Advanced Practice Provider Academy

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1 (+)Jay A. Kaplan, MD, FACEP Director, Service and Operational Excellence, CEP America, Emeryville, California; Member, Board of Directors, American College of Emergency Physicians; Immediate Past Chair, Emergency Medicine Foundation Advanced Practice Provider Academy April San Diego, CA The Patient With Multiple Complaints We have all been there. The patient in bed 4 has a chief complaint of chest pain, headache, vaginal bleeding, and I am out of my Percocet. How do you maneuver through the maze of complaints your patient has? What exactly should you work up? How do you intelligently ignore certain complaints? The presenter will offer a strategy for dealing with these difficult ED patients. Objectives: Describe an approach to the patient with multiple complaints. Discuss a method of filtering multiple complaints. Describe a method of deciphering what complaints need to be worked up in the ED. Date: 4/14/2014 Time: 9:00 AM 9:30 AM Course Number: MO 03 (+) No significant financial relationships to disclose

2 The Patient With Multiple Complaints Jay Kaplan, MD, FACEP Practicing Clinician and Director, Service/Operational Excellence, CEP America Board of Directors, American College of Emergency Physicians Provider Communication = Compliance = Quality Provider communication correlates STRONGLY with adherence rates by patients in acute and chronic disease. There are now over 100 observational and 20+ experimental studies published demonstrating the correlation of communication (patient satisfaction) with compliance. Compliance with treatment regimens has significant influence on quality measures in chronic disease and outcomes. Medical Care: August Volume 47 - Issue 8 - pp Jay Kaplan, M.D. 2014

3 What Makes A Patient Difficult? Multiple complaints Angry Demanding Chronic Pain I have seen 10 doctors and no one has helped me. What Makes A Patient Difficult? Back again... And again... And again... Needs far more resources than you can offer Jay Kaplan, M.D. 2014

4 Every Patient Interaction Has a... Beginning Middle End or seen in another way... It s about... Relationship Task Relationship The Construct of the Physician/Patient Visit The Beginning (A/I)- The first impression The Middle (D/E)- Gathering and explaining information, and the creation of a collaborative plan The End (T)- Review of information and ending strong 3 Jay Kaplan, M.D. 2014

5 How Do You Walk Into the Room? Know what you are doing and who you are meeting prior to entering the exam room Intoduce/Connect Knock, pause 2 seconds prior to entry Acknowledge everyone in the room Introduce self-role in care and experience Sit at eye level, facing the patient Non-medical query Smile and establish eye contact Use the patient s name Middle Acknowledge/Articulate Let the patient agenda/concerns drive the visit Let the patient speak without interruption (2 minute rule) Paraphrase the patient history Convey physical exam findings while doing the exam 4 Jay Kaplan, M.D. 2014

6 The Middle Part II Review A clear summary of the diagnostic impression, work-up and time-frame Clarity on what will happen next (Rx s, Discharge instructions, Follow-up appointments) Educate/Ensure Understanding What questions do you have for me? Is there anything you would like for me to go over again? Tell me what your understanding is. Multiple Complaints Let me go over what the nurse has written so you don t have to repeat yourself all over again. What is the one most important issue that brought you to us today? What is one thing we need to do for you to make this ED visit an excellent one? Excuse me... Let s take your concerns one at a time. What most concerns you? 5 Jay Kaplan, M.D. 2014

7 Angry Acknowledge the anger I can feel that you are upset and angry. Are you upset at me or at the situation? Okay, I understand. We have not met before. So be upset at the situation, just don t be angry at me. I am here to make it right for you. Demanding What are you most worried about this being? What do you think you need? Let s discuss what you want. What you want will not give you the answer you desire. This is not the best time to do that test or to give you that medicine. Here are the potential costs ($, exposure, future consequences). Negotiate a compromise call me tomorrow, etc.) 6 Jay Kaplan, M.D. 2014

8 Chronic Pain Do not walk into the room with judgment. Chronic Pain Review the medical history Print copies of previous records Review the state database; Call local pharmacy chains Consistency amongst practitioners is crucial. Here are my findings. Here is my plan. What questions do you have for me? The state Medical Board is reviewing Rx s... 7 Jay Kaplan, M.D. 2014

9 I have seen 10 doctors... Review the history you have, if any. Replace frustration with fascination. Consider yourself Sherlock Holmes. Is there anything that has missed the careful eye? Connect with body language and tone (rather than words) Suggest alternative and complementary medicine alternatives (diet, acupuncture, yoga, etc.) Back Again... Get Social Services involved. Create a special needs patient file. Talk with hospital administration regarding the cost of caring for such patients and the ROI of creating a program to dal with them. Can you make an appointment for him/her at the FQHC? 8 Jay Kaplan, M.D. 2014

10 Others What other types of patients are difficult for you? Do you want to role-play some interactions? Summary Know what you are doing when you walk in the room. Do not walk in with judgment. Be systematic. Resist jumping to conclusions. Practice your EQ as well as your IQ. 9 Jay Kaplan, M.D. 2014

11 Thanking you... Jay Kaplan, M.D., FACEP 10 Jay Kaplan, M.D. 2014

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