Negotiating Care: A Learned Skill

The name pretty much says it all: “doorknob complaint.”

Just as you turn the doorknob to exit the examining room, the patient pipes up with a new complaint, sometimes more serious than anything else discussed during the visit.

It’s not hard to shut the door on doorknob complaints, though. “One of the things that’s been found to be helpful is this concept of setting an agenda at the beginning of a visit,” saysDr Eric Holmboe, chief medical officer of the American Board of Internal Medicine. “What’s concerning you today? What questions do you have? What would you like to cover?” If the list is long, the physician can suggest what should be at the top and what can wait for a subsequent, longer appointment if necessary.

In a recently released summary of a February workshop, the Institute of Medicine’s (IOM) Roundtable on Value & Science-Driven Health Care noted that physicians aren’t born knowing how to engage patients, just as patients aren’t born knowing how to engage with physicians. “Patients and clinicians learn these skills over time and through partnership with a supportive care team,” according to the summary.

Even physicians who haven’t picked up those skills after decades of seeing patients can improve, says Holmboe, who spoke at the IOM workshop (see a short video about the workshop here). In an interview, he describes a community-based primary care doctor whose patients weren’t exactly crazy about him. They thought he was grumpy, and his partner agreed. At age 60, the guy was suffering from burnout. But then he took a 1-week course on improving clinical skills, and “he was totally transformed,” Holmboe says. “He realized that these techniques could not only make him more effective and his patients more satisfied, but they actually brought him more joy in his work.”

Doctors need to be able to present treatment options, discuss the pros and cons and, if there’s a difference of opinion with the patient, negotiate their way out of conflicts, says Dr Sherrie Kaplan, who also spoke at the IOM workshop. “That’s a skill set you can define.” Kaplan, who is not a clinician, and her husband, primary care physician Dr Sheldon Greenfield, serve as executive co-directors of the Health Policy Research Institute at the University of California, Irvine. Yet, Kaplan says, she and her husband have found that such discussions take place in only 15% of visits. Granted, she says, not every doctor visit involves deciding on a new treatment, but far more than 15% do.

Having that conversation doesn’t have to lengthen patient visits, Kaplan and Holmboe say. Besides, simply handing patients a prescription for antihypertension medication might leave them confused, increasing the risk that they won’t take the medicine correctly or at all, Holmboe says. “That’s the irony, right?” he says. “I don’t have the time [to explain], but you may end up paying for that in repeat visits.”

Somebody, perhaps schools or physicians or web-based tutorials, also needs to teach patients how to interact better with physicians, Kaplan says. “Doctors are half of the equation,” she says. “Patients are the other half. And patients aren’t used to doing this.” If they were, Kaplan says, women would come to appointments ready to answer the routine question about the date of their last menstrual period, and both men and women would be able to tell their doctor when the pain started.

And they’d be prepared to ask questions as well, she says. “The average patient in a 15-minute office visit asks 5 or fewer questions, and that includes, ‘where’s the men’s room?’ and ‘can you validate my parking?’”