Julie Lord, MD
Colin Dauria, MD
Heidi Combs, MD
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2.
3.
Decide what content and circumstances
are appropriate for giving advice to
patients
Determine how directive the advice should
be
Demonstrate the skill of anticipatory
guidance in role play
 With
higher functioning patients, limit
your advice to the scope of your
professional expertise such as mental
illness, psychiatric treatments, medical
topics, etc. Don’t give advice that they
could get from others in their lives (social
conversation vs therapy.)
 For seriously impaired patients, it is often
appropriate to give advice about
activities of daily living. These folks
sometimes need help with the basics and
lack other supports.
 Try
to enhance the patient’s own problem
solving skills when possible.
 Try to avoid giving commands. Give in the
advice in such a way that the pt can reject it
without feeling uncomfortable.
 Phrase it as a proposal rather than a direct
recommendation.
 Pt:
“The cat keep me up all night again. I’m
just not getting any sleep. I feel tired all
day.”
 MD#1: “Why don’t you give cat away?”
 MD#2: “Would you consider giving the cat
away?”
 MD#3: “What are your alternatives?”
 Unneeded
advice can be annoying or
demeaning.
 Take care not to impose your personal
preferences or values on patients.
 Giving advice that is not followed weakens
the MD-Pt alliance. Pt may feel angry or
embarrassed, and MD may feel frustrated or
angry.
 Pt:
“I was laid off. A lot of us were. I
need a new job in a hurry.”
 MD#1: “You should read the classified ads
every day and read all of them, not just
the ones for the jobs you thought about.”
 MD#2: “What’s your plan for finding a
job?”
 MD#3: “Do you need any advice about
how to go about looking for a job?”
A
patient comes to you and complains that
his marriage is not happy and goes on to
describe how over the years they have
become more distant and have only been
staying together until their kids graduate
from high school. They tried marriage
counseling in the past but did not find it
helpful.
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2.
3.
Discuss how many years they have been
together and encourage him to stick it
out, better times will come.
Suggest there were probably good and
bad things about the marriage and
recommend the patient spend some
time reflecting on why they had stayed
together for such a long time
Help the patient to see enough is
enough and it is time to call it quits
before things get really bad.
 You
help the patient to consider what
problems might come up in future situations.
You anticipate potential issues and help
provide guidance on what to do if issues
arise.
 The
pt can prepare strategies for dealing
with them. Think of it like a rehearsal.
 The pt anticipates possible future situations
and becomes more familiar with them
leading to less anxiety.
 It is much easier to think about how to deal
with something when not being confronted
by it!
 Don’t
work harder than the pt.
 Be flexible.
 Quit rather than fighting with pt.
 The more impaired the patient, the more
concrete and direct the guidance
required.
 Very confident pts may not anticipate
difficulties about the proposed course of
action. Try to incorporate the message
that preparing for obstacles is a normal
part of everyday living, not a
contradiction of pt’s optimism or a putdown.
 45
yo patient with chronic schizophrenia is
really worried about discharge because he
needs to go to his case manager’s office and
then take the bus to Tacoma to pick up some
belongings. D/C is tomorrow.
 MD: “What is your plan for tomorrow
morning?”
 Pt: “I don’t know. I have to get my stuff
 Pt
cont: “from Tacoma but I don’t have any
way to get there because I left all my money
down there.” Pt appears anxious.
 MD: “Have you thought about transportation
to Tacoma?”
 Pt: “Yeah, I could take the bus but I don’t
have any bus money.”
 MD: “Do you know of any place to get a bus
token?”
 Pt:
“My case manager has them, and he also
has some money for me. I guess that I should
go to my case manager first. Maybe I could
take the shuttle over there [to HMC] to his
office.”
 MD: “That sounds like a solid plan that will
work for you [reinforcing problem solving and
building hope]. Now, are there any problems
that might come up . . .” etc
 50
yo trucker who had always considered
himself a loner, recently lost job and does
not know how to fill days. Pt knows that he
has too much free time on his hands. MD
first tried repeatedly to elicit ideas from pt
(pt had none) and then began giving direct
suggestions.
 MD: “What about volunteering at the local
animal shelter?”
 Pt:
“I don’t have enough gas to get there.
They probably don’t have any openings
anyway.”
 MD: “Are there other ways to get there?”
 Pt: “Yeah, but I hate riding the bus.”
 MD: “I am trying my hardest to help you
here, but none of my suggestions are
working. Would you like to take a break
from this topic and revisit in the future?”
 57
yo woman in treatment for depression.
She works fulltime in a professional job
and lives alone. She is starting to feel
better during the work week, but she
feels very lonely and anxious on
weekends. When she feels this way, she
stays home and ruminates about her
emotional state and negative ideas about
her future. She recognizes that she feels
better when she has structure and is
around people. Help her prepare for next
weekend. One student is patient, one is
doctor. In groups, take turns being the
doctor.
 Break
into small groups
 Each member describe an example of advice
giving or anticipatory guidance you have
done
 Discuss how the advice giving went- both the
good, the bad and the ugly!