The Internal Medicine Work-Up (Patient Encounters)

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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.

By: Garibaldi, Brian T. MD

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. 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.

Third, we used a brief checklist to detect symptom-related expectations. Kravitz et al 55 as well as other investigators 56 , 57 using much longer instruments or interviews have identified other common expectations eg, physician preparation for the visit, history taking, physical examination that we did not measure.

Although we invited patients to write in other expectations, they did so infrequently. Finally, studies have found that patients with somatoform disorders are particularly likely to be considered difficult. However, the fact that multiple, severe somatic complaints were strongly associated with being considered difficult corroborates the impact of such disorders on difficulty. The strengths of this study include its prospective design, large sample size, measurement of multiple symptom-relevant outcomes at different time points in the patient's care, inclusion of physician psychosocial belief measurements, and the use of a validated instrument for determining patient difficulty.

The arbitrary method of assigning patients to clinicians prevented biased sampling from potential concentration of patients with known psychosocial problems into particular clinician's practices. The portrait of patients likely to be considered difficult is gradually being clarified as a consequence of a number of studies. Difficult patients are more likely to have multiple somatic complaints, to be seriously worried about their symptom, to report greater symptom severity, have underlying mental disorders, and to report poorer self-reported functional status.

Adverse patient outcomes of difficult encounters can include more unmet expectations, less satisfaction with care, and higher utilization rates. Finally, clinicians with poorer psychosocial attitudes are more likely to experience patient encounters as difficult. In the judgment of the physician, following her closely and conservatively may be the best course available. For patients to share in the decision about the best course of action, they must be fully informed about the potential risks and benefits of their various options.

This principal of informed consent, which is commonly applied to clinical care decisions, must encompass dilemmas resulting from financial constraints when they exist. As shown in Figure 1 , the third set of issues physicians must address pertain to the billing procedure. In the case of Ms. Wade, the physician undercoded the office visit and waived the professional fee, without any documentation of her need. Had she been insured by the government or privately, he would have put his institution at legal risk. In striving to aid patients financially, then, the physician faces a third dilemma: Should a physician adjust billing or claims information to reduce costs for an indigent patient?

Problems may be aggravated when clinics have not developed adequate protocols for adjusting fees.

“I Can't Afford That!”

If the physician caring for Ms. Wade had been able to refer her for a means test and sliding fee scale, he might have achieved the same reduced fee without miscoding the visit. Nearly all physicians think about issues of liability when they think about the standard of care. In civil court hearings for malpractice, disputes of quality of care often revolve around questions of the standard of care, and whether the patient received it. When a patient does not receive the standard of care, documentation is especially critical.

The physician must chart why a particular nonstandard plan of care was selected and that the patient was informed of the risks involved.

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Wade, the physician would need to document, for example, that although he has informed her that endoscopy is indicated, she cannot afford the procedure and declines referral to a public facility. He would then need to explain why following her conservatively treating her with medicine and watching her clinically is the best option under the circumstances.

While good documentation is a physician's best asset in court, 16 a good physician-patient relationship is the best protection against legal conflict. When a patient is turned away, that opportunity is lost. The literature suggests that patients are most likely to be angered if they feel abandoned. Shared decision making describes a partnership between physician and patient in which each contributes equally to the decision making process. Should the physician caring for Ms. Wade weigh the impact of referring an uninsured patient to the county hospital on an already overburdened safety net?

Are there ways to help her choose between missing work waiting for medical care at the county hospital and the increased peace of mind that may come from knowing her actual cancer and heart disease risk, and from avoiding the bill collector? Theories of distributive justice, such as utilitarianism and egalitarianism, have emphasized the importance of applying decision-making principals uniformly and consistently. Wade's physician may be consistent in abiding by a framework that adapts to the needs and wishes of each patient.

Patients such as Ms. Wade must choose among options for which the outcome is uncertain. Preferences under conditions of uncertainty are called utilities as opposed to values, which reflect choices among known outcomes. There are a variety of methodologies for measuring preferences including standard gamble, 23 time trade-off, and categorical rating techniques which include magnitude estimation, equivalence, willingness-to-pay, 24 and, most recently, multiattribute utility theory.

Nevertheless, familiarity with these methods may facilitate shared decision making as a more informal process. The principal thesis of this article is that when financial considerations intervene in decision making for the individual patient, the clinician is forced off of well-trodden clinical pathways, leaving uncertainty about what is best for the patient.

