1. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE The following presentation contains some items that are covered by copyright and are used under Fair Use for education and the federally legislated TEACH Act. Any use for other purposes must follow U.S. copyright rules. The contents of this module are accurate at the time of publication.

2. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE

3. Patient: “I have a coupon for this new sleeping medicine. Can you please sign it so I can get samples?” 1. How might you respond to this patient? Please enter your answer below. Questions

4. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE

5. Questions Patient: “The pharmacy filled my prescription with a generic. I just don’t feel like it’s working as well.” 2. How might you respond to this patient? Please enter your answer below.

6. Communicating with Patients

7. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Objectives Identify communication challenges that relate to prescribing Describe the value of a shared decision-making model in challenging prescribing situations Use behaviors that demonstrate listening and understanding of the patient’s perspective Educate and negotiate with the patient around pharmaceutical prescribing

8. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Provider-Patient Interaction

9. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Does this sound familiar to you?

10. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Briefly describe one challenge you have in communicating with patients about prescription medications. (Please enter your answer below)

11. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Challenges to Communicating About Prescription Medications Personality types – Demanding or accepting Already “knows” what’s best – Friend, advertising, or internet Refuses to see the other perspective Language/literacy issues

12. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Communication: Self-Assessment of Skills Create a comfortable environment for patients to ask questions Give patients enough time to weigh treatment options Explain the benefits and risks for various treatment options Incorporate values into treatment decisions Identify patients’ preferred learning style and use strategies to help them retain and learn How would you rate your ability to…

13. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Shared Decision Making 1. Elicit patient’s understanding of illness and goals of treatment 2. Present options in light of patient’s goals 3. Ask a patient to state their understanding of alternatives 4. Discuss pros and cons of options (benefits, risks, costs convenience) 5. Ask for a patient’s decision (include checks for understanding) 6. If the patient cannot communicate or reason, solicit help 7. Arrange a follow-up discussion 8. Support your patient’s choice Adapted from: Makoul, et al. Patient Educ Couns. 2006;60(3):301-312.

14. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Evidence Favoring Shared Decision-Making problem and symptom resolution functional status pain anxiety Fraenkel, et al. J Gen Intern Med. 2007;22(5):614-619; King, et al. Am J Law Med. 2006;32(4):429-501.

15. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Step 1: Understand the Patient’s Experience and Expectations Step 2: Build Partnerships Step 3: Provide Evidence, Including Uncertainties Step 4: Present Recommendations Step 5: Check for Understanding and Agreement Participatory Decision Making Model Adapted from: Epstein, et al. JAMA. 2004;291(19):2359-2366.

16. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE LEARN Model Berlin, et al. West J Med. 1983;139(6):934-938. L isten E xplain A cknowledge R ecommend N egotiate

17. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Understand Your Patient –Acquiescent (accepting) –Partner (involved and informed) –Assertive (in control) Boston Consulting Group. BCG FOCUS. 2003;(Dec):1-8. Available at: www.bcg.comwww.bcg.com

18. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE LEARN: Listen

19. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE How did the provider use the LEARN model? (Please enter your answer below)

20. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE The prescriber listened attentively. A A A

21. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE LEARN: Explain & Acknowledge

22. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE LEARN: Explain & Acknowledge

23. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE LEARN: Recommend & Negotiate

24. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Was this use of the LEARN model effective? (Please enter your answer below)

25. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Shared Decision Making There are times during interactions when you as a provider may not be comfortable with the direction of the conversation There are a number of skills you can use to help reframe the discussion You may not have to use all of them in each interaction but can select what is best for the circumstances of a particular case

26. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Conflict Resolution Skills – Negative Assertion – Negative Inquiry – Fogging – Repetition Smith MJ. 1975. Bantam Books..

27. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Negative Assertion

28. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Negative Inquiry

29. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Fogging

30. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Repetition

31. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE How might you incorporate these skills into your practice? (Please enter your answer below)

32. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Key Points Patients have different needs and styles of interactions Shared decision-making can improve patient interactions, adherence and outcomes Specific models or techniques may help prescribers improve communication and shared decision-making

33. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Recommendations Talk to your patients about what level of involvement they want in their own care Ensure understanding and agreement, consider using the LEARN model Consider using conflict resolution techniques

34. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE References  Berlin EA, Fowkes Jr, WC. A Teaching Framework for Cross-cultural Health Care—Application in Family Practice. West J Med. 1983;139(6):934–938.  Boston Consulting Group. The hidden epidemic: finding a cure for unfilled prescriptions and missed doses. BCG FOCUS. 2003;(Dec):1-8. Available at: www.bcg.comwww.bcg.com  Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291(19):2359-2366.  Fraenkel L, McGraw S. What are the essential elements to enable patient participation in medical decision making? J Gen Intern Med. 2007;22(5):614-619.  King JS, Moulton BW. Rethinking informed consent: the case for shared medical decision-making. Am J Law Med. 2006;32(4):429-501.  Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns. 2006;60(3):301-312.  Smith MJ. When I say no, I feel guilty. How to cope – using skills of systematic assertive therapy. 1975; New York, NY: Bantam Books.

35. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Resources Consumer Reports Best Buy Drugs http://www.consumerreports.org/health/best-buy-drugs/index.htm Journal Watch http://www.jwatch.org/ Medical Letter http://www.medicalletter.org/ Medline (through the U.S. National Library of Medicine) http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed Attorney General Consumer and Prescriber Education Grant Program Initiated Resources Brigham & Women's Hospitalhttp://www.rxfacts.org/http://www.rxfacts.org/ Georgetown Universityhttp://www.pharmedout.org/http://www.pharmedout.org/ MGH Institute of Health Professionalshttp://www.perxinfo.org/perx.htmlhttp://www.perxinfo.org/perx.html University of Kentuckyhttp://www.cecentral.com/http://www.cecentral.com/ University of North Carolina, Chapel Hillhttp://harryguess.unc.edu/http://harryguess.unc.edu/ University of Massachusetts Medical School/http://www.umassmed.edu/meyers/index.aspxhttp://www.umassmed.edu/meyers/index.aspx Meyers Primary Care Institute

36. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Resources  Evidence-Based Medicine (EBM)  Organizational Influences on Prescribing  Pharmaceutical Development and Regulation  Pharmaceutical Marketing  Provider-Pharmaceutical Representative (PR) Communication  Links to Web-Access and Downloadable Versions Available at: http://www.umassmed.edu/meyers/index.aspx http://www.umassmed.edu/meyers/index.aspx Additional Learning Modules in This Series

37. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 1. Shared decision-making can lead to improvements in patient problems and symptom resolution. A. True B. False

38. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 1. A: True. This can include improved functional status, reduced pain and anxiety..

39. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 2. Shared decision-making can include encouragement of patient questions, providing written information and checking patient understanding. A. True B. False

40. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 2. A: True. A 2004 JAMA article outlined the steps of a shared decision-making model to include 1) understand the patient’s experience and expectations; 2) build partnerships; 3) provide evidence including uncertainties; 4) present recommendations; 5) check for understanding and agreement.

41. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 3. In the ‘LEARN’ model of patient communication, the ‘L’ stands for: A. Learn B. Logical discussion C. Listen D. Longitudinal care

42. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 3. C: Listen. Listen to what the patient says and the patient’s perception of the problem. What are the patient’s goals and values? How will this impact decision- making and care?

43. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 4. In the ‘LEARN’ model of patient communication, the ‘E’ stands for: A. Elicit B. Explain C. give Examples D. use Electronic resources

44. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 4. B: Explain. Explain your perception of the problem to the patient.

45. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 5. In the ‘LEARN’ model of patient communication, the ‘A’ stands for: A. Adapt B. Assess C. Accommodate D. Acknowledge

46. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 5. D: Acknowledge. Acknowledge and discuss similarities and differences. This helps clarify understanding and allows you to understand how to proceed.

47. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 6. In the ‘LEARN’ model of patient communication, the ‘R’ stands for: A. Repeat B. Rationalize C. Recommend D. Routine

48. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 6. C: Recommend. You can now make recommendations for treatment based on your knowledge of the patient and of the disease.

49. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 7.In the ‘LEARN’ model of patient communication, the letter ‘N’ stands for: A. Nuances B. Next steps C. Negotiate D. Navigate the system

50. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 7. C: Negotiate. The first 4 steps of the LEARN model may identify differences and similarities in your desired approaches to care. At this point you are ready to negotiate any differences to achieve a clear plan.

51. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 8.You are having difficulty communicating with a patient regarding a medication request and state “I understand that you are concerned about whether this medication will be effective in controlling your symptoms.” This statement demonstrates what technique of conflict resolution? A. Negative Assertion B. Negative Inquiry C. Fogging D. Repetition

52. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 8. A: Negative Assertion. Using this technique a provider is acknowledging the patient’s negative comment or concern. This could be a criticism of the treatment plan or the healthcare system, for example. Discussion should move on to address this specific concern.

53. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 9.In conflict resolution, the technique of ‘fogging’ refers to: A. Acknowledging a patient’s negative comment or concern. B. Prompting a patient to reflect on a specific aspect of the conflict in discussion. C. Agreeing with patients in principle without actually supporting specific points. D. Repeating a point until the patient compromises or raises a different issue or question.

54. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 9. C: Agreeing with patients in principle without actually supporting specific points. This technique works through settling tense moments without providing any new source of conflict. However, prescribers must be careful not to appear patronizing when using this technique.

55. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 10. In conflict resolution, the technique of ‘negative inquiry’ refers to: A. Acknowledging a patient’s negative comment or concern. B. Prompting a patient to reflect on a specific aspect of the conflict in discussion. C. Agreeing with patients in principle without actually supporting specific points. D. Repeating a point until the patient compromises or raises a different issue or question.

56. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Answer 10. B: Prompting a patient to reflect on a specific aspect of the conflict in discussion. For example, you might respond to your patient by asking “I’m not sure I understand why you think that medication would be better for you.”

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58. Questions Patient: “I have a coupon for this new sleeping medicine. Can you please sign it so I can get samples?” 11. How might you respond to this patient?

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60. Questions Patient: “The pharmacy filled my prescription with a generic. I just don’t feel like it’s working as well.” 12. How might you respond to this patient?

61. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 13. Did completing this module help you to describe the value of a shared decision-making model in challenging prescribing situations ? A. Yes, definitely B. Yes, probably C. Probably not D. Definitely not E. Not sure 14. Would you recommend this training module to a colleague? A. Yes, definitely B. Yes, probably C. Probably not D. Definitely not E. Not sure

62. UMASS MEDICAL SCHOOL MEYERS PRIMARY CARE INSTITUTE Questions 15. Will you do anything differently in your practice as a result of this training module? A. Yes, definitely B. Yes, probably C. Probably not D. Definitely not E. Not sure 16. Please tell us about any changes you are considering or planning: