maximizing the patient encounter strategies to provide excellent patient education emily fenton,...

Maximizing the Patient EncounterSTRATEGIES TO PROVIDE EXCELLENT PATIENT EDUCATION

EMILY FENTON, PA-S, SATF

ANTHONY BRENNEMAN MPAS, PA-C

Disclosures

Emily Fenton University of Iowa, student Student Advisory Task Force of the PAEA

Anthony Brenneman, MPAS, PAC University of Iowa, Program Director Multiple positions within the PAEA

Objectives For This Session

Define the Physician Assistant (PA) role as a patient educator

Apply communication strategies and skills that provide effective patient education

Explore the integration of specific preventative medicine/health guidelines into patient education sessions

Patient Education

Why Is It Important??

Patient satisfactionPatient complianceClinician satisfaction

Patient Education

Like all clinical skills, it takes time and practice to develop this skill!

Be an effective communicator It can be difficult to find the right words You feel like you don’t have the “extra time”

Use systematic communication strategies to maximize your interaction with the patient

Overview: 2 Strategies For Today

“SPIKES” protocolHow to break bad news – a method for

relaying the message of a negative diagnosis that will significantly alter a patient’s health, happiness, lifestyle, or even lead to their death

Motivational Interviewing How to increase patient compliance – strengthen your patient’s commitment to change a

behavior adversely affecting their physical or mental health

“SPIKES” Protocol: How To Deliver Bad News

Introduction

SPIKESSettingPatient’s PerceptionInvitation for InformationKnowledgeExplore Emotions and EmpathizeStrategy and Summary


S.P.I.K.E.S.

Setting: Private location with adequate time to deliver news

“Is there anyone else you would like to be here?”

Patient’s Perception: Patient knowledge: “What do you know about your disease?”

Invitation for Information “Would you like to know more about your illness/your treatment

options right now?”


S.P.I.K.E.S.

Knowledge Warning shot: “Unfortunately, I do have bad news to discuss with you

today.”

Give information in small chunks and “signpost” when moving to new topics

Explore Emotions and Empathize “How are you feeling?”

Non-verbal cues

Strategy and Summary “Can you tell me what I told you about your disease today?”

Schedule follow-up visit


Patient Response To Bad News

“We came back and he told me it was cancerous. It was just like my whole body went dead. I went completely numb. The doctor sat and told us things. I never heard another word he said.”

“Your mind is racing like, ‘How long am I going to be out of work?’ I am going to have to make lesson plans for 8 weeks. It also raced through my mind, ‘How did I get it? Was it because of stress or just luck?’ You want to know why you have it when there is no answer.”

Slide courtesy of Marcy Rosenbaum


Clinical Scenario

Patient is 36 yo nulliparous female who is monogamous with her husband of 4 years. She initially went to her ob/gyn PA to discuss her desire to become pregnant. However, a routine Pap test report came back as abnormal and ultimately led to a diagnosis of cervical cancer. Over the following year, she has yet been unable to become pregnant due to the aggressive recurrence of her cancer. Her PA has scheduled an appointment for today to discuss her most recent work-up, which indicates endocervical tissue margins are still positive for microinvasive carcinoma, and the best option is now radical hysterectomy.


Cervical Cancer Screening Guidelines

Bethesda system for Pap test screening: ASC-US, ASC-H, LSIL, HSIL

Histologic evaluation of cervical biopsy obtained during colposcopy CIN I, II, III

Age 21-29 Pap test only Age 30-65 Pap test every 3 years OR

Pap test + HPV co-test every 5 years

http://wcs-stl.com/wp-content/uploads/2011/09/cervix_exam.327131242_std.gifhttp://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/managing-hpv/Screening


Clinical Scenario

Patient is 36 yo nulliparous female who is monogamous with her husband of 4 years. She initially went to her ob/gyn PA to discuss her desire to become pregnant. However, a routine Pap test report came back as abnormal and ultimately led to a diagnosis of cervical cancer. Over the following year, she has yet been unable to become pregnant due to the aggressive nature of her cancer. Her PA has scheduled an appointment for today to discuss her most recent work-up, which indicates endocervical tissue margins are still positive for microinvasive carcinoma, and the best option is now radical hysterectomy.


Discussion

SPIKESSettingPatient’s PerceptionInvitation for InformationKnowledgeExplore Emotions and EmpathizeStrategy and Summary

Overview: 2 Strategies For Today

“SPIKES” protocol

How to break bad news – a method for relaying the message of a negative diagnosis

Motivational InterviewingHow to strengthen your patient’s

commitment to change a behavior adversely affecting their physical or mental health

Motivational Interviewing: Commit To Change

A Provider’s “Typical Approach”

How do we typically try to convince a patient to change problematic or unhealthy behaviors? Explain what he/she could do differently

Warn them about what will happen if they don’t change

Counsel them about how to change their behavior

Refer them to a specialist

Be frustrated by your non-compliant patient!


