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Wednesday, February 15, 2006 10:30 AM

Consumer/Quality Insider: Getting the Most out of a Visit with a Primary Health Care Professional

Debra: Each year over 210 million Americans of all ages visit a primary care doctor or other health professional. Some of these are for checkups or are general wellness visits; some are because the patient doesn’t feel well. But many patients don’t feel satisfied with the quality of their time with their health provider. According to AHRQ’s Medical Expenditure Panel Survey, nearly 14 percent of adults ages 18 or older feel that their health provider sometimes or never spends enough time with them, 9 percent say their provider sometimes or never listens to them, and 8 percent say their provider sometimes or never explains things clearly to them. Sometimes the problem is with the health care provider or how the office is run. But there are a number of things that patients can do to improve the quality of the time with their provider. We have with us AHRQ Director Doctor Carolyn Clancy to discuss how to get the most out of a visit with a primary care health professional.Here’s Rand Gardner with Dr. Clancy.

Rand: Doctor Clancy, thank you for joining us. You have said frequently that patients should become and stay active participants in their own care. Can you explain what that means?

Dr. Clancy: As a physician I’m often struck by the fact that many people invest more time in preparing for a visit to a car mechanic than they do coming to a physician’s office. I think potentially because the encounter with the doctor may be a bit threatening or intimidating, people arrive, sit back and expect the doctor to be the conductor of the conversation and the visit. And many doctors are prepared to do just that. On the other hand, we know from many studies that people who play an active roll in their own health care have better outcomes. We also know that these days many health care professionals are really pressed for time and patients pick up on that signal right away. So, it’s very important to think before you go in for a visit. Jot down a few questions that you have so that you know that you’re getting your own questions answered. It’s also very important to ask, "If I think of another question on my way out the door or after I get home, who do I call?"

Rand: Most people see a nurse before they actually see a doctor. Should they provide all of their information to the nurse? Should they hold some it back for the doctor? Or should they be telling both people everything?

Dr. Clancy: That is a really, really great question. There are many offices and I, myself as a patient have been to them, where you tell your whole story to the nurse and then the doctor starts from scratch as if this never happened before. In general, that actually works in your favor because often times when recounting your medical history, you’ll think of something else to tell the doctor. But in general, you should be giving as much information as possible - what medications you’re on; what diagnoses you’ve had in the past; what types of conditions run in your family, if you know about that; and any other information including what over-the-counter medicine or herbal or vitamin supplements that you take. Rand: Giving a good history is one thing if you’re seeing a new doctor or you haven’t seen your doctor in a year and it’s just a check-up. But, if you don’t feel well and are seeing a doctor because you have current symptoms, do you need to go through any history?

Dr. Clancy: Even if you go in for a visit for a pretty acute illness - say you’ve had a fever and a cough for a couple of days - it is still important to let the physician know about your past medical history. What diagnoses have you had before, what medicines are you on and so forth. Because often times symptoms may be attributable to some of the medicines that you are already taking, or there may be something in your medical history that is relevant to the symptoms that you’re having now.

Rand: Don’t they already have the history and know what medicines a patient is taking?

Dr. Clancy: In theory a physician that you’ve been seeing on a regular basis does have your whole history and will know what medicines you’re taking. However, many people see more than one doctor and another doctor may have made changes in the medicines that you’re taking. Sometimes charts aren’t available. Or, in the modern era, the computer or network may be down. So, it’s very important that you have a copy of all of this information and can actually make that available to the doctor. In general physicians communicate with each other about your care. But, that’s often done as a matter of sending specific letters in response to a specific question. Often times you are going to be the steward of the information about you. So, in general you should err on the side of giving too much information rather than too little. Never assume that what the cardiologist told you last week is already in the internist’s personal memory bank.

Rand: Lets say a patient usually has a lot of questions when they go to the doctor but they end up not asking all those questions because they’re afraid that the doctor is going to get mad at them for taking up too much time. How should that be dealt with?

Dr. Clancy: It’s very important to prepare and write down questions. It doesn’t have to be fancy. You don’t need to bring it in on a CD or a little thumb drive or anything like that. It can be written on the back of a napkin. But, it’s important to give some thought ahead of time to what questions you have. There will be situations - for example, there’s an emergency with another patient or the doctor is hours behind by the time you even get to the office - where you’re simply not going to have as much time as you need. Having written it down, you will be able to know which of the questions are most important, and you may need to come back for another visit, follow up with a nurse, or by telephone, or some other strategy.

