Integrative Medicine Office Visits: Avoiding Patient Overwhelm and Meeting Patients' Needs

The Basics

Kathy Cole-Kelly, MS, MSW, and Prof. Emerita, Case Western Reserve University School of Medicine Cleveland, Ohio, commented in an interview that there are two keys when optimizing clinician–patient communication, and they are (1) agenda setting and (2) “teach back.” Cole-Kelly stated: “Being patient centered rather than doctor centered means that clinicians will let the patient set the agenda or collaboratively set the agenda.” When a clinician starts a conversation with a patient such as “Hello, what brings you here today?” the patient may respond by saying, “I'm worried about my high blood pressure, a pain in my foot, and I have a lot of stress at work.” The clinician may then say, “Is there anything else?” and wait for a response. After this initial discovery discussion the physician may say, “You've mentioned several things. Why don't you tell me the order of importance of the things you mentioned in your mind. I'm not sure we can get to all of them today, but let's talk about the priorities as you see them and then I will share the priorities from my perspective.”

Cole-Kelly said that after agenda setting and the physical examination, another way to make sure a clinician is not overwhelming their patients is to use teach back, which has been highly recommended by academic organizations for medical curriculum. Cole-Kelly stated, “As one is nearing the end of the appointment, the clinician may say, ‘We have talked about a lot of things today, and I want to make sure we are on the same page. When you go home today, what are you going to tell your family and friends that you are going to do next?’ If the patient cannot answer the question, then one possibility is that she or he may be feeling overwhelmed.”

Cole-Kelly concluded that agenda setting and teach back are two of the tried and true communication skills for not overwhelming patients. She also said the discussion about how not to have patients overwhelm doctors is another important topic.

Step by Step

Laurie S. Sadler, MD, an internist and previous principle site investigator at a dedicated National Institutes of Health (NIH) sponsored Action to Control Cardiovascular Risk in Diabetes (ACCORD) site at a community hospital in Cleveland, Ohio, is an expert in seeing people with chronic problems and using an integrative approach. In an interview, Sadler commented: “Visits with people who have chronic problems can be overwhelming for both clinicians and patients. Rome wasn't built in a day, and particularly when people come in with multiple problems it is going to take time to address their issues. I explain to patients where conventional medicine begins and where it ends and tell them that what they feel can't always be addressed or explained by conventional medicine. What can be significantly influenced is: what and how one eats, physical activity and exercise and duration and quality of sleep—all of which can play a role in how a person feels.”

Sadler continued, “In our clinic, there were patients who had diabetes from a year to 20 years, and one might expect them to know a lot about their disease. But I learned that clinicians have to start at the beginning with every single patient in discerning what their patients' understand and perceive. Do they know what a carbohydrate is?” She added: “I thought patients knew about health and wellness, but the vast majority of times the patients could not explain how or why they were sick. So first I would discern their minimal level of understanding, and assess safety by asking questions such as “Have you ever experienced low blood sugar and are you aware of the symptoms?” “Does your blood sugar fluctuate?” etc.—understanding what the patient understands is critical.”

Sadler said that she writes the things down that she is telling the patient and then makes a copy and gives it to them. Then when the patient returns, together they can discuss “So how did that work for you? What were you able to accomplish?” Sadler said, “It's important to give patients the ability to manage themselves.”

Follow-up is also critical to help patients avoid overwhelm. Sadler said, “I proposed follow-up phone calls with certain patients and often found that there were significant problems between what you thought they were going to do and what they were actually doing and understood.” In this case, Sadler said clinicians can ask patients to provide a detailed record of their health issues/habits/medications over the course of a single day, and this helps clinicians recognize the small details in regard to how to optimize patients' health and safety. Sadler reported, “The truth is, it takes time to not overwhelm patients. One has to take things step by step.”

Clinicians often have different trainings and beliefs about nutrition, exercise, and physical activity, and the role of these areas in a patient's health and how to get patients engaged in heathier habits. Sadler recommends having patients write down foods they like to eat and can afford to buy and work off of that list when making nutritional recommendations. She said, “Ask the patients directly, ‘What will you eat and what can you eat?’ Remarkably if you have an involved patient, you can achieve a lot with that person.” For example, Sadler stated that in people with high blood pressure and diabetes, a few successes make a huge difference in buying in to what you are teaching them. Sadler stated, “Ask them what they are willing to do; however, clinicians have to remember that they must be patient because change may take a long time with some of these patients.”

Another point of potential overwhelm for patients are extensive history forms and questionnaires, which can be very helpful for clinicians, but also frustrating for patients. Sadler recommended, “Break the questionnaire down into specific categories and make sure the patient receives it well ahead of their scheduled visit. Over the course of a number of visits, clinicians can begin to address the results of the questionnaire.” Sadler continued: “As soon as I explain what I want patients to do, I have them state back to me what I explained—almost always they remember the first few words, but not the rest of the sentences. Speak slowly, use pictures/graphs. Set realistic goals. Not just a goal they can make on their own, but ask what their expectations are of what a clinician can help them achieve. The doctor-patient relationship should be a partnership.”

Creating a practice plan

One of the things that I, the author, eventually did in my private integrative medicine consultation practice was to set my practice up such that I required patients to commit to a minimum of 6 one-hour visits over the course of two or three months. This really helped patients know if my practice was right for them and if they wanted to commit. I also started out with a 20-minute phone call before seeing the patients to explain how I worked and this, too, helped determine who was going to be a right fit. Some patients were eager to get started and others thanked me for explaining and felt that this was not for them.

Allowing for a series of visits helped set the pace, avoid overwhelm and the majority of those patients either received what they needed in those visits or continued to see me in practice for many years. Six visits allowed for a preliminary discussion about various aspects of a person's care that may benefit them. It is an introduction to healthy lifestyle behaviors and complementary therapies. Some clinicians try to make that introduction in one visit and that is a burden for both the clinician and patient. Clinicians and patients can benefit when there is an initial plan in place for getting to know each other and assessing how complex the problems may be that need to be addressed and then seeing how the patient would like to proceed. This also takes a great burden off of the clinician who in decades past felt they had to preach and cajole to get patients to do what they believed is right for the patient. That is a very different approach from patient-centered care.