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Getting the most out of a visit to the Doctor

Given all the obstacles that prevent us from getting to the doctor’s office — scheduling an appointment, digging out the insurance card and plain old procrastination — it is good health sense to make the most of your time when you are finally face-to-face with your health care provider.

Easier said than done, says health researcher Sherrie Kaplan.

"I am happy when a patient comes in and has read some information about their illness and has some questions. You feel stimulated, you are on your guard and you are more careful."
- Dr. Francesca Dwamena

“We’re in various states of undress, we are nervous, naked and we didn’t prepare. What a setup for a performance fiasco,” says Kaplan, associate dean for Clinical Policy and Health Services at the University of California Irving School of Medicine.”

Kaplan says the lifetime probability of being a patient in the United States is 100 percent, so each of us should practice for “effective patienthood.”

Kaplan studies interactions between patients and physicians. According to her research there is a teachable window for patients just before they are called into a medical appointment..

“In the 20 minutes when patients would normally be reading a magazine, our researchers showed them their medical records and guided them through a diagram of how their disease is going to be managed, then we sharpened up their questions,” Kaplan says.

“We call it coached care. We try to tell patients: Go in prepared, think of those three things you want to get out of the encounter. But also be flexible, understand what’s going on, be there in the moment and ask questions,” she says.

Audio recordings revealed that coached patients and doctors communicated more effectively. Kaplan’s team also found improvements in some health markers like blood glucose and blood pressure.

It is not clear just how coached care leads to better communication, and possibly better health. But Kaplan says: “We hypothesize that people who are more effective during office visits are more committed to following through on the regimen they end up negotiating with the doctor.”

Most patients do not have access to Kaplan’s coaches or any kind of patienthood training, yet the current medical system almost demands that patients to be ready to make good use of limited time with the doctor.

Negotiating a medical visit takes skills that are neither easy nor innate for most people, but research on doctor-patient interactions suggests learning those skills is worth some independent effort. Consider the alternative. Unprepared patients may waste time and money or miss vital health information.

Many health organizations have developed checklists or other tools to aid patients during a doctor’s visit, but internal medicine physician Francesca Dwamena says effective patienthood usually requires more.

“Patients who’ve been ‘activated’ with a checklist or other tools are actually less satisfied with their medical encounter, perhaps — this is a possible explanation — because they know how things should go but they don’t have the skills to achieve that goal,” says Dwamena, an associate professor in the Michigan State University Department of Medicine.

"Medical care is a conversation. So to have influence in that conversation you have to speak up."
- Health communication expert Richard Street

Dwamena and colleagues at Michigan State developed a three-session course to coach Medicaid participants on ways to better communicate with their doctors. The Michigan State strategy transcends any particular health concern.

“What we are trying to do is teach patients to communicate in general with their physicians,” Dwamena says. In addition to building communication skills, the classes were designed to promote doctor-patient relationships that can be a springboard for mutual problem solving.

The course includes role-playing as well as information on the structure of a typical medical encounter, and participants are shown videos of different models of doctor-patient interaction.

“Dwamena says many students liked the partnership model, but discovered that their actions during a doctor’s appointment did not signal that preference.

The Medicaid patients also learned how to tell their stories. “We taught them every story has three parts: bio-psycho-social. The physician needs to get the whole picture,” Dwamena says.

“The first is the physical part, which is the symptom that they came with,” she says. “There is also the personal, social context of the physical problem. Patients need to ask themselves, ‘Are the circumstances of my life affecting the symptoms of this disease?’”

Emotions are important too, Dwamena says.

Susan Beach, from Lansing, participated in the Michigan State course. The 40-year-old fast-food cashier has knee pain, high blood pressure and chronic stomach trouble.

“If I’m feeling depressed, [being aware of] that might help my doctor. Telling him what I’m going through, what’s going on in my life stress-wise, that could help him pinpoint maybe what’s going on with me. I never knew that,” Beach says.

Dwamena says one student tested her skills after the class and found that speaking up paid off. “Her doctor said he had 10 minutes, but it turned out they spent about 30 minutes and he answered all of her questions,” says Dwamena.

“The doctor was more open because she was.”

Still Dwamena admits some patients can go overboard. “If you have 15 minutes and the patient expects to cover 20 complaints, it’s pretty frustrating,” she says.

But she adds, “I am happy when a patient comes in and has read some information about their illness and has some questions. You feel stimulated, you are on your guard and you are more careful.”

Besides, Kaplan says, “Doctors will tell you about the difficult patient, the patient who was obnoxious and scooped up all the time, that’s the rare exception. Most people sit there like wallpaper.”

Communication researcher Richard L. Street, Jr., says when a patient and physician meet there are two experts in the room.

“Take the case of a clinical breast exam. The doctor has probably done countless exams and knows what’s abnormal. But the woman, if she has been doing self breast exams, she also knows what’s normal,” Street says.

Physicians and patients should strive for agreement at the end of a medical encounter, an agreement that considers the patient’s values and everyday realities, says Street, director of the Program in Health Communication and Decision Making in the Houston Center for Quality of Care and Utilization Studies at the Baylor College of Medicine.

“Medical care is a conversation. So to have influence in that conversation you have to speak up,” he says.

“A doctor may come up with a diet that says eat this, this and this,” Street says. “But different cultural groups, different backgrounds have different kinds of cuisine, things they eat and like to eat. So rather than saying, ‘Eat half a cup of rice.’ Maybe it ought to be something like ‘Let’s talk about what starches we can use.’”

“You get very little adherence to doctors’ recommendations when you didn’t get the patient’s buy-in on what will work for them,” Street says.

It is not happening widely now, but Kaplan thinks in the future insurance companies and other health payers will invest in effective patienthood training.

“If prepared patients go and use health care services more efficiently and effectively, if they follow through on doctor’s recommendations more, why wouldn’t insurance companies pay to make patients more prepared?

Otherwise services are wasted and payers are going to end up paying for more visits because patients have goofed up their health care regimens.”