|One of the tenets of patient-centered interviewing suggests that it is important to make sure that patient priorities are identified and addressed with the same thoroughness and energy as other well-recognized medical priorities like hypertension, diabetes, or dyslipidemia. When presented with a patient whose medical problems include diabetes, hypertension, or dyslipidemia, it is easy to become entirely focused on achieving the necessary goals for each of these important medical problems. Within the confines of the typical 7-15 minute office visit, making sure the A1c, BP, and LDL are working their way towards recommended goals is certainly important, but are there other vital components of the interaction that might be missed? Critical issues might be neglected unless clinicians provide an opportunity for patients to indicate--at the outset of a visit--what their priorities are.
Consider the following patient: A 50- to 75-year-old Type II diabetic with comorbid obesity, hypertension, diabetes, dyslipidemia, and constipation. How might the "regular" interview go?Doc: So, Martha, I see you're back for a check of your diabetes and BP. Looks like we can get a little better on that BP, and your A1c needs to be just slightly lower, and....
Patient: Do I really have to take another medicine for my sugar, doctor?
The discussion that would likely ensue would easily use up the entire visit, and never arrive at the issue of constipation. Instead, if one were to use the patient-centered interviewing opening inquiry:Doc: Hello, Martha. Nice to see you again. Your records show that it's time for a recheck of your diabetes and BP today. Before we get started, are there any other issues you'd like to bring up, so we can best decide how we'll spend our time together today?
Martha: Well, Doctor, to be quite frank, I've been having some trouble with constipation that is bothering me. Could you advise me about that and then we can talk about the other things?
Doc: Of course. Tell me more about your constipation....
If you were to prioritize a list of topics to address from the traditional physician point of view, you might put everything above constipation. But, consider the patient's perspective. What would happen if you were to ask that patient, "What's more important to you to address? Your constipation? Or the fact that your LDL was 97? Or that your blood pressure was 132?" Experience has taught me that more often than not, the patient's priority (at least in the short term) would be the constipation.
Patient priorities should help to direct care. Too often, we end up missing the boat by not finding out what is most important to our patients. There is an unspoken process we've undertaken as clinicians in which we actually "train" our patients what to talk about. Clinicians "teach" their patients to focus on the blood pressure and the cholesterol, for instance, and don't often leave room to inquire about other issues.
Early in any interaction with the patient, it is a good idea to approach what might be called "lifestyle vital signs" such as bladder function, bowel function, sexual health, and sleep. We know that these issues are often neglected by clinicians and, for a variety of reasons, the patients may not bring them up. Sometimes they are embarrassed about an issue; sometimes they don't think the issue is important because the clinician doesn't ask; sometimes they are trying to deal with the issue themselves (eg, with home remedies). I would advise primary care clinicians to leave the door open to addressing lifestyle issues with their patients at each visit; let your patients know that these issues are important to you, and that essentially, any disorder that is a priority to them is a priority to you.
Introduce the opportunity for them to discuss these issues specifically, as well as asking the open-ended question, "Are there any other issues you would like to discuss today?" One of the ways that I have been able to save a lot of time as a primary care clinician is to help the patient share responsibility for taking the reins of control over which way the visit should go. Too often, the clinician takes full control without allowing the patient the chance to guide them.
Another time to routinely address the issue of bowel function with a patient is when they have been prescribed a medication likely to induce constipation as a side effect, or when they have become less mobile due to an injury or disease. Don't miss opportunities to bring lifestyle issues up with your patients; you'll likely uncover a lot suffering patients who will be grateful that you brought the topic up.
Louis Kuritzky, MD
Clinical Assistant Professor
Dept. of Community Health and Family Medicine
University of Florida