CHAPTER 5

Skill Set Three: Delivering Diagnoses and Treatment Plans

The great enemy of communication … is the illusion of it.
We have talked enough; but we have not listened.¹
—W. H. Whyte

At the end of a busy clinic session, Dr. Brash angrily heads back to his office. He slams down his stethoscope and exclaims, “Why are patients always so noncompliant? Why don’t they do what I tell them to do? They just don’t want to be helped!”

“Sounds frustrating,” says his colleague sympathetically. “What happened?”

“One of my patients, Ms. Jones, clearly has the classic signs of clinical depression and anxiety. She’s even having panic attacks. Last visit I started her on an antidepressant, but this time, six weeks later, she hasn’t even touched it! I remember I went over all of the reasons she should be on it, and I even went over side effects. How does she expect to get any better if she doesn’t take the medication? I just don’t get it!”

Faulty Receiver or Transmitter?

When patients don’t do what we think we asked them to do, we have a tendency to label them as “noncompliant” or “difficult” patients. We blame them for not following the treatment plan that we feel we clearly laid out for them—in other words, we accuse the receiver of being faulty. Certainly, we could attribute the lack of adherence to Ms. Jones’s underlying depression or blame the patient for not doing what she was “supposed” to do.

On the other hand, this may not be completely the patient’s fault. For instance, did we discern whether the patient was on board with the plan in the first place? Did the patient even understand what we told her? Did we explore what her concerns might have been about the diagnosis or treatment plan? Despite all of our wishes to the contrary, and as painful as it may be to admit, it is the messenger—or the transmission of the message—that is sometimes to blame.

To address these questions, let’s rewind and take a peek into the conversation that Dr. Brash had with Ms. Jones on the first encounter, when he initially raised the idea of prescribing an antidepressant medication. Ms. Jones had presented to the clinic with fatigue, insomnia, poor concentration, and episodic palpitations and chest tightness, sometimes associated with shortness of breath.

Dr. Brash: Ms. Jones, I’m going to prescribe a medication for you that will help you feel better. It’s an antidepressant and should also help with the anxiety. You should start taking half a pill in the morning, and then after a week, as long as you don’t have any side effects, you can go up to a full pill. The most common side effect is feeling a little jumpy, which is why I want you to take it in the morning—but this is only at the beginning and it wears off as you continue to take it. Sometimes there’s some diarrhea or a little bit of nausea that goes away, and then sometimes some sexual side effects. I’m going to send it straight to your pharmacy so you can start taking it tomorrow, and I’ll see you back again in six weeks to see how you’re doing. Any questions?

Ms. Jones: Uh, I guess not.

Ms. Jones (as Dr. Brash prepares to leave the room): But what about my heart?

Problematic Signal Transmission

Dr. Brash indeed made a critical diagnosis and covered important aspects of starting a medication, including the dosing, timing of administration of the medication, side effects, what to expect, and follow-up interval. He likely believes that he has done a thorough job explaining to the patient what to do. However, he delivered all of this important information in a download—an all-too-common, and usually ineffective, communication style. It mirrors the educational process of many clinicians, who traditionally have passively sat in auditoriums being lectured at for hours. That is what “education” was. It is no wonder that we think that “educating” patients involves a similar dynamic.

What we emphasize as being important, in addition to how it is taught, has an impact as well. We spend our entire training learning how to make the correct diagnosis and hone our medical decision-making to implement the proper treatment. We congratulate ourselves when we have clinched the diagnosis and consider ourselves smart when we know the appropriate management strategy. In other words, the emphasis is on making sure the content of the message is accurate. And we tell patients everything in the message without thinking as much about how the message comes across.

