Maximizing the Patient
Encounter
STRATEGIES TO PROVIDE EXCELLENT PATIENT EDUCATION
EMILY FENTON, PA-S, SATF
ANTHONY BRENNEMAN MPAS, PA-C
Disclosures
 Emily
Fenton
 University
of Iowa, student
 Student Advisory Task Force of the PAEA
 Anthony
Brenneman, MPAS, PAC
 University
of Iowa, Program Director
 Multiple positions within the PAEA
Objectives For This Session

Define the Physician Assistant (PA) role as a
patient educator

Apply communication strategies and skills that
provide effective patient education

Explore the integration of specific preventative
medicine/health guidelines into patient
education sessions
Patient Education
Why Is It Important??
 Patient
satisfaction
 Patient
compliance
 Clinician
satisfaction
Patient Education
Like all clinical skills, it takes time and
practice to develop this skill!

Be an effective communicator

It can be difficult to find the right words

You feel like you don’t have the “extra time”

Use systematic communication strategies to maximize
your interaction with the patient
Overview: 2 Strategies For Today


“SPIKES” protocol
 How to break bad news – a method for
relaying the message of a negative diagnosis
that will significantly alter a patient’s health,
happiness, lifestyle, or even lead to their death
Motivational Interviewing

How to increase patient compliance – strengthen your patient’s commitment to change a
behavior adversely affecting their physical or mental health
“SPIKES” Protocol: How To Deliver Bad News
Introduction

SPIKES
 Setting
 Patient’s
Perception
 Invitation
for Information
 Knowledge
 Explore
Emotions and Empathize
 Strategy
and Summary
“SPIKES” Protocol: How To Deliver Bad News
Clinical Scenario
Patient is 36 yo nulliparous female who is monogamous with her
husband of 4 years. She initially went to her ob/gyn PA to discuss her
desire to become pregnant. However, a routine Pap test report came
back as abnormal and ultimately led to a diagnosis of cervical
cancer. Over the following year, she has yet been unable to become
pregnant due to the aggressive recurrence of her cancer. Her PA has
scheduled an appointment for today to discuss her most recent workup, which indicates endocervical tissue margins are still positive for
microinvasive carcinoma, and the best option is now