Discussions

Responding to patients with printouts, what's best?

Posted by Patricia F. Anderson @pfanderson, Thu, May 16 2:35pm

This article https://doi.org/10.1016/j.clindermatol.2018.08.002 was posted to an internal forum for clinicians as an example of ways to manage patients who come into clinic with questions from Google search results or answers from social media or other online sources. The article recommendations seemed problematic to me, but I wasn't certain. I posted the link to it a few places, and got replies from other HCSM folk that it bugged them, too. There is talk about writing a letter to the editor, or a new article in response to this article. I wanted to run the article past this group, to see what folk thought about it. I suspect this is a pretty nuanced issue, and that any recommendations could be problematic. It's tricky once the social media crosses over into clinic spaces. Thoughts?

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You have raised a good question here, @pfanderson. I actually like the approach this article takes to resolving patient questions based on internet research – reassure, redirect, and refer. In what ways do you find the advice problematic?

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@DanHinmon

You have raised a good question here, @pfanderson. I actually like the approach this article takes to resolving patient questions based on internet research – reassure, redirect, and refer. In what ways do you find the advice problematic?

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Initially, I agree, I thought this sounded actually almost okay. I wanted to add another "R" up front for "Respectful listening" but it was almost there. And then I read the article. You see, I was thinking this would be a process you would work through with the individual patient. You would respectfully listen to their concerns and why they were bringing this up in the first place. You would address their concerns by reassuring them that they were heard and that you have further thoughts on what to do. You would redirect the conversational focus from the web site or paper they brought to the actual clinical concern, and then refer them to better and accessible online information that addresses their concerns and touches on what the clinical concern/treatment plan area.

No. That's not what the article says. There is nothing about the quality of the information, helping people understand the information. The "redirect" section is about referring to better information, thank goodness. But this is a multiple choice exam to triage the patient into the proper bin. Patient presents with website or article they found. The clinician then has to decide whether to reassure the patient there is no concern, redirect the patient to better info, or give them a clinical referral to another doctor.

I don't know. This seems rather inadequate to me. And reading this has me second guessing doctors who I have trusted. Are they actually partnering with me, or is there a note somewhere that says "this strategy will get her to go away for a while"?

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You're making some interesting points here, @pfanderson. If this is simply a tool for dividing patients into buckets, I can see your concern. I'd like to hear what some of our physician friends think of this article and approach. Tagging @matthewrehrl @bryanvartabedian @christiansinclair @tariqazammd for more insights.

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I responded privately to Patricia on this previously but will share it here too.
The three R's could work but if every time a patient comes to you with info from the internet you think of it as an "unsolicited request" that could be a problem. Why isn't this an engaged patient being pro-active in their health care?
The doctor should acknowledge that the patient has a valid concern that she could develop Parkinson's due to the family history. Seems strange that the recommendation was to find a motivation for her request. To me it sure seems obvious.

Why couldn't the dermatologist tell her he will examine her " skin problems that could be associated with Parkinson disease, such as seborrheic dermatitis, hyperhidrosis, and skin cancer." then direct her to reliable resources and to a neurologist if she hasn't already seen one. Plus if the doctor doesn't know anything about this specific test he/she should tell the patient exactly that. Then look into it and get back to the patient – call or e-mail or through the patient portal.

I might have missed something but I don't get this phrase at all – "Appropriate categorization of patients within this construct"

Finally – "Outside information can be an ally in educating patients instead of a potential source of confusion and contention." This article didn't seem to show outside info as an ally at all.Rather just something that takes time to attend to during the visit .

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This scenario isn’t uncommon. A few points.

1. Always assume the patient may have run across something you don’t know, and, within reasonable time constraints, give it very careful thought.
2. Don’t harm the patient.
3. Lean towards the patients request if it doesn’t conflict with 2, and the patient is aware they may need to assume the financial burden. (Insurance companies will often have a different definition of medical necessity of newer tests, and the expectation should be that it won’t be covered).

Experience helps, but for example, if a patient requests a CT angio (which requires contrast, which has a small, but real risk of anaphylaxis), but all my experience and training suggest it is not needed, then I will not get the test. My number one job isn’t for the patient to like me, but for me not to hurt the patient.

Now, if an adult patient really wants an ankle X-ray for a moderate strain, even though they probably don’t need it, and they are comfortable with the possibility of the insurance company declining it, then I would lean towards getting it. The medical risk is negligible (in an adult), the false positive risk is low, and the patient may be reassured, probably saving them from a follow up visit. ( Low back xrays would is more tricky, as the radiation exposure on the side view maybe 40 times higher than that of a chest X-ray, going right through a pelvis.)

A skin biopsy is somewhere in between. It’s an invasive procedure with a real infection risk, and there might be a secondary the risk of false positives and more invasive tests ( and costs) to follow. In practice, I would probably get someone with more experience to weigh in if I don’t know which way to go.

Anyway, if you always take the patients requests seriously, then 99% of the time, with a good rapport, you can come up with a plan. The other 1% of the time, when you really believe you would be putting a patient at risk, then stand firm.

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@womenofteal

I responded privately to Patricia on this previously but will share it here too.
The three R's could work but if every time a patient comes to you with info from the internet you think of it as an "unsolicited request" that could be a problem. Why isn't this an engaged patient being pro-active in their health care?
The doctor should acknowledge that the patient has a valid concern that she could develop Parkinson's due to the family history. Seems strange that the recommendation was to find a motivation for her request. To me it sure seems obvious.