However, making the correct diagnosis and knowing how to manage the illness, while necessary, is not sufficient. What we sometimes fail to realize is how all of that information lands on the patient. Is the information digestible? Is it something the patient understands? From Ms. Jones’s point of view, she was not given a chance to see how her fatigue translated into a diagnosis of depression, and how the medication would help her feel better. Neither did Dr. Brash explore her fears or concerns about starting a medication for depression and anxiety, or her personal thoughts that her symptoms were a sign of a heart attack, though it was clear to Dr. Brash that she was having panic attacks. In the midst of the data download, it’s a wonder that the patient returned at all! It’s like we learned Morse code to transmit our message, but we didn’t stop to check that our patient even knew Morse code. If we know what to put in the message but do not pay attention to how it is being transmitted, the patient’s health outcome is ultimately what is adversely affected. If patients don’t understand or agree with the plan, then they won’t follow through, which is, unfortunately, what happened with Ms. Jones. And we have missed an opportunity to achieve a successful treatment for the patient, despite our brilliant diagnosis and treatment plan.

Strengthening the Transmission with ART

What will maximize a patient’s buy-in to the plan and improve the transmission of the message? How can we change the conversations to maximize patient understanding? Instead of a data dump, break the information down into digestible chunks, with frequent check-ins and continued input from the patient. This approach will maximize the potential for the patient to actually follow the correct treatment plan. We often refer to this approach as “chunk and check.” One would never think, for example, to eat an entire pineapple in one mouthful: we can only chew and digest smaller chunks.

To operationalize this approach, our colleague Maysel Kemp White coined the “ART” method, which uses dialogue instead of download to convey information to the patient and ensure understanding.²

The ART method has three basic steps:

1.   Ask the patient for his or her perspective about the diagnosis or about symptoms.

2.   Respond to them with active listening and/or empathy.

3.   Tell your perspective.

The method can repeat in ART cycles, where a first series of attempts at mutual understanding deepen and repeat. For example, here is what Dr. Brash and Ms. Jones’s conversation might look like using ART to share the information about the diagnosis.

Dr. Brash: Ms. Jones, based on your history and exam, I believe that your symptoms are a sign of depression and anxiety. What are your thoughts on that? (Ask)

Ms. Jones: I guess I can buy that. But what about my heart? I mean, these chest pains and heart racing are really scary! Is depression and anxiety actually causing these symptoms? Can depression cause a heart attack?

Dr. Brash: I can definitely see why you thought you were having a heart attack. Chest pain, heart racing, and shortness of breath can be very scary. (Respond) I can tell you, though, that you are young and otherwise healthy, and have no risk factors for heart attack. In these circumstances, your symptoms of chest pain and heart racing are a symptom of the anxiety you are feeling and are very typical for a panic attack. (Tell) What do you know about panic attacks? (Ask—beginning of second ART cycle)

Ms. Jones: Is that what this is—a panic attack! I mean, I know I’m stressed, but I’ve never had this kind of reaction to stress. What do I do about it? Are you going to check me into a loony bin?

Dr. Brash: Many people who have never had a panic attack have the same concerns that you do. (Respond) I know you want to feel better, and I want to help you get there. Luckily, we will not have to send you to a loony bin in order to do so! There are a couple of other options to help you get better. (Tell) Would you like to review them now? (Ask—beginning of third ART cycle)

This conversation is more of a back-and-forth dialogue, engaging the patient by recapping the patient’s ideas and perspectives and leading to a conversation, rather than a download.

Why would we check in with our patient, when we have already made a diagnosis and treatment plan on our own?

If we know what our patient is thinking, we can get a lot of valuable information about what he or she does not know, and can spend our time filling in gaps in the information or correcting misconceptions rather than spewing information that the patient already has. This allows us to tailor the discussion to what the patient needs or wants to know.

This technique also improves the patient experience because patients feel that the clinician listened and explained things in a way that they could understand. Sharing the plan this way effectively enhances patient buy-in and increases adherence to the medical plan. Because Dr. Brash heard and acknowledged Ms. Jones’s concerns about a potential heart attack, she was much more open to the idea that her symptoms were caused by depression and anxiety.

Finally, the clinician will also feel less frustrated, not only from a sense of satisfaction that the patient is getting what he or she needs, but also as a result of an improved connection with the patient. It ultimately might even save time. As is the case earlier in the encounter, finding out up front what the patient is thinking or worrying about—this time regarding the diagnosis and treatment—cuts down on doorknob questions at the end of the visit. It also increases the likelihood that the desired outcome will be achieved because the patient will be on board with the plan and more likely to follow through.

