Jul-Aug 2004 Table of Contents

IMPROVING PATIENT CARE

Sticking the Landing: How to Create a Clean End to a Medical Visit



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Seven skills will help you end the medical visit with greater satisfaction for both you and your patient.

Fam Pract Manag. 2004 Jul-Aug;11(7):51-53.

This content conforms to AAFP CME criteria. See FPM CME Quiz.

In the gymnast’s world, the dismount is the last thing a judge sees before determining the athlete’s score. If you have ever watched a gymnastics competition, you may have heard the commentator’s voice rise in anticipation as the gymnast’s body left the balance beam and catapulted through the air. “She stuck the landing!” the commentator would yell as the program came to a perfect close.

The close of a medical visit is much like the gymnast’s dismount. It influences the patient’s judgment of the physician and the health care he or she has provided. This in turn can affect patient satisfaction, adherence to treatment and health outcomes.1

The quality of the “dismount” affects the physician as well. Recently, I shadowed a highly regarded intern during his continuity clinic. His knowledge base is sound, his history taking is pertinent and his exam skills are above average. Still, he needs work on his dismount; I have yet to see him stick a landing. The result is a frustrated young physician who struggles with feelings of incompetence.

This article highlights seven specific skills that lead to a clean end to a medical visit and greater satisfaction for both you and your patient.

1. Start with an agenda. You can prepare for a good end to a patient visit by starting right. Agenda setting orients patients to the structure and time frame of the visit, and it helps circumvent last-minute concerns. Agenda setting includes “exhausting” the agenda. In other words, after your initial query into the reason for the visit, ask, “Is there anything else?” until the patient answers, “That’s it.” After adding your own items to the list, negotiate the agenda with the patient. Through collaboration, decide which concerns will be addressed at the current visit and which, if any, will require a future visit.

2. Use verbal cues. Once the agenda is set, continue to highlight the structure of the medical visit as it progresses.1 For example, transitional statements such as “Let me wash my hands, and then I’ll take a look…” and “As we wrap up today, let’s make sure we are on the same page…” draw attention to the organization of the visit and contribute to the natural flow toward closure. Foreshadowing can also be useful. For example, you might say, “I am going to get those samples for you. When I come back, we’ll talk about how to take the medication, and then we’ll be through for today.” Transitional statements and foreshadowing help both you and your patient stay organized.

3. Address the patient’s emotions up front. Emotions, if not dealt with strategically, can sabotage the agenda, prolong the medical visit and lead to an untidy closure. Eliciting patients’ emotional or psychosocial issues early in the visit can help provide a sense of control over what is often considered a Pandora’s box. The BATHE technique2 (see the box) provides a structured, time-sensitive method for addressing psychosocial issues and can be employed at any point in a medical encounter. If you or your patient believes an issue warrants more time than the agreed-upon agenda allows, simply renegotiate the agenda or schedule a follow-up appointment.

THE BATHE TECHNIQUE

The following five-step technique is designed to help physicians uncover patients’ emotional issues quickly during an encounter. The first four letters of the BATHE acronym prompt physicians to ask questions that elicit the context for the visit. The final step is to show empathy.

  • Background: “What’s going on in your life?”

  • Affect: “How do you feel about it?” or “What has that been like for you?”

  • Troubles: “What troubles (concerns, worries) you most about it?”

  • Handling: “How are you handling (dealing with, coping with) it?”

  • Empathy: “That must be difficult for you.”

4. Address your own emotions. Physician emotions, especially the feelings of guilt and inadequacy that often plague young physicians, can play a major role in prolonging visits. These feelings may surface when you do not address all of a patient’s complaints, ask a patient to return for follow-up care, keep the patient waiting too long, or fail to “fix” the patient’s problem. Compensating for these feelings by extending the current visit is counterproductive and often leaves you and the patient feeling frustrated.

Instead, you need to deal with what cognitive-behavioral therapists call cognitive distortions, that is, overly negative and largely inaccurate thoughts that typically underlie uncomfortable emotional states. Addressing these errors in thinking is an adaptive method of handling the situation. For example, if you feel overwhelmed at the thought of having to address all four of a patient’s complaints at the current visit, replace that thought with this:

“I will overwhelm my patient and myself if I tackle too much during this visit. I would serve my patient better if we focused on two or three issues and reached some common ground on how to proceed.” (For more examples, see "Common errors in thinking.") When feeling confident, calm and optimistic, you are more likely to close the encounter successfully.

COMMON ERRORS IN THINKING

Emotions such as guilt and inadequacy can cause physicians to prolong visits unnecessarily. To deal with cognitive distortions, physicians must learn to recognize them and replace them with more rational thoughts.

Cognitive distortion Feeling Alternative thought Feeling

“I have to address all four of my patient’s complaints and cover health maintenance issues at this visit. I am never going to get it all done!”

Overwhelmed Frustrated Resentful

“I will overwhelm my patient and myself if I tackle too much during this visit. I would serve my patient better if we focused on two or three issues and reached some common ground on how to proceed.”

Confident Calm Optimistic

“My patient will be mad if I ask her to return for a follow-up visit.”

