Patient-centered care from admission to discharge
How to improve bedside visits
By Naveed Sheikh, MD, ACP Member, and Dorothea Wild, MD, ACP Member
When primary care physicians admit their patients to the hospital, they have an advantage of pre-established trust, and sometimes a decades-long relationship with the patients and family. Patients feel secure, thinking “My doc knows me.” Hospitalists do not have this long-term relationship with their patients, and are left with the challenge of establishing a trusting and therapeutic relationship in just a few visits.
The majority of a hospitalist's time is taken up by admissions, writing orders, communicating with consultants, following up with test results, and discharging patients. Trust-building, addressing the patient's and family's concerns, counseling, and safe discharge planning are all time-consuming. On average, hospitalists care for 10 to 25 patients each shift. That leaves on average only 10 minutes or less for talking to each patient at the bedside. These time constraints may lead to poor patient-physician relationships and less trust.
Courtesy of Dr. Sheikh.
Given the time constraints, it is hard to increase the amount of time spent with each patient. Improving the quality of available bedside time is the only workable alternative. To this end, better communication is vital.
Many hospitalists spend a lot of time on new admissions or discharges, but scrimp on follow-up visits. A “routine” follow-up visit may just involve a brief chat regarding new and existing symptoms, and a brief examination, followed by an even briefer explanation of the plan of care for the day. Such a visit may leave many patients unsatisfied.
Courtesy of Dr. Wild.
While many checklists or guidelines have addressed the outpatient visit, there is much less information on how to structure an inpatient visit. We propose a more patient-centered structure of the hospitalist follow-up visit based on the existing model of patient-centered interviewing developed by Robert C. Smith, MD, FACP. It has helped us to enhance communication and trust in a time-efficient way.
The patient-centered hospitalist visit
Below are the steps we recommend to help establish a patient-centered follow-up visit.
1. Introduction and greeting
It is extremely important to identify yourself as the point person to discuss any problems or concerns. In most hospitals, patients are seen by many caregivers. Nurses, residents, students, specialists and hospitalists all weave in and out of the room all day. Phlebotomy technicians, radiology technicians, and pharmacists may also be wearing white coats. It is common for patients to be very confused about who is who, and to whom to turn if they have a problem or concern.
- Each day introduce yourself by your name, even if you think that the patient probably knows you.
- Introduce your role in the patient's care every day.
- Hand out your business card every day if you don't see it on the bedside table.
- Good morning, Mr. Jones. My name is Dr. Sheikh. I am in charge of the team taking care of you.
- Good morning, Mr. Jones. My name is Dr. Sheikh. I am your primary doctor taking care of you during your stay in the hospital.
- Good morning, Mr. Jones. My name is Dr. Sheikh and I am covering for your primary doctor while you are in the hospital.
2. Take a seat and listen carefully
The hospitalist's posture and verbal and non-verbal cues should reassure the patient that the hospitalist is not in a hurry and is listening carefully. A study in the July-August 1998 Family Practice Management indicated that patients perceive a doctor has spent more time with them if the doctor sits during the visit.
- Be at the same eye level as the patient. Take a seat and look comfortable.
- Use verbal cues such as “hmmmm,” “OK,” etc.
- Use non-verbal cues such as facial expressions, leaning a little forward when listening, head movements, etc.
- Look at your watch.
- Talk while you are walking out of the room.
- Interrupt while the patient is talking.
3. Negotiate the agenda
Obviously, the hospitalist wants to check in on the patient, examine and leave. However, it is not uncommon for a patient to say: “By the way, I have one more question for you” as the hospitalist is about to leave the room. This moment is well known to our outpatient colleagues as a “doorknob moment.” From the patient's standpoint, the issue is often of great importance, and may take a significant amount of time to address. The issue may be the patient's own health, a complaint about the care received, worries about the discharge plan, or anything else going on in the patient's life. The patient may be worried about an unattended elderly parent at home, a pet at home without food, a utility bill that needs to be paid on time, or even a scheduled court hearing. The patient may be angry because of the noisy medical unit at night, a “nasty” night nurse, a prolonged ED wait or a cold room. Getting the patient's full agenda early in the visit, before attending to the doctor's agenda, may reduce the risk of last-minute questions. The hospitalist may or may not be in a position to resolve every issue directly; however, talking about the patient's concern may build trust in the relationship.
- Explain why you are in the room, what you will discuss, and what you will do in the next few minutes.
- Ask patients if there is anything else on their minds that they want to talk about.
- “Wring out the towel” by asking several times for other agenda items.
“Mr. Jones, in the next few minutes I would like to talk to you about the progress you made since we met yesterday. I will briefly examine you, go over the results of the tests available and then we will talk about your diagnosis and plan of care. Is that OK with you? Is there something else on your mind we need to talk about?” [Patient answers.]
“I'll be happy to talk about this in a minute. Is there anything else you want to talk about? Anything else?”
4. Relevant follow-up history and examination
Detailed explanation of follow-up medical history-taking and focused follow-up examination is beyond the scope of this discussion. We suggest review of relevant literature regarding patient-centered interviewing and rational clinical examination.