“Treat to Target”: Outcome Is Important

At the end of the day, we want our patients to have favorable medical outcomes. Therefore, we must ensure that the transmission of our medical message reaches its target, or the correct diagnosis will be wasted. Although transmitting our messages more effectively may require an investment of time up front, it is all worthwhile when our patients understand, agree with, and follow through with the treatment plan. In comparison, consider how much time (at least six weeks) was wasted on Ms. Jones’s treatment when Dr. Brash did not confirm her understanding of the diagnosis, let alone her commitment to the treatment plan.

The same ART cycle can be applied to the remaining tasks of the interaction, which include negotiating and collaborating on the plan. Let’s see how the ART cycle is used effectively in this situation.

Dr. Brash: As I mentioned, there are some treatment options, but before I go further, I’d like to hear your thoughts about how best to manage your depression. (Ask)

Ms. Jones: I know that some people take pills. But my aunt took “happy pills,” and she was a zombie. I don’t want to be a zombie. I really want to avoid pills if possible. Do you think I can get better without medications?

Dr. Brash: I can see why you’d be worried about pills based on your aunt’s experience, and I hear that you don’t want to feel like a zombie. (Respond) I’d like to work with you to figure out a treatment that will make you feel better, not worse. (Tell) Can we talk about your options? (Ask)

Ms. Jones: Yes, I want to know what I can do.

Dr. Brash: The options are to take a medication every day for a period of months, or to talk things out with a counselor, or to do both. The score on the test that you filled out tells us that your depression is pretty severe. In these instances, we usually recommend that you take medication to treat your depression. If we were to go ahead with this, we’d be sure to choose one that doesn’t make you feel like a zombie. (Tell) What are your thoughts now? (Ask)

Ms. Jones: Well, if you put it that way … I mean, I really am sick of feeling this bad, and I want to feel better as soon as possible.

Dr. Brash: I can only imagine how lousy you must be feeling. (Respond) And I am hopeful that this will help you to feel better soon. (Tell)

Dr. Brash used three ART cycles to break down the information into smaller chunks that Ms. Jones could digest. He leveraged the ART cycles to elicit Ms. Jones’s concerns while he presented his plan. In this manner, he could address her concerns with empathy as they arose and modify his plan in a timely manner based on her input. This approach can also allow Dr. Brash to illuminate Ms. Jones’s misperceptions, appease her fears, and improve the chances that she will understand and follow the treatment plan. Because of the ART approach, Ms. Jones was more amenable to the idea of starting a medication. This is because Dr. Brash validated her concerns and expressed a desire to partner with her to make her feel better. Compared to how Ms. Jones was after the data download, she is much more engaged in this process, and Dr. Brash is constantly checking in with her to make sure she is on board.

The ART cycle can be used as many times as needed to review all aspects of the plan and until all of Ms. Jones’s concerns have been elicited and addressed.

“Teach-back” to Ensure Proper Two-Way Transmission

ART can even be used to assess the patient’s understanding of the plan, which often takes the form of a teach-back. If the patient can teach the plan back to us, then we can check for accuracy and understanding, and correct any errors.

Dr. Brash: I know I did a lot of talking just now. Just so I know I made myself clear, tell me what you will do when you go home. (Ask)

Ms. Jones: Well, I’m going to start this pill once a day in the morning, but I’m going to take the lower dose for one week, and then I’ll start the higher dose if I’m not having any of the side effects that you mentioned.

Dr. Brash: That’s right. (Respond)

Ms. Jones: And you said I’m not going to feel better right away, that I have to stick with this for at least a few weeks before I start feeling better. And even if I feel jittery, I should keep taking it. And in the meantime, I should call to set up an appointment with a counselor.

Dr. Brash: That’s right also. I know you are nervous about this, (Respond) so we will set up a follow-up appointment in a month to see how you are doing. But if you do start feeling those side effects we talked about or have any questions at all, I want you to give me a call before then. (Tell) How does that sound? (Ask)

Ms. Jones: As long as I can call you if anything goes wrong.

