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Doctors use new cues to get patient history

Communication techniques can lead to a better understanding of the patient perspective, and, therefore, strengthen the physician-patient relationship.

By Victoria Stagg Elliott, amednews staff. June 23, 2003.

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When Patricia Barrier, MD, was in medical school a little more than a quarter of a century ago, she was taught how to take a medical history -- how to get all the facts out of a patient, but just the facts.

Over the years, however, she has come to believe that there is a better way to communicate with patients, a method that improves their satisfaction, increases their adherence to treatment regimens and reduces her feelings of physician burnout.

She's part of a growing cadre of medical communication experts who favor building rather than taking patients' medical histories.

Central to the approach is its emphasis on maintaining patient perspectives and taking into account their worries and goals.

"We have swung so far to the biomedical, technical side of things, and our patients feel that," said Dr. Barrier, an associate dean for student affairs at the Mayo Medical School in Rochester, Minn., and author of a related paper in the February issue of Mayo Clinical Proceedings. "Now, we have to swing the emphasis a bit more in the other direction to look at the bio-psychosocial dimensions."

Most recently, the concept was highlighted in a special article published in the May 26 issue of the Archives of Internal Medicine.

Paul Haidet, MD, MPH, the lead author and a staff physician at the Houston VA Medical Center, suggested that physicians might get useful information out of patients by using an open interviewing style that encourages them to reveal more than just the biomedical facts.

"Patients come into the medical interview with views about what they think is going on and what they need," said Dr. Haidet, who is also an assistant professor at Baylor College of Medicine in Houston. "Before a doctor and a patient can really negotiate a treatment plan that's going to have buy-in by both, they need to get all the data out onto the table, and all the data are not just the biomedical signs and symptoms."

Beyond asking questions

In official lingo, it's called "narrative-based medicine," and it requires physicians to do more than just ask questions. Doctors also have to paraphrase patient's statements, initiate requests for clarifications and sometimes just remain silent.

"Patients need to tell a story. When they get directed off that story, they don't feel heard," Dr. Haidet said. "They don't feel like the doctor cared. They lose trust in that physician."

In some ways, the approach is part of a trend -- a reaction to what many physicians refer to as "checklist medicine."

Those who advocate this approach say it's a response to the combination of managed care pressures and technological advances that produce absolute answers, which has thrown the art and science of medicine out of balance.

"Patients and doctors are frustrated and saying we need to get back to some basics. We need to talk to each other," said Frank Boehm, MD, professor of obstetrics and gynecology at Vanderbilt Medical Center in Nashville, Tenn.

And the movement has begun to make inroads into clinical practice.

Anecdotal evidence suggests that an increasing number of medical schools are adopting the narrative approach, meaning a new generation of physicians may have a more conversational style. Those who lead training sessions for practicing physicians say their seminars are packed.

Time and cost savings in the long run

But while there is clearly a growing interest, there are still some snags. It's unclear, for instance, how to document the patient perspective in a medical record.

Time is also a constant worry. Many physicians fear that allowing patients to talk may mean that they go on for hours, although experts say physicians experienced in the narrative style can complete the process as fast as if they were conducting a traditional interview.

"Where the real communicative skill comes in is being able to manage [it] so that you're getting not only the biomedical facts but also the patient's story and doing that efficiently," Dr. Haidet said. "Patients will often be done fairly quickly, but it's hard sometimes to get out of the way."

A more open style also may produce time and cost savings in the long run. A study published in the May 2002 Family Medicine found that the additional time investment was modest but yielded significant information and increased patient satisfaction.

Advocates say that not uncovering and addressing patients' worries up front -- even if they are unfounded -- may result in additional office or emergency department visits. Patients also may suggest a medical condition that a physician hadn't thought of, but might be on the right track.

"Patient ideas can actually clue you to the right diagnosis," said Forrest Lang, MD, who researches medical communication issues and is a professor of family medicine at East Tennessee State University in Johnson City. "And data from my own practice show that fewer of my patients wind up in the emergency room. They get fewer tests, and I make fewer referrals."

One of the biggest hurdles for physicians is the fear that they will be drawn into situations that they can do nothing about.

Medical communication experts suggest, though, that even in such circumstances, just by listening, the doctor has done some good.

"Sometimes, when you have little to offer a patient but listening, that is the most therapeutic tool," Dr. Barrier said.

Some small studies have suggested that a better physician-patient relationship can produce better health results for patients with some chronic conditions as well as lead to fewer malpractice lawsuits.

But the evidence is limited, although common sense and ancedotal experience offer support for the contention. Some physicians even say, evidence or not, collaborating with patients on developing a history is just the right thing to do.

"Sometimes we get a little crazy with trying to prove things," said Dr. Boehm, author of Doctors Cry, Too. "Doesn't it [all] make more sense if a person winds up enjoying their time with the doctor, feeling that their complaints were heard and developing a trusting relationship?"

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