently psychiatry. I embarked on an academic career, inspired by my mentors at the University of Rochester, which is known for it's focus on the "biopsychosocial model" and the importance of strong training in interpersonal and communication skills. I have been very fortunate during my career to have had many opportunities to teach communication skills to medical students, residents and practicing clinicians and my current job includes a heavy emphasis on developing and implementing training and other strategies to improve clinician-patient communication.


And, despite some progress in recent years, there is great need for improvement in clinicians' communication skills. The evidence for this comes from not only a large body of research in clinician-patient communication, but also from my personal experience as a patient, from your stories on this list, and from the stories of many, many other patients and caregivers.


The good news is that we, as patients, can take steps to improve the communication process, steps that will increase our participation in care, help us to make good health care decisions, and ultimately improve the quality of our lives. This will be the focus of subsequent posts to this column, which will include links to resources, tools and other useful information on this topic. I also hope you will contribute your thoughts, ideas and experiences. Tell us what has worked for you and your family members and where you see opportunities for improvement. We will all benefit if we share "best practices".


With best wishes,


Michael"

People with Higher Levels of Empathy Enjoy Sex More

Researchers have identified another benefit to working on enhancing empathy skills.

A recent study, published in the June 3rd issue of the Journal of Adolescent Health, found that empathy, self-esteem and autonomy are associated with sexual pleasure among students, aged 18 - 26 though, for men, only empathy was significantly associated with sexual pleasure.

"Sexual health includes sexual well-being, and sexual enjoyment is an important part [of that]," said study researcher Adena Galinsky, of Johns Hopkins Bloomberg School of Public Health. "How people interact and their ability to listen to each other and take each other's perspective can really influence the sex that they have."

The study analyzed data from about 3,200 students, ages 18 to 26, who were surveyed between 2001 and 2002 as part of the third wave of the National Longitudinal Study of Adolescent Health.

The study citation is: Galinsky AM, Sonenstein FL. The association between developmental assets and sexual enjoyment among emerging adults. J Adolescent Health. Jun;48(6):610-5, 2011. Epub 2010 Dec 30.

An Oncologist's Experience with his Spouse's Cancer

It has been a while since I posted. I was inspired to place an entry here after reading the last in a series of New York Times blog posts by Peter Bach, an oncologist at Memorial Sloan-Kettering Cancer Center about his and his wife's experience with her cancer diagnosis and treatment. I highly recommend this series, as well as the comments posed by readers. See below for the comment I posted to the NYT blog:

"Thanks to Dr. B, and his wife, for being so willing to share their experience with us, in such a public way. Dr. Bach's openness and honesty, his efforts to be reflective and mindful, and his capacity to use his insights and learning to improve his caring for patients, is both instructive and inspiring.

As a medical educator, I have encouraged students to learn from the experiences of patients and their caregivers. They are our most valuable teachers. Hearing first hand about the emotional, physical, interpersonal and spiritual challenges of having an illness helps us to learn what patients and their loved-ones need. Learning about their experience also provides opportunities to respond with empathy and compassion, as well as with treatments, resources and services that might be available to help tthem to manage and cope. If we don't have the skills or capacity to respond ourselves, we can refer patients and their caregivers to colleagues or to valuable services and programs in the community, including those provided by other patients and peers. Yet, as many others have commented, too many clinicians feel unprepared to both uncover these needs, or respond effectively. This must change. Hopefully, Dr. B and other enlightened faculty will continue to help future students to develop competencies in clinician-patient communication, compassionate care, patient activation and self-management support.

As Dr. B has demonstrated, we can also learn valuable lessons from those clinicians who are willing to share their personal experiences with us, however painful. Thanks again for sharing his story and providing an opportunity to learn from all those commenting here. I join others wishing Dr. B. and his wife well. I also want to second the recommendation made by another reader about Rachel Remen's books, Kitchen Table Wisdom, and My Grandfather's Blessings. Rachel is a physician who epitomizes the skills associated with compassionate relationship-centered healing. She is also a fabulous writer and storyteller."

Michael

Wish Statements Help Doctors Deliver Painful News to Patients : Internal Medicine News

Wish Statements Help Doctors Deliver Painful News to Patients : Internal Medicine News

Tim Quill, an old buddy of mine from my Rochester training days, is a wonderful and truly compassionate physician. His writing on this topic is insightful and extremely practical and helpful. See especially:

Quill, T. E., Arnold, R. M., & Platt, F. (2001). "I wish things were different": expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med, 135(7), 551-555.

Michael

CBC News - Canada - The limits of feeling someone else's pain

CBC News - Canada - The limits of feeling someone else's pain

Interesting article that questions the value of empathy in some situations, particularly in the political contex.

The author also quotes an article by a physician, Jane Macnaughton, in a recent journal of Lancet who writes that feeling the distress of patients can be "unhelpful and even dangerous". Dangerous? Well, if one is in the midst of a delicate proceedure, maybe. And, sure, it may be emotionally and physically exhausting to work in a setting that exposes us to the pain of those who are suffering. We all have limits, and as professionals, we must learn to measure our own internal reserves, and find ways to replenish them when we are depleted.

Macnaughton apparently also writes that a doctor who says "I understand how you feel" can be perceived as insincere, provoking resentment from the patient. I agree that clinicians must be careful not to use this rather paternalistic response when a patient expresses a strong emotion. They also need to be careful not to prematurely assume what the patient is feeling. However, genuine efforts to understand the a patient's distress will almost always be valued and appreciated, especially when reflected back to the patient to check for undertanding. Softer responses like, "I can imagine" or "I think I understand what are you feeling" are more likely to be fully accepted by the patient.

I will go read the original Lancet article...look for more on this later.

However, in my own experience, one can never be too empathic.

Michael

Can Clinicians Empower Patients?

On first blush, my answer to the questions, "Can clinicians empower patients?" was an unqualified "Yes"!.

Recently, however, on my Facebook page, I posted a link to a NY Times book review of "The Empowered Patient" by Elizabeth Cohen. Cohen, a CNN journalist, writes about her personal experiences dealing with medical crises and what she learned about the need to advocate for quality health care. Her book provides suggestions about how patients can prepare and arm themselves to increase their chances of getting the care that they, or a loved oned, need.

My posting led to a lively discussion among some of my Facebook friends about the term, empowerment. Eleni Chambers, a UK-based expert in self-management strategies, stated that clinicians can't actually empower patients, just support or enable empowerment. Some patients, she argues, don't want to be empowered, and others have serious barriers to empowerment (e.g., lack of access, low socioeconomic status) that can't be easily addressed by clinicians.

However, I do believe that I, as a clinician, can empower many of my patients. For one, I can share the "power" of choosing tests, procedures and treatments. I can collaborate and partner with patients, rather than simply prescribe, direct or even advise. I can also encourage my patients to let me know their ideas, expectations, feeling and goals, so I can better tailor my recommendations for them. Once I have a good idea about what a patient wants and needs, I can offer options and choices and help my patients to consider the pros and cons for each. Others have referred to this process as shared decision making. Ultimately, patients decide, unless of course they have a condition that limits their capacity to make rational decisions. Sure, some patients, particularly some older patients, want me to decide or direct therapy. That is ok, I am happy to do that if the patient prefers that I take the lead in picking a treatment.

However, I also know that patients are more likely to follow through with treatment when their autonomy is supported and respected and they are provided with choices and options. (See expecially the work of Geoff Williams, MD, PhD, and other proponents of Self-Determination Theory - a topic of a future column).

I agree, however, that there are limits to what I as a clinician can do to "truly" empower some patients. I can't empower a person who doesn't want to be empowered, and I can't overcome barriers that neither I nor the patient have control over. As Jessie Gruman, PhD, of the Center for Advancing Health (CFAH) has noted (see link in my link section), it may be better to use the terms "prepared" patient or "engaged" patient, rather than "empowered" patient. Activated, a term championed by Judith Hibbard, is another way of framing the approach. See the CFAH website and its associated Prepared Patient Forum (see my link to this site) for lots of useful tools, resources and strategies for arming patients, their families, and other advocates.

Whatever the term, helping our patients to more fully participate in care provides all sorts of positive benefits!