Dr. Brash: Absolutely. (Respond)

In this outpatient-based example, imagine the time you might save answering follow-up phone calls from patients because they walked out of your office confused. This approach also strongly benefits our colleagues in inpatient and emergency department settings, who might otherwise field extra questions or pages from ancillary staff because the original plan was unclear. In fact, this approach works very well in many settings and when used by any healthcare clinician. As an example, a few weekends later, Ms. Jones makes a trip to the emergency department because she has had a particularly severe recurrence of palpitations, chest pain, and shortness of breath. The nurse practitioner in the emergency department performs appropriate studies, confirms that the patient does not have a cardiac cause of her chest pain, and relays the diagnosis to the patient.

Nurse Practitioner Miller: I have all of your studies back, including chest x-ray, EKG, and lab work, and I’m happy to tell you that you have not suffered a heart attack. Your symptoms are most consistent with a different kind of attack—a panic attack. Have you ever considered that that might be the cause of your symptoms? (Ask)

Ms. Jones: Actually, my doctor told me the same thing, and he started me on a medication, but it’s been taking so long, and I was worried again about my heart, so my mom told me to come in.

Nurse Practitioner Miller: I’m glad you did. (Respond) I do think it would be a good idea to treat the anxiety that is causing these panic attacks. (Tell) I assume that is why you are on the citalopram.

Ms. Jones: Yes. He did warn me it would take a while to start working, but this last panic attack, as you call it, was worse than ever. He mentioned I could take lorazepam to ward it off when it happened, but I don’t want to take that pill.

Nurse Practitioner Miller: What are your concerns about taking lorazepam? (Ask)

Ms. Jones: My aunt took it for a while and it made her a zombie. I don’t want that. It seems too strong.

Nurse Practitioner Miller: I can understand why that would make you want to avoid the medication. (Respond) On the other hand, we need to help you manage the panic attacks when they happen, until the citalopram kicks in. Another option would be to talk to a therapist who can help you with stress management and biofeedback. (Tell) What do you know about managing anxiety using these techniques? (Ask)

Ms. Jones: I told Dr. Brash I would call for an appointment with a therapist, but I just haven’t gotten around to it yet. I thought maybe the medicine would kick in before then. Do you think that would help?

Nurse Practitioner Miller: I can see why you wanted to wait to see how the medication would work. (Respond) Yes, I do think it would help, not only with talking through your problems but also specifically with managing the symptoms of the panic attack when they come on. (Tell)

Ms. Jones: OK, I will call when I get home.

Here, Nurse Practitioner Miller uses the ART technique to notify Ms. Jones of the diagnosis, explore barriers she has about the proposed treatment plan, and explore potential solutions with her. What’s more, ensuring understanding of the plan has been shown to improve healthcare outcomes including blood pressure control, cholesterol control, and diabetes control.³ The teach-back technique has specifically been shown to be associated with reduced errors in medication dosing.⁴ Finally, this type of approach proves more satisfying not only for patients, but clinicians as well, thus achieving a triple aim of patient satisfaction, patient outcome, and clinician satisfaction.⁵ On her follow-up appointment with Dr. Brash several weeks later, Ms. Jones reported that she had been taking her citalopram daily, had felt an improvement in her depressive symptoms, and, with the help of a therapist, had learned some biofeedback techniques to help manage her anxiety episodes as they were occurring.

Conclusion

Skill Set Three involves giving information about diagnosis and treatment to a patient in a way that makes it more likely for him or her to buy into and follow through with a therapeutically successful plan. The “magic” used to achieve this important task involves using the ART technique of Ask, Respond, Tell: breaking the information about the diagnosis and treatment plan into digestible chunks and checking with the patient frequently to ensure understanding of and collaboration on a mutually agreed-upon plan. We will see further examples throughout the book about how this fundamental technique can strengthen understanding in such disparate applications as challenging conversations, motivational interviewing, feedback, coaching, and team communication.