Anxious Guilty

“By asking my patient to return for a follow-up visit, I am sending the message that her health is important. She will be better served if we develop a relationship over several visits.”

Satisfied

“I know this patient is going to be angry that I kept him waiting.”

Guilty Defensive

“I usually run on time. I’ll apologize for keeping him waiting and see if he accepts it.”

Cautious

“I have no idea what is going on with this patient’s stomach pain. She is going to think I am incompetent.”

Ashamed Nervous

“Medicine is not an exact science. I have done a good workup and have ruled out anything life threatening.”

Relaxed Competent

“I can’t fix any of this patient’s problems. I have nothing useful to offer her.”

Incompetent Defensive Hopeless Frustrated

“These are not my problems to fix. I can listen to her and feed back what I hear her saying. It may help her to have a sounding board.”

Relaxed Confident Interested

Cognitive distortion Feeling Alternative thought Feeling

“I have to address all four of my patient’s complaints and cover health maintenance issues at this visit. I am never going to get it all done!”

Overwhelmed Frustrated Resentful

“I will overwhelm my patient and myself if I tackle too much during this visit. I would serve my patient better if we focused on two or three issues and reached some common ground on how to proceed.”

Confident Calm Optimistic

“My patient will be mad if I ask her to return for a follow-up visit.”

Anxious Guilty

“By asking my patient to return for a follow-up visit, I am sending the message that her health is important. She will be better served if we develop a relationship over several visits.”

Satisfied

“I know this patient is going to be angry that I kept him waiting.”

Guilty Defensive

“I usually run on time. I’ll apologize for keeping him waiting and see if he accepts it.”

Cautious

“I have no idea what is going on with this patient’s stomach pain. She is going to think I am incompetent.”

Ashamed Nervous

“Medicine is not an exact science. I have done a good workup and have ruled out anything life threatening.”

Relaxed Competent

“I can’t fix any of this patient’s problems. I have nothing useful to offer her.”

Incompetent Defensive Hopeless Frustrated

“These are not my problems to fix. I can listen to her and feed back what I hear her saying. It may help her to have a sounding board.”

Relaxed Confident Interested

5. Have a seat. Physicians often need to leave the room near the end of a visit to get medication samples, allow a patient to get dressed or await lab results. Although it is counterintuitive, you should sit down when you re-enter the room even if you do not expect a lengthy wrap-up. Research has shown that most communication is nonverbal, and sitting down creates positive perceptions. Additionally, sitting down gives you the opportunity to stand up at a later point. Standing up is a clear nonverbal cue that the meeting is coming to a close.

6. Be prepared for “oh by the way.” Last-minute patient complaints, known as the “oh by the way” or “hand on the door” phenomenon, can surface even when you exhaust and negotiate the patient’s agenda at the beginning of the visit. It’s important to evaluate these last-minute concerns and classify them as emergent or nonemergent. A patient’s overwhelming fear of a serious illness may preclude him or her from mentioning chest pain at the beginning of a visit. Emotions can create similar barriers to divulging serious mental health or psychosocial issues, such as interpersonal violence or suicidal thoughts. These emergent issues need to be addressed immediately.

Most last-minute issues are not emergencies. Patient’s fears about bringing up “sensitive” but nonemergent issues should not be reinforced. For instance, to evaluate and treat sexual dysfunction, you will need more than a hurried prescription. An appropriate response is to say, “I know this can be uncomfortable to discuss, and I am glad you brought it to my attention. In order to deal with it adequately, I am going to need more time to talk to you. I’d like to schedule an appointment so that we can give it the attention it deserves. How does that sound?” You acknowledge the patient’s possible discomfort in bringing up the topic, validate the concern and maintain the structure of the visit. The same approach can be taken with less sensitive issues, such as concerns about sleep. Over time, patients will learn to prioritize their concerns even before you ask them to do so.

7. Be more specific. One final behavior that can be problematic is when the physician asks at the end of the visit for additional questions or concerns. To the patient, this may appear as a genuine request for additional dialogue. To the physician, this is often a rhetorical question intended as the penultimate step to closing the visit. Patients will understand the signal for closure better if you replace the broad query “Do you have any more questions or concerns?” with a more specific question, such as “Do you have any questions about what we discussed today?”

Gymnasts know that a messy dismount can ruin an otherwise fine performance. Accordingly, they spend as much time practicing the dismount as they do any other part of their program. With practice, you can feel in control during those final moments of the medical encounter, confident that you will stick the landing and that the patient will judge the visit a success.

Dr. Lutton is director of behavioral medicine for the Family Medicine Residency Program at Moses Cone Health System, Greensboro, N.C.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

1. White JC, Rosson C, Christensen J, Hart R, Levinson W. Wrapping things up: a qualitative analysis of the closing moments of the medical visit. Patient Educ Couns. 1997;302:155-165.

2. Stuart MR, Lieberman JA. The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician. 2nd ed. Westport, Conn: Praeger Publishers; 1993.

Copyright © 2004 by the American Academy of Family Physicians.
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