A Patient’s “Typical Response”

How do patients respond to being told what to do? “Paradoxical effect of coercion”:

When a provider takes up the “good” side of an ambivalent behavior, the patient is more likely to argue the other side

We tend to believe and act on what we hear ourselves say The more we hear ourselves defending our behavior, the

more committed we become to it

New approach: Actively try to guide the conversation so that it is the client rather than the clinician voicing the argument for change


4 Steps To Learning MI

1. Understand the spirit of MI

2. Learn how to ask

3. Learn how to respond

4. Learn how to really listen


The Spirit Of MI

CollaborationWith Patient

AcceptanceOf Stage

MakeA Commitment

CompassionAnd

Honesty


Your Patient’s Stage Of Change

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Relapse


Mnemonic To Ask And Respond

OARSOpen questionsAffirmationReflection Summarize


Learn How To Ask: Open Questions

Closed questions invite brief answers, e.g. yes or no: OLDCARTS – “When did you start smoking?” or

“How many ppd?”

Open questions evoke more elaborate responses: “What, if anything, has been your experience with

cigarette smoking?”


Learn How To Respond: Affirmations

An affirmation is a genuine statement that emphasizes a strength of the patient. Notice and appreciate a positive action Express positive regard and caring “I see you have tried to quit smoking before, which

I think is a great starting point.”


Learn How To Respond: Reflections

A reflection is a statement of inference, or hypothesis, about what your patient has told you Attempt to extrapolate the essential meaning of what

the patient has told you back to them The patient must respond by confirming, correcting, or

elaborating on your comment “You say you don’t see yourself quitting. So you plan to

smoke for all the rest of your days.”


Learn How To Respond: Summarize

A summary wraps up what the patient has told you Shows you have been listening carefully Allows you to end the conversation and make

recommendations for follow-up “This is what I heard you say. Now let’s plan to

address that again next time.”


Learn How To Really Listen

RULEResist the righting reflexUnderstand their motivationsListen to your patientEmpower your patient


Video Scenario


Mnemonic To Ask And Respond

How did the clinician do?OARS

Open questionsAffirmationReflection Summarize


Clinical Scenario

Patient is 55 yo with a history of poorly-controlled hypertension (170/90) who has an appointment with you, their family practice PA, for a discussion about lifestyle modification. The patient is obese (BMI = 35), eats a high-salt diet, does not exercise, and refuses to take medications regularly.

Use the OARS approach to begin a conversation with your patient about making healthy changes.


2013 ACC/AHA Blood Cholesterol Guidelines

Atherosclerosis is a primary risk factor for cardiovascular disease, including MI or stroke

Preventative statin therapy should be initiated in most patients with the following risk factors for atherosclerotic Cardiovascular Disease: Clinical atherosclerotic CV disease LDL ≥ 190 mg/dL Type 1 or 2 diabetes + 10-year ACVD risk ≥ 7.5% 10-year ACVD risk ≥ 7.5%

http://jama.jamanetwork.com/article.aspx?articleid=1791497#Results(Recommendations)


Clinical Scenario

Patient is 55 yo with a history of poorly-controlled hypertension (170/90) who has an appointment with you, their family practice PA, for a discussion about lifestyle modification. The patient is obese (BMI = 35), eats a high-salt diet, does not exercise, and refuses to take medications regularly.

Use the OARS approach to begin a conversation with your patient about making healthy changes.


Discussion

OARSOpen-ended questions: not yes/noAffirmations: positive attributesReflections: infer patient’s ultimate

viewSummarize: show you’re listening

Conclusion:Your Role As A Patient Educator

Soon you will be a practicing PA Patient education is a part of your job Understand the impact good communication

skills can have on the well-being of your patients Use SPIKES and OARS to address difficult but

common! clinical scenarios with your patients Be confident in your ability to meet the

healthcare needs of your patients

Additional Resources And Information

Next session: more on your role as an educator in your profession!

Future opportunities to learn about PA education:

Future Educator Fellowship in November 2015: small number of students + scholarship to attend Education Forum in Washington DC

SPIKES information

http://www.each.eu/teaching/resources/breaking-bad-news-experiential-module-curriculum-iowa-120613/

Motivational Interviewing information

Miller, W.R.; Rollnick, S. (2002). "Motivational Interviewing: Preparing People to Change'". Guilford press.

A special thanks to Marcy Rosenbaum, PhD and Dr. Michael Flaum, MD for their contributions of time and materials in the making of this presentation.

maximizing the patient encounter strategies to provide excellent patient education emily fenton,...

Documents

patient slide

patient knowledge

bad news patient response

patient educator

effective patient education

paea slide

patient education sessions

spikes protocol