maximizing the patient encounter strategies to provide excellent patient education emily fenton,...
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Maximizing the Patient EncounterSTRATEGIES TO PROVIDE EXCELLENT PATIENT EDUCATION
EMILY FENTON, PA-S, SATF
ANTHONY BRENNEMAN MPAS, PA-C
Disclosures
Emily Fenton University of Iowa, student Student Advisory Task Force of the PAEA
Anthony Brenneman, MPAS, PAC University of Iowa, Program Director Multiple positions within the PAEA
Objectives For This Session
Define the Physician Assistant (PA) role as a patient educator
Apply communication strategies and skills that provide effective patient education
Explore the integration of specific preventative medicine/health guidelines into patient education sessions
Patient Education
Why Is It Important??
Patient satisfactionPatient complianceClinician satisfaction
Patient Education
Like all clinical skills, it takes time and practice to develop this skill!
Be an effective communicator It can be difficult to find the right words You feel like you don’t have the “extra time”
Use systematic communication strategies to maximize your interaction with the patient
Overview: 2 Strategies For Today
“SPIKES” protocolHow to break bad news – a method for
relaying the message of a negative diagnosis that will significantly alter a patient’s health, happiness, lifestyle, or even lead to their death
Motivational Interviewing How to increase patient compliance – strengthen your patient’s commitment to change a
behavior adversely affecting their physical or mental health
“SPIKES” Protocol: How To Deliver Bad News
Introduction
SPIKESSettingPatient’s PerceptionInvitation for InformationKnowledgeExplore Emotions and EmpathizeStrategy and Summary
“SPIKES” Protocol: How To Deliver Bad News
S.P.I.K.E.S.
Setting: Private location with adequate time to deliver news
“Is there anyone else you would like to be here?”
Patient’s Perception: Patient knowledge: “What do you know about your disease?”
Invitation for Information “Would you like to know more about your illness/your treatment
options right now?”
“SPIKES” Protocol: How To Deliver Bad News
S.P.I.K.E.S.
Knowledge Warning shot: “Unfortunately, I do have bad news to discuss with you
today.”
Give information in small chunks and “signpost” when moving to new topics
Explore Emotions and Empathize “How are you feeling?”
Non-verbal cues
Strategy and Summary “Can you tell me what I told you about your disease today?”
Schedule follow-up visit
“SPIKES” Protocol: How To Deliver Bad News
Patient Response To Bad News
“We came back and he told me it was cancerous. It was just like my whole body went dead. I went completely numb. The doctor sat and told us things. I never heard another word he said.”
“Your mind is racing like, ‘How long am I going to be out of work?’ I am going to have to make lesson plans for 8 weeks. It also raced through my mind, ‘How did I get it? Was it because of stress or just luck?’ You want to know why you have it when there is no answer.”
Slide courtesy of Marcy Rosenbaum
“SPIKES” Protocol: How To Deliver Bad News
Clinical Scenario
Patient is 36 yo nulliparous female who is monogamous with her husband of 4 years. She initially went to her ob/gyn PA to discuss her desire to become pregnant. However, a routine Pap test report came back as abnormal and ultimately led to a diagnosis of cervical cancer. Over the following year, she has yet been unable to become pregnant due to the aggressive recurrence of her cancer. Her PA has scheduled an appointment for today to discuss her most recent work-up, which indicates endocervical tissue margins are still positive for microinvasive carcinoma, and the best option is now radical hysterectomy.
“SPIKES” Protocol: How To Deliver Bad News
Cervical Cancer Screening Guidelines
Bethesda system for Pap test screening: ASC-US, ASC-H, LSIL, HSIL
Histologic evaluation of cervical biopsy obtained during colposcopy CIN I, II, III
Age 21-29 Pap test only Age 30-65 Pap test every 3 years OR
Pap test + HPV co-test every 5 years
http://wcs-stl.com/wp-content/uploads/2011/09/cervix_exam.327131242_std.gifhttp://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/managing-hpv/Screening
“SPIKES” Protocol: How To Deliver Bad News
Clinical Scenario
Patient is 36 yo nulliparous female who is monogamous with her husband of 4 years. She initially went to her ob/gyn PA to discuss her desire to become pregnant. However, a routine Pap test report came back as abnormal and ultimately led to a diagnosis of cervical cancer. Over the following year, she has yet been unable to become pregnant due to the aggressive nature of her cancer. Her PA has scheduled an appointment for today to discuss her most recent work-up, which indicates endocervical tissue margins are still positive for microinvasive carcinoma, and the best option is now radical hysterectomy.
“SPIKES” Protocol: How To Deliver Bad News
Discussion
SPIKESSettingPatient’s PerceptionInvitation for InformationKnowledgeExplore Emotions and EmpathizeStrategy and Summary
Overview: 2 Strategies For Today
“SPIKES” protocol
How to break bad news – a method for relaying the message of a negative diagnosis
Motivational InterviewingHow to strengthen your patient’s
commitment to change a behavior adversely affecting their physical or mental health
Motivational Interviewing: Commit To Change
A Provider’s “Typical Approach”
How do we typically try to convince a patient to change problematic or unhealthy behaviors? Explain what he/she could do differently
Warn them about what will happen if they don’t change
Counsel them about how to change their behavior
Refer them to a specialist
Be frustrated by your non-compliant patient!
