Coaching moment - The physician fears..."A patient who comes with a list of questions." A constructive reframing

An issue that arose today: “We learned to fear the patient who came to a visit with a list of questions.”

Why? We thought that this patient was excessively tuned into his symptoms. We thought we wouldn’t have time to handle his problems well. We thought his list of problems were not worth solving. We thought we could provide stellar care without knowing his concerns.

A constructive reframing: This patient prepared for the visit. This patient is less likely to raise a last minute, “doorknob moment,” concern. This patient is more prepared to take what we teach them, build on their fund of knowledge, and improve their self-care capacity, their ability to be a full partner in their care.

Picture, for example, the diabetic patient. The fund of knowledge that this patient can benefit from is enormous. Their ability to take in new knowledge is limited (See references to cognitive load theory in earlier blogposts) so we want each visit to potentially add to their knowledge and self-care skill. We want them to be thinking. We want them to be ready to absorb more. That is our leverage. Picture, for example, the “functional” patient. Have we thought about the colleague - the massage therapist, physical therapist, or psychologist - who might be capable (more capable than we are) of helping the patient move forward or are we writing that patient off? (Business people would describe the write-off as “thinly disguised contempt for the customer.” Carl Rogers would urge us to have “unconditional positive regard” for every individual we care for.

For specific information on efficient management of patients with multiple concerns (in our language, we call these patient “agendas,” a word that has no negative connotation, see Mauksch LB et al. Relationship, Communication, and Efficiency in the Medical Encounter; Creating a Clinical Model From a Literature Review. Arch Int Med 2008;168:1387-1395.)