david sun lectureuniverse-syllabi.gi.org/acg2012_16_slides.pdf · “the concept of the separation...

ACG Postgraduate Course Copyright 2012 ACG

October 2012 1

David Sun LectureHelping Your Patient by Helping

Yourself: How to Improve the Patient Physician Relationship

Douglas A. Drossman, MD, MACGCenter for the Education and Practice of

Biopsychosocial CareDrossmanGastroenterology PLLCDrossmanGastroenterology PLLC

Adjunct Professor of Medicine and PsychiatryUniversity of North Carolina

www.drossmancare.com


October 2012 2

“The concept of the separation of mind and body is dominant andbody is dominant and pervasive in Western thinking. This has had profound negative effects on research, patient care and the patient physicianand the patient-physician relationship.”

The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.

Plato400 BC


October 2012 3

Res Extensa

Res Cogitans

Descartes1637 CE

DiseaseVerifiable“Organic”

IllnessPerception“Functional”

Organic


October 2012 4

Biomedical Model: Cartesian Reductionism

EnvironmentalExposures

“PsychologicOverlay”Exposures Overlay”

BiologicalPredisposition

ClinicalOutcomes

Disease

Illness? ??

Illness Perception

Disease Verifiable

ches

t pai

n

fatig

ue

dizz

ines

s

head

ache

edem

a

back

pai

n

dysp

hagi

a

inso

mni

a

abdo

min

al

pain

num

bnes

s

Kroenke, et. al., AJM, 1989


October 2012 5

“Well, I guess that explains the abdominal pains.”

The pain stillbothers me!

Maybe he Missed it

Does this meanIt’s in my head?

Does he believe me?

My whole life is affected

I can not eat ordrink – how will

I manage?


October 2012 6

“Well, the old body checks out. Now let’s see what Doc Atkins here makes of the old mind.”


October 2012 7

ECOPING RIGHTFUL

SUFFERINGAsymptomatic ulcer

HypertensionCOPD

Cancer

AIDSDI

SEAS

E

FUNCTIONAL

Chronicback pain

FGIDs

Motility DisordersChronic fatigue

Chronic abdominal pain

ILLNESS

HEALTHFUNCTIONAL

(PSYCHOSOMATIC)

S e r i o u s n e s s o f t h e p ro b l e m F u n c t i o n a lF u n c t i o n a lOrga n icOrga n ic

MD Perceptions of Patients: Organic vs. Functional

Sat i s f ied wi th re commendat ion

He lpfu lne s s o f doctor

Re a s o n a b l e n e ss o f re q u e st

D is a b i l i ty o f the pat ie nt

00 2020 4040 6060 8080

L ike ab i l i ty o f doctor/pat ie nt

Dalton, Drossman, Clin Gastro and Hepatol, 2004; 2:121-126

% Pos i t i ve l y e n d o rs e d% Pos i t i ve l y e n d o rs e d


October 2012 8

“The results of your test were negative. Get lost!”

Cost-Effective Psychological Treatment?


October 2012 9

“To see is to forgetthe name of thething one sees ”thing one sees.”

Paul Valéry


October 2012 10

140

120

25

Acupuncture for IBS: 6 WeeksFollow-up After Treatment

IBS-SSS (sy m ptom s ) IBS-Q u a l i ty Of Life

MeanChange(+SE) from Baseline

100

80

60

40

20

15

5

10

20

0Waitlist

n=77 Limitedn=34

Augmentedn=41

35 53 108

5

07.5 7.4 16.9

Waitlistn=77

Sham AcupunctureLimited

n=34Augmented

n=41

Sham Acupuncture

Kaptchuk TJ, et al., BMJ 2008;336:999


October 2012 11


October 2012 12

listen actively

identify agenda(s)

empathize

validate feelings

set realistic goals

educate

reassurereassure

negotiate

“be there”

My symptomsDo I havecancer?

