Physicians Practice - February 2008 - (Page 44)

IN PRACTICE • Setting — Secure a quiet, private room, sit down, turn off your beeper, and meet your patient’s eyes on the same level. Look relaxed, regardless of how you feel. • Perception — Before divulging any information, assess what the patient may know or suspect about his diagnosis. • Indication — Ascertain the level of information the patient wants. Some may indicate that they want to be spared the details at present, favoring a more generalized diagnosis. Others, particularly those from different cultures, may prefer not to know their own diagnosis, asking you to inform their families instead. • Knowledge — Give the patient the medical facts in small chunks, making sure you don’t overwhelm him with information overload. • Emotion — Buckman calls this ARE YOU THERE, GOD? As the founder and director of The George Washington Institute for Spirituality and Health in Washington, D.C. — a center that develops educational, clinical, and research programs for physicians regarding the role of spirituality in medicine — internist Christina Puchalski believes that a patient’s spiritual beliefs play a large role within the context of healthcare delivery because physicians arming themselves with this information can better broach difﬁcult conversations with patients. To that end, she developed a simple questionnaire that she recommends all physicians use as part of the standard history they take during a patient’s ﬁrst visit. “the most important step of all,” as it’s the time for listening — not telling. Acknowledge whatever emotion the patient expresses, especially if it’s strong. He recommends that physicians employ an empathetic response, in which they identify the patient’s emotion — be it fear, anger, or depression — and validate it with responses such as “This obviously comes as a major shock to you,” or “That bone scan was clearly not what you were hoping for.” Allow the patient time to digest the information, react to it, and express what she is feeling. • Strategy and Summary — Rather The FICA Tool for Taking a Spiritual History F — Faith and Belief Ask patients — “Do you consider yourself spiritual or religious?” or “Do you have spiritual beliefs that help you cope with stress?” If the patient responds “No,” the physician might ask, “What gives your life meaning?” Sometimes patients respond with answers such as family, career, or nature. I — Importance “What importance does your faith or belief have in your life? Have your beliefs inﬂuenced how you take care of yourself in this illness? What role do your beliefs play in regaining your health?” C — Community “Are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?” Communities such as churches, temples, and mosques, or a group of like-minded friends, can serve as strong support systems for some patients. A — Address in Care “How would you like me, your doctor, to address these issues in your healthcare?” than ending the conversation by abruptly telling your patient her 15 minutes are up, assure her that she is not alone and that she may count on you for continued support. Establish your next steps, and summarize with a clear close to your discussion. Buckman maintains that if the SPIKES approach is employed correctly, a patient visit shouldn’t take longer than 15 minutes. “The amount of time you spend doesn’t have any relationship to how satisfactory the interview is from the patient’s point of view,” he says. “Effective communication really does depend on you being a support to the patient, which doesn’t take more time than not being a support.” SHOOTING THE MESSENGER Even if lacking this information, Puchalski suggests that — after breaking the news and allowing patients some time to process it (“You don’t want to bring it up too quickly, lest patients think they’re dying,” she warns) — the physician gently ask the patient if he has some type of belief system, spiritual or other, that may help him cope in such situations. Puchalski maintains that this helps physicians to identify possible sources of hope and support for individual patients. “One of the skills that we teach in breaking bad news is how you can deliver news and not take hope away,” she says. “And I think spirituality is critical in that area.” Puchalski does advise that physicians avoid heavy-duty spiritual or religious discussions with their patients: “We have to be very careful of the boundaries. It’s inappropriate for doctors to proselytize or to convert.” Adapted with permission from Puchalski CM, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Pall Med 2000; 3:129-37. Copyright, Christina M. Puchalski, MD, 1996. One of the most common human reactions to unexpected or startling news is to attack the news-bearer. Doubtless every physician, regardless of specialty, has been on the receiving end of this reaction. Indeed, with some people, you will be the target, no matter what you do. But you can blunt the unpleasant experience by taking proactive measures: • Collapse the distance between you and your patient. Buckman says, “As you acknowledge how the patient is feeling, somehow you come around to their side of the desk, WWW.PHYSICIANSPRACTICE.COM 44 | PHYSICIANS PRACTICE | FEBRUARY 2008 http://WWW.PHYSICIANSPRACTICE.COM

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Physicians Practice - February 2008 Contents The Bigger Picture: Your Future is in Your Hands Letters Physicians Practice Pearls: Creating an A+ Practice Noteworthy Cover Story: Conquering Time: 5 Keys to a More Efficient Practice In Balance: A Family Affair Technology: Making EMRs Work in the Exam Room In Practice: "I've Got Some Bad News" The Tech Doctor - The EMR: Savior or Poseur? Ask the Experts NEW! Healthonomics: How to Handle Health Savings Accounts The Administrator's Desk: Finishing School for New Managers Human Resources: Is Your Partner Impaired The Great Practice Makeover: Too Well-Liked for His Own Good? Coding Idealab: 'Why I Blog' Classifieds Advertiser Index

Physicians Practice - February 2008

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