Seeing Patients efficiently: Teaching strategies to improve patient care Wendy Shen, MD, PhD; Jill Endres, MD; Anne Gaglioti, MD; Alison Lynch, MD; Kelly Skelly, MD; Kate Thoma, MD; Jason Wilbur, MD Department of Family Medicine University of Iowa, Iowa City, Iowa

Objective Provide communication skills to improve clinic efficiency Help faculty develop effective teaching tools for clinical efficiency To help faculty identify learner’s difficulty in clinical efficiency (assessment) To provide education opportunities of how to use time more efficiently (intervention) Evalaute the outcome with the teaching method.

The Reality  Providing high quality care in the time allotted for primary care encounters is a major challenge.  Most of adult primary care patients have 2 or more chronic conditions  So much to do, so little time  For a panel of 2500 primary care patients 1,2  Estimate of time required to provide appropriate preventive care : 7.5h/d  Estimates of time required to provide appropriate chronic disease care: 10.5/d  1.Is There Time for Management of Patients With Chronic Diseases in Primary Care?  Truls Østbye, MD, PhD, et al Annals of Family Medicine 3: (2005) 2. Primary care: is there enough time for prevention?  Yarnall KS et al Am J Public Health Apr;93(4):635-41

Components of care affected by Time  Physician satisfaction  Risk of Malpractice Claims  Patient Satisfaction  Outcomes of chronic diseases  Prescribing practices Time and the patient-physician relationship. Dugdale DC, et al J Gen Intern Med Jan;14 Suppl 1:S How strategies for managing patient visit time affect physician job satisfaction: a qualitative analysis. Solomon J. J Gen Intern Med Jun;23(6): Epub 2008 Mar 26.

What are the most common causes for running behind during clinic session?  Faculty observation  Not clarifying goals with the patients  Collecting more information than needed  Trying to address too many issues  Not prioritizing problems  Doing nursing tasks  Lack of confidence  Limited knowledge base  Lack of pre-clinic preparation  Taking time for staffing  Resident self-assessment  Patient having multiple complaints  Waiting for patients to be roomed  Not prioritizing patients’ problems  New symptoms in follow-up appointment  “By the Way” on the way out  Talkative patient  Prolonged waiting for staffing  Setting limits on patient issues  Complicated patients

Categorization of the difficulties Pre-clinic preparation: Organizing workflow Rapport building Patients that are complicated or talkative Open the discussion and gather information Collect more information than needed Find myself having intense pressure to attend to everything New onset of symptoms in follow up Set agenda and reach agreement (Establishing and maintaining focus) Not prioritizing patient’s problems Limiting issues and talking points Closure Lack of time sensitivity/awareness New concerns while I am wrapping up

Fundamental elements for efficient clinic encounters  Pre-clinic preparation  Build the relationship: foundation  Open the discussion and screen information  Understand the patient’s perspective and shared decision making  Provide closure Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Makaul G. Acad Med Apr;76(4): Relationship, Communication, and Efficiency in the Medical Encounter. Creating a Clinical Model From a Literature Review Larry B. Mauksch, MEd; David C. Dugdale, MD; Sherry Dodson, MLS; Ronald Epstein, MD Arch Intern Med. 2008;168(13):

Rapport Building -Using non- verbal behavior -Attentive -Involving the patient (Alison & Jill) Opening the discussion and screen information Patient’s opening statement Background information Screening Initiating the session Pre-clinic Preparation Establishing initial rapport Share medical decision making Exploring the patient’s perspective Cocreating a plan and shared decision-making Closure Full summarization of issues Forward planning Providing structure -Providing Agenda setting -Topic tracking (Kate & Wendy) Providing structure -agenda setting -topic tracking Rapport Building -Non- verbal behavior -Attentive -Involving the patient Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement Makoul, Gregory PhD Academic Medicine: April Volume 76 (4) - p

How did you learn to practice efficiently in the office setting?

Workshops on the Strategies on improve clinic efficiency  Workshop1: Pre clinic preparation  Workshop 2: Rapport building and relationship maintenance  Workshop 3: Open the discussion and screen information  Workshop 4: Share medical decision making  Workshop 5: Closure

Presentation to the Department of Family Medicine  Format:  Background information  Common practice style  Helpful tips: research supporting evidence  Pitfalls  Role playing using case scenarios and pocket cards  Discussion

Presentation to the Teaching Scholars  Total attendees: 12  Three-year scholarship for community and College of Medicine faculties  Members include community primary care physicians, hospital specialists and basic medical science instructors.  Workshop 3: Open the discussion and gather information

Survey Questions  I am comfortable asking a patient to share all concerns at the beginning of an encounter  After this presentation, I feel more comfortable asking a patient to list all concerns at a clinic visit

Presentation to the Family Medicine Refresher Course: Demographic

Presentation to the Family Medicine Refresher Course  Total attendees: 35  Workshop 3: Open the discussion and gather information

Survey Questions  I typically ask patients to list all their health concerns at the beginning of the clinic visit  After this presentation, I feel more comfortable asking a patient to list all concerns at a clinic visit

Other Survey Questions  I believe these strategies will work in my clinic

Other Survey Questions  I intent to use these strategies in my clinic in the next week

Other Survey Questions  I will recommend these efficiency strategies to my colleagues.

Summary  There is a generally consensus that clinic efficiency should be a vital skill to teach  A systemic teaching approach is necessary  Workshops were well received by attendees  Continuing improvement of the materials.