For many patients, being admitted to the hospital means struggling with a life-threatening illness. Patients can be scared, anxious, worried, frustrated, and depressed. It is extremely important for the physician to completely understand the underlying emotion that may manifest as anger, agitation or nervousness. Empathy provides a very strong base for building a relationship
Actively look for verbal and non-verbal cues for emotions throughout the encounter (these are called empathetic opportunities). Promptly and empathically respond to any such expression with a method called NURS, outlined by Dr. Auguste Fortin in the Fall 2002 Ethnicity and Disease. The acronym stands for Name the emotion, Understand, Respect and Support. If the patient doesn't demonstrate an emotion or volunteer a feeling, ask “How are you dealing with this?” or “How does this make you feel?”
(Name the emotion) “Mr. Jones, you look ______ [nervous, unhappy, upset, or other appropriate emotion].”
(Understand) “I can understand how you might feel that way.”
(Respect) “This has been a tough time for you.”
(Support) “Let's see what we can do to make you feel better.” [By using “we,” you share the responsibility with the patient.]
6. Explore the patient's understanding
Patients may have their own views about their medical problems. They may attribute medical complaints to an irrelevant issue or a medication. It is extremely important to grasp the patient's own understanding to address issues appropriately. Even if you do not agree with the patient's opinion, reassure him that he has been heard. Respecting a patient's views may provide an opportunity for building trust.
On the other hand, if a patient accurately knows the diagnosis and plan of care, the hospitalist may not have to spend any extra time explaining this.
“Mr. Jones, what do you think caused your problem?”
Summarizing your history and examination findings may provide an opportunity for the patient to amend or volunteer more information. Explain the diagnosis and plan of care. This part may be skipped if the patient has demonstrated accurate understanding of his own medical problems and plan of care previously.
- Give your honest opinion about the problems and the progress.
- Be straightforward even if the patient is not doing well. Be sure to ask the patient if he or she is ready for the discussion, though.
- Ask if the patient wants a family member to be present for the discussion or the information to be shared with any family members.
- Assure the patient that the information will be conveyed to the primary care physician who will follow up on the issues after discharge from the hospital (most important for a major new diagnosis like cancer).
- “Mr. Jones, I have the results of your biopsy. Are you ready to talk about the results? Do you want a family member with you when we talk about the results?”
- “Mr. Jones, I will let your primary care doctor know to follow up on your biopsy results and arrange an early meeting with you.”
8. Teach back
Most patients will not reveal if they did not understand what you said. Instead they may ask the nurse or a family member: “What did the doctor say?” Hospitalists may overestimate the patient's understanding. Factors including the patient's education level, social and cultural background, undiagnosed dementia or delirium, and the physician's accent may affect comprehension.
- Always ask patients to teach back—i.e., to demonstrate that they understand what you have told them.
- Be careful how you word your sentences. Poorly composed sentences may make patients think that the hospitalist considers them uneducated or even dumb.
- “Mr. Jones, let's recap. Would you mind telling me what you understand about the diagnosis and plan of care? I just want to ensure that both of us are on the same page.”
- “Mr. Jones, if your wife asks you ‘What did the doc say?’, what are you going to tell her?”
9. Closing the encounter
- Close the encounter gently. Tell the patient what to expect next.
- Try closing on a happy note if possible. Show optimism when the patient is doing well.
- A simple gesture like tapping the patient's toes gently or softly rubbing your palm against the patient's shoulder may leave a very warm feeling with the patient.
- Provide the patient with the opportunity to ask more questions.
- Say goodbye and walk slowly while leaving the room.
- “Is there something else you want to talk about?”
- “Is there anything else we should talk about?”
- “What other questions do you have?”
How to integrate these steps into practice
Adapting to a new style of practice is never easy. The suggestions above may appear to be a lot to do, but most of them are just simple gestures that do not take much extra time. Initially, we suggest that you keep a written checklist with you as a reminder. Once you have developed your own routine and phrases, you will be able to follow this model without resorting to a checklist. In our experience, after about two weeks one does not need to carry the checklist, and the hospitalist does not need to make any conscious effort in deploying this model during rounds.
Once the checklist becomes ingrained in a hospitalist's routine, encounters will run more smoothly, and she will be able to establish better relationships with patients. While some of the suggestions may be difficult to grasp at first, they save time in the end. For example, airing patient concerns as they arise cuts down on headaches on discharge day. An excellent physician-patient relationship provides a base for improved patient satisfaction, an overall better hospital experience, and a safer discharge.
Drs. Sheikh and Wild are ACP Members and hospitalists at Griffin Hospital in Derby, Conn.
Follow-up visit checklist
Greet patient and introduce yourself.
- Provide your name and role in the care.
- Introduce yourself every day.
Take a seat and listen carefully.
- Provide verbal cues (“hmmmm,” “OK,” etc).
- Provide non-verbal cues (eye contact, sit at patient's eye level, attain a comfortable posture, lean forward while listening).
Negotiate the agenda.
- Explain why you are in the room, what you will discuss, and what you will do in the next few minutes.
- Check whether the patient has her own agenda.
Conduct relevant follow-up history and examination.
- Empathy is appropriate at any time during the encounter.
- Remember NURS (Name, Understand, Respect and Support).
Explore the patient's understanding.
- The patient may have her own theory of etiology.
- Respect the patient's opinion and reassure that she has been heard (even if you do not fully agree).
- Review your findings, assessment, progress and plan of care with the patient.
- Ask the patient if she is ready for the discussion or wants a family member to be there.
- Reassure the patient there will be a smooth transition of care to the primary care physician, with timely transfer of medical information and signout.
- Ask the patient to demonstrate what she understands about the diagnosis and plan of care.
Close the encounter.
- Try to close the encounter on a positive note.
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