Why couldn't the dermatologist tell her he will examine her " skin problems that could be associated with Parkinson disease, such as seborrheic dermatitis, hyperhidrosis, and skin cancer." then direct her to reliable resources and to a neurologist if she hasn't already seen one. Plus if the doctor doesn't know anything about this specific test he/she should tell the patient exactly that. Then look into it and get back to the patient – call or e-mail or through the patient portal.

I might have missed something but I don't get this phrase at all – "Appropriate categorization of patients within this construct"

Finally – "Outside information can be an ally in educating patients instead of a potential source of confusion and contention." This article didn't seem to show outside info as an ally at all.Rather just something that takes time to attend to during the visit .

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Thanks for sharing this reply with us, @womenofteal. Great insights we can all learn from. More inclusion and transparency can benefit doctor AND patient.

I have a friend – not a doctor – who owns and manages physician clinics in a nearby community in the greater Portland Oregon area. He's feeling immense financial pressure from declining reimbursement. He told me that some clinics are requiring family practice and internal medicine physicians to see 30-40 patients a day. As a result, during their 10 minutes with a patient they're essentially referring them to specialists all day long.

A sad tale, but insightful. How does he or she take time to listen, learn, respond, and care in that environment?

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@DanHinmon

Thanks for sharing this reply with us, @womenofteal. Great insights we can all learn from. More inclusion and transparency can benefit doctor AND patient.

I have a friend – not a doctor – who owns and manages physician clinics in a nearby community in the greater Portland Oregon area. He's feeling immense financial pressure from declining reimbursement. He told me that some clinics are requiring family practice and internal medicine physicians to see 30-40 patients a day. As a result, during their 10 minutes with a patient they're essentially referring them to specialists all day long.

A sad tale, but insightful. How does he or she take time to listen, learn, respond, and care in that environment?

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I know it is a sad and very difficult position for physicians to be in.

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Thank you @womenofteal and @matthewrehrl! Excellent thoughts, here, and I'm grateful that other folk are seeing layers of complexity in this that could benefit from a more nuanced approach, one that is respectful of the constraints on clinicians and respectful of the needs of patients. Looking forward to further conversation on this. Tagging @colleenyoung to pull in on this.

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In my opinion, the article is a good start. I believe the authors' intent is well placed. While the case study is illustrative, it is limiting and has led to this fruitful conversation. It is nearly impossible to apply a construct (the 3 "R's") to patient-provider conversations, although I do like the distinction of well patients, newly diagnosed and those managing chronic conditions. That information is useful for understanding the motivation of the patient's search for answers and will inform the response as well.

How might we illustrate the complexities, help the busy clinician and benefit the patient with ever-compressed consult times?

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@DanHinmon

Thanks for sharing this reply with us, @womenofteal. Great insights we can all learn from. More inclusion and transparency can benefit doctor AND patient.

I have a friend – not a doctor – who owns and manages physician clinics in a nearby community in the greater Portland Oregon area. He's feeling immense financial pressure from declining reimbursement. He told me that some clinics are requiring family practice and internal medicine physicians to see 30-40 patients a day. As a result, during their 10 minutes with a patient they're essentially referring them to specialists all day long.

A sad tale, but insightful. How does he or she take time to listen, learn, respond, and care in that environment?

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Wow, does this hit a chord with me, @DanHinmon For years my wife's GP was in a small group. The GP would spend the time necessary to truly help my wife (who was battling brain cancer at the time). Then the GP went with a larger group in town and no matter what an appointment was 20 minutes. PERIOD! This was absolutely inadequate for any type of care other than a quick thump and tap and Rx renewals. No real care. Sad indeed! This doc was my GP as well and I would even try to get back-to-back appointments for my wife and I then 'give' my 20 minutes to my wife (while paying my copay) but they wouldn't allow it. This caused us to leave her after more than 12 years as patients.

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Hello @pfanderson Timely topic for me to read.

Last week our daughter, a well educated Gen Xer, was just in a large hospital in Chicago for, at first, unknown reasons. Long story short, she ended up in the MICU for three days of her five day stay. (Amazing care, etc. especially in the ICU and is recovering nicely.)

While I don't think I've ever Googled a health concern in my life, she was doing it constantly as each piece of information came in, test results were revealed, meds introduced, diagnoses made, etc. I was so astounded at this I asked her about it and she was equally astounded that I found this out of the ordinary. She said 'I always check everything medical on the internet. What do you think I was doing in the waiting room during your recent surgery?' Her response dragged me into the present!

It also reminded me of the old adage about nature abhorring a vacuum.

The internet has, indeed, intersected with healthcare in a big way so perhaps a response article would be appropriate to fill what you see as the 'empty' points in their approach. Just my view from a patient/caregiver standpoint.

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Getting back to social media, I often “take a runner” at the idea that social media marketing folks should spend a lot more time on physician recruiting than on other areas.

The problems mentioned above are mostly driven by supply, for example the projected primary care physician shortage may be close to 50,000 in 11 years, making the problems above much worse https://news.aamc.org/press-releases/article/workforce_report_shortage_04112018/. ! And I for one don’t think telemedicine is going to save the day, and the numbers aren’t there for nurse practitioners and physician assistants to make a big dent.

Look the quality and quantity of care your specific organization (as described above) is going to be able to deliver will be driven by the quality and quantity of physicians you hire. The organizations which masters the digital recruiting component of recruiting will do a lot better.

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Thanks for starting this discussion @pfanderson. Lots of great responses here. What do you think about providing a response to the publication? And what form would that take?

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