Rand: Well, how about the patient that doesn’t understand a lot of the medical terms that a doctor is using?

Dr. Clancy: One of the most important parts of a physician-patient relationship is good communication. And, it is a two way street. If you’re not understanding answers to questions, you need to say, "Can we back up?" or "Can we go back to the answer you just gave me? I’m not sure I get it. It sounded logical" or "I thought it made sense, but as I’m thinking about it a few minutes later, it doesn’t." It can save unbelievable amounts of time in the future. If you sit there and nod, and say, "Uh huh, uh huh," you’re waiting for the doctor to pick up on the fact that she’s not getting it at all. In which case you will have wasted more time together than would have been the case if you had simply said, "Excuse me, I need to go back a step or a couple of questions."

Rand: Well now if you start with a new physician, is it always best to start with a physical to establish a baseline with that new doctor?

Dr. Clancy: In general, there’s no rule about how you meet a new physician. Often times people are going to meet a new physician when they become ill and suddenly need to find a physician, and they call a friend/neighbor or figure out some other way of identifying a doctor, and they go in. I think it’s a great idea if you can actually make an appointment for what we would call a "Health Maintenance Exam." Where you review your medical history. Where you go over with the doctor what preventive tests you might need or not. Go over your medications, other questions that you have and so forth.

Rand: Well what about you, Doctor Clancy? Do you have a lot of patients who bring people with them to every visit to help them remember what to ask?

Dr. Clancy: I have a number of patients who come in with questions written down, and I think that’s a good thing. Even though, on occasion, when I’m feeling very pressed for time, I recognize that we may get to a point where we’re going to have to focus on the most important questions and save the rest for another visit. Many patients will bring someone with them. For example, an elderly person who may not find it so easy to move around will often have someone with them. People may bring a spouse or a family member, and I think that’s a great idea. It means there’s someone else there who’s listening, who can be taking notes, who may remember something said during the discussion that the patient - him or herself - might not remember later on.

Rand: Well here’s a question about medical pamphlets? Should you ask for information about whatever is being discussed at the appointment so that you can read up on it at home? And is there a danger that the doctor won’t tell you all you need to know there at the appointment because he’s handing you a brochure and feels he doesn’t have to explain it?

Dr. Clancy: Many people these days, actually, are doing a fair amount of reading before they even come in for a visit with the doctor which, I think, is a great idea. It’s a way to focus your mind and attention and actually refine the kinds of questions that you have - might even make you think of some that you hadn’t thought about, as a matter of reading. As a matter of policy, I think every patient should know how their physician’s practice works with respect to asking questions, answering questions that you think of after you leave the office. Other sources of literature can be very, very helpful and it’s good to know who in the practice is very good at helping you out with that. Sometimes it’s a nurse, sometimes it’s going to be the doctor. In general, I don’t rely on a brochure or a Web site or any other source of material as a substitute for having a conversation with the patient, but it’s a way to reinforce important messages.

Rand: Well, what if a doctor is suggesting a patient get some tests? What should be asked about these tests?

Dr. Clancy: Two questions to ask about all tests: one is, "Why am I having it?" The second is, "How will I find out about the results?" Many practices have completely different policies and if you don’t ask, you won’t know. In general, I think it is much better if patients, themselves, play an active role in finding out what are the results. For example, I often tell my patients when I order mammograms or do a Pap smear, you can expect a letter from me about the results. If you don’t hear from me, please call if you haven’t heard in two weeks. I often ask people as well, "What phone number can I leave the results on, and is it okay, if you’re not there, to leave a message?" "Are you the only person picking up messages?"

Rand: One last question Doctor Clancy. You’ve already said that you like patients coming in with a list of questions, but is there anything else that makes the visit go easier for you, the physician?

Dr. Clancy: I think it’s important to remember that a good physician-patient relationship is a lot like a marriage. There will be some bumps in the road, but it requires good communication on both sides. In general, what I would love from patients is - if they have a problem with something I’m telling them - that they tell me, so that I know about it. I know that some people will find that difficult to do, but if I don’t know about it, I can’t address their problem.

Rand: Dr. Carolyn Clancy, thank you for joining us.

Dr. Clancy: Thank you.

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