Motivational Interviewing: Commit To Change
A Patient’s “Typical Response”
How do patients respond to being told what to do? “Paradoxical effect of coercion”:
When a provider takes up the “good” side of an ambivalent behavior, the patient is more likely to argue the other side
We tend to believe and act on what we hear ourselves say The more we hear ourselves defending our behavior, the
more committed we become to it
New approach: Actively try to guide the conversation so that it is the client rather than the clinician voicing the argument for change
Motivational Interviewing: Commit To Change
4 Steps To Learning MI
1. Understand the spirit of MI
2. Learn how to ask
3. Learn how to respond
4. Learn how to really listen
Motivational Interviewing: Commit To Change
The Spirit Of MI
CollaborationWith Patient
AcceptanceOf Stage
MakeA Commitment
CompassionAnd
Honesty
Motivational Interviewing: Commit To Change
Your Patient’s Stage Of Change
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Motivational Interviewing: Commit To Change
Mnemonic To Ask And Respond
OARSOpen questionsAffirmationReflection Summarize
Motivational Interviewing: Commit To Change
Learn How To Ask: Open Questions
Closed questions invite brief answers, e.g. yes or no: OLDCARTS – “When did you start smoking?” or
“How many ppd?”
Open questions evoke more elaborate responses: “What, if anything, has been your experience with
cigarette smoking?”
Motivational Interviewing: Commit To Change
Learn How To Respond: Affirmations
An affirmation is a genuine statement that emphasizes a strength of the patient. Notice and appreciate a positive action Express positive regard and caring “I see you have tried to quit smoking before, which
I think is a great starting point.”
Motivational Interviewing: Commit To Change
Learn How To Respond: Reflections
A reflection is a statement of inference, or hypothesis, about what your patient has told you Attempt to extrapolate the essential meaning of what
the patient has told you back to them The patient must respond by confirming, correcting, or
elaborating on your comment “You say you don’t see yourself quitting. So you plan to
smoke for all the rest of your days.”
Motivational Interviewing: Commit To Change
Learn How To Respond: Summarize
A summary wraps up what the patient has told you Shows you have been listening carefully Allows you to end the conversation and make
recommendations for follow-up “This is what I heard you say. Now let’s plan to
address that again next time.”
Motivational Interviewing: Commit To Change
Learn How To Really Listen
RULEResist the righting reflexUnderstand their motivationsListen to your patientEmpower your patient
Motivational Interviewing: Commit To Change
Video Scenario
Motivational Interviewing: Commit To Change
Mnemonic To Ask And Respond
How did the clinician do?OARS
Open questionsAffirmationReflection Summarize
Motivational Interviewing: Commit To Change
Clinical Scenario
Patient is 55 yo with a history of poorly-controlled hypertension (170/90) who has an appointment with you, their family practice PA, for a discussion about lifestyle modification. The patient is obese (BMI = 35), eats a high-salt diet, does not exercise, and refuses to take medications regularly.
Use the OARS approach to begin a conversation with your patient about making healthy changes.
Motivational Interviewing: Commit To Change
2013 ACC/AHA Blood Cholesterol Guidelines
Atherosclerosis is a primary risk factor for cardiovascular disease, including MI or stroke
Preventative statin therapy should be initiated in most patients with the following risk factors for atherosclerotic Cardiovascular Disease: Clinical atherosclerotic CV disease LDL ≥ 190 mg/dL Type 1 or 2 diabetes + 10-year ACVD risk ≥ 7.5% 10-year ACVD risk ≥ 7.5%
http://jama.jamanetwork.com/article.aspx?articleid=1791497#Results(Recommendations)
Motivational Interviewing: Commit To Change
Clinical Scenario
Patient is 55 yo with a history of poorly-controlled hypertension (170/90) who has an appointment with you, their family practice PA, for a discussion about lifestyle modification. The patient is obese (BMI = 35), eats a high-salt diet, does not exercise, and refuses to take medications regularly.
Use the OARS approach to begin a conversation with your patient about making healthy changes.
Motivational Interviewing: Commit To Change
Discussion
OARSOpen-ended questions: not yes/noAffirmations: positive attributesReflections: infer patient’s ultimate
viewSummarize: show you’re listening
Conclusion:Your Role As A Patient Educator
Soon you will be a practicing PA Patient education is a part of your job Understand the impact good communication
skills can have on the well-being of your patients Use SPIKES and OARS to address difficult but
common! clinical scenarios with your patients Be confident in your ability to meet the
healthcare needs of your patients
Additional Resources And Information
Next session: more on your role as an educator in your profession!
Future opportunities to learn about PA education:
Future Educator Fellowship in November 2015: small number of students + scholarship to attend Education Forum in Washington DC
SPIKES information
http://www.each.eu/teaching/resources/breaking-bad-news-experiential-module-curriculum-iowa-120613/
Motivational Interviewing information
Miller, W.R.; Rollnick, S. (2002). "Motivational Interviewing: Preparing People to Change'". Guilford press.
A special thanks to Marcy Rosenbaum, PhD and Dr. Michael Flaum, MD for their contributions of time and materials in the making of this presentation.