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Voices of Geisel

Helping patients speak up

By Dale Collins Vidal, MD

First, let's look at the facts. The average patient visit with a doctor lasts 11 minutes. During that average visit, the doctor will interrupt the patient 12 seconds after entering the room and repeatedly thereafter.

These interruptions haven't always been considered a bad thing. In fact, I was trained as a medical student to interrupt patients so that we could quickly focus on the many questions we viewed as important. That approach, however, does not leave much room for patients to be heard or to reveal the issues that are most important to them.

And what matters most to patients? According to research over the past 20 years, their top three concerns are doctors' uncaring attitudes, the dismissal or trivialization of the patient's voice, and a lack of information.

Dale Collins Vidal is a professor of surgery at Geisel and chief of plastic surgery and medical director of the Center for Shared Decision Making at DHMC.

These are three huge problems for health care. How do we restore empathy to the physician-patient partnership? What does it take for patients to be heard? How can they insert themselves into the conversation? Where can they go for better information on their health and health care?

There are no easy answers to these challenges, but there are things we can do to help patients to be heard. Getting the patient's voice into the office visit requires that 1) physicians provide the psychological space for patients to enter the conversation; 2) patients have sufficient understanding of their condition to talk meaningfully about treatment options; and 3) the patient and the doctor discuss together what is important.

There are many ways to support patient engagement in health-care discussions. One is to provide them with good information for them to review outside of the clinical consultation. This way, patients come armed with knowledge and are more confident in discussing complex topics with their doctors.

At Dartmouth-Hitchcock, a number of clinical areas are using videos called decision aids to help patients. These helpful tools cover more than just static information about the specific condition and treatment choices. They include testimonials from actual patients who have previously chosen the different treatment options and how they feel about their outcomes.

In some instances, we are able to couple these tools with support from volunteers who help patients structure their questions in a one-page summary before the visit with their doctor. This program is called the Patient Support Corps (PSC). In addition to helping patients create the question list, the volunteers accompany patients to their visits, make an audio recording of the discussion, take written notes, and use these notes to update the question list with the answers provided in the consultation. Patients are given the audio recording and updated question-and-answer list at the end of the visit for review later.

The PSC is a highly effective strategy for getting the patient's voice into the room. It is right there in black and white on the question list—even if the patient never says a word. Interestingly, however, the question list seems to be an impetus for patient engagement. I have seen patients who would normally be reticent to speak participate fully in a discussion of treatment choices. Patients tell us that their question list is comforting to have and that it allows them to relax and not worry about trying to remember what they wanted to ask.

So who are these volunteers? Currently they are either Dartmouth College undergraduates who are interested in pursuing medicine or Geisel medical students. These students are carefully trained to provide support for patients but to not provide clinical information themselves. The experience helps patients navigate a difficult situation and helps students develop more caring attitudes for patients that they can take with them into their future practices. The quote below, from a fourth-year student at Geisel, is typical of the kinds of comments our student volunteers make.

"While working with the PSC, I talked with patients about their priorities, support systems, preferences, and even their fears. I connected with them on a very personal level. This can be difficult to learn later on in more demanding contexts, such as third year, fourth year, and beyond and can be lost if not learned early. Having had these experiences early on influenced how I communicate with patients and will be part of the foundation I have in how I connect and interact with patients throughout my medical career."

The PSC manages to tackle all three of patients' top concerns—a lack of caring attitudes, the trivialization of the patient's voice, and a lack of information. We need to continue to innovate and to design systems to support patients. Understanding what matters to patients matters.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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