In instances where physicians are forced to compromise the standard of care, there is a potential reduction in quality. Such instances will occur until there is universal access to a basic standard of care. If the art of medicine is applying the science of medicine to the context of the patient, the artful physician will provide the best care possible under the circumstances. The following are proposed as guidelines. The author would like to acknowledge Gordon D. Schiff, MD for careful review of the manuscript and helpful suggestions which led to substantive changes.

National Center for Biotechnology Information , U. J Gen Intern Med. Saul Weiner , MD. Author information Copyright and License information Disclaimer. Address correspondence to Dr. Copyright by the Society of General Internal Medicine. This article has been cited by other articles in PMC. Abstract When patients lack sufficient health care insurance, financial matters become integrally intertwined with biomedical considerations in the process of clinical decision making. Open in a separate window. Physicians should explicitly ask about financial concerns rather than ignore the problem or wait for patients to raise the issue first.

As with other sensitive questions physicians ask, patients may react with anxiety or discomfort, but the information they provide is important to the care plan.

If financial considerations will affect the delivery of medical services, it is better to know sooner rather than later. This will enable the clinician, before embarking on an extensive work-up, to consider the ramifications of transferring a patient with a particular medical need to an indigent care facility versus retaining the individual with a goal of providing care at lower cost.

Physicians need to be knowledgeable about the resources available at their institution and in the community for the medically indigent, so they can maximize services that aid their underinsured patients. They may benefit from ancillary staff, often in social work, who can provide appropriate guidance and referral information. They should be certain that their patients with financial hardship are getting full benefit from the public and private resources that are available, such as public aid and pharmaceutical industry indigent drug programs.

In considering whether to retain a patient or refer to a safety net provider, physicians must take into account the loss of continuity of care and uncertainties about the level of service available at alternative sites. They should also consider that services might be better elsewhere if the referral option is an academic institution or the patient is from an ethnic minority group with which the safety net provider is especially familiar.

If a decision is made to refer, the physician should make direct contact with providers at the referral site to identify a contact liaison to optimize the referral process. If retaining a patient appears to be the preferable or only option, a physician may be forced to provide a nonstandard approach to care in order to best serve that individual. Documentation that a patient has declined a recommended study or therapy, including referral to a safety net provider, if available, and has been informed of the risks involved is critical.

In such cases, close observation with frequent visits and basic laboratory studies can be an inexpensive alternative to ordering costly tests which may have only a marginal benefit over careful observation. The relationship that develops in this setting can be a patient's lifeline when a strong physician advocate who knows the patient well is needed. Physicians should actively work to lower the cost of their services when they have clear evidence of financial hardship. For underinsured patients, they must do so in a manner that will not be interpreted as financially self-serving or in violation of the law.

For uninsured patients, adjustments in fees are allowed. When the demand for free care threatens the financial viability of the provider institution, the physician can promote the adoption of charity policies that help direct subsidies to the most needy patients. To best serve their patients in the broadest terms, physicians must address issues of social justice outside of the office. Within their institution, they can lobby for a charity care policy, the use of means testing, and the application of sliding fee scales.

In their community and through professional societies, they can lobby for support of safety net institutions, such as publicly funded hospitals and clinics. At a state and national level, they can participate in educating the public about the consequences of unaffordable health insurance for tens of millions of Americans. Finally, they can advocate for reforms that will broaden access to medical care and services, including medications and supplies. Acknowledgments The author would like to acknowledge Gordon D. The American health care system.

New Engl J Med. A profile of uncompensated hospital care, — Health Aff Millwood ; Physician manipulation of reimbursement rules for patients: Health Insurance Portability and Accountability Act. 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 Internal Medicine Work-up : Brian Garibaldi :

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.

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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.

The Internal Medicine Work-up

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. Some of the very important practical advices are listed below [ 18 - 20 ]: Communicating with the attendants This scenario usually comes when a doctor is treating an indoor patient. Never be informal with them. Conduct conferences once and if possible twice daily. Talk about and appreciate the efforts made by them.

Communicating with colleagues Junior doctors including postgraduate students, fellows and interns along with nursing and supportive staffs are part of the team. Following principles should be followed [ 24 ]: Conclusion 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.

References [1] S Chatterjee, N Choudhury. Medical communication skills training in the Indian setting: Need of the hour. Asian J Transfus Sci. Latest News, Videos, Photos. Times of India [Internet]. Am J Med Qual. Consultation skills of young doctors: I-Benefits of feedback training in interviewing as students persist. Mental health of hospital consultants: The relationship with malpractice claims among primary care doctors and surgeons.

Physician communication and patient adherence to treatment: Effective physician-patient communication and health outcomes:

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