I’m undermore stress

Patient’s Agendalisten actively

identify agenda(s)

empathize

Why am I not gettingbetter?

Am I crazy?

What brought you here today?

validate feelings

set realistic goals

educate

reassure

What do you feel I can do to help?

What brought you here today?

What do you think you have?

What worries or concerns do you have?

reassure

negotiate

“be there”


October 2012 13

listen actively

identify agenda(s)

empathize

“ I can see how diff icult i t

validate feelings

set realistic goals

educate

reassure I can see how di ff icult i t has been to manage with

your pain.”

reassure

negotiate

“be there”

“I can see you are frustrated when

listen actively

identify agenda(s)

empathize

frustrated when people say this is due

to stress and you know it ’s real.”

validate feelings

set realistic goals

educate

reassurereassure

negotiate

“be there”


October 2012 14

listen actively

identify agenda(s)

empathize

validate feelings

set realistic goals

educate

reassure

Video 1

reassure

negotiate

“be there”

Validating Patient Feelings Relating to Stress

• Avoided responding to patient’s “either-or” question– “You don’t think it’s in my head do you?”don t think it s in my head do you?

• Dr. asked why patient is asking - to get more data

• Reflected back on patient concerns and validated them: “So you’re wondering by my question if I think it’s a psychiatric problem?”

• Distinguished the stigmatizing term “psychiatric problem” g g g p y pfrom “stress” a common influence on symptoms

• THEN validated patient feeling that it’s not a psychiatric problem while maintaining the plausibility of stress as a factor


October 2012 15

listen actively

identify agenda(s)

empathize

validate feelings

set realistic goals

educate

reassure

Set up an init ial mutual understanding.

reassure

negotiate

“be there”

listen actively

identify agenda(s)

empathize

validate feelingsvalidate feelings

set realistic goals

educate

reassure

Video 2negotiate

“be there”


October 2012 16

• Avoided responding defensively to challenge – “Is there something you can do?”

Patient Dissatisfaction with Care –Establishing Realistic Expectations

• Asks about patient expectations

• Acknowledges that mutual realistic goals not established on first visit

• Does not respond to nonverbal and verbal pain behaviors “I have to live with this, forever?”

• Acknowledged concerns without need to do something (“Don’t just do something, stand there”)

• Offers a realistic goal for improvement

• Elicit patient ’s understanding

• Address misunderstandings

listen actively

identify agenda(s)

empathize• Address misunderstandings• Provide information

consistent with patient ’s frame of reference

• Check the patient ’s understanding of what was

validate feelings

set realistic goals

educate

reassure gdiscussed

reassure

negotiate

“be there”


October 2012 17

• Identify patient’s worries, concerns

• Acknowledge (validate)

listen actively

identify agenda(s)

empathize• Acknowledge (validate)

them• Respond to the specific

concerns• Avoid “false”

validate feelings

set realistic goals

educate

reassurereassurances

reassure

negotiate

“be there”

listen actively

identify agenda(s)

empathize

validate feelings

set realistic goals

educate

reassurereassure

negotiate

“be there”


October 2012 18

listen actively

identify agenda(s)

empathize

validate feelings

set realistic goals

educate

reassure

Prov ide support and a l i sten ing ear.

reassure

negotiate

“be there”

listen actively

identify agenda(s)

empathize

validate feelingsvalidate feelings

set realistic goals

educate

reassure

Video 3negotiate

“be there”


October 2012 19

“Be There” for Uncomfortable Issues• Nonjudgmental - Used questions and reflections

• Addressed patient feelings “Helpless”, “Out of control” p g p ,as related to symptoms

• Reflected on similarity of current feelings to feelings generated from earlier traumatic events

• Used silence and reflection as a means of support

• Gently acknowledged options for further exploration

• Stayed with the patient, and offered availability to discuss further or to refer

david sun lectureuniverse-syllabi.gi.org/acg2012_16_slides.pdf · “the concept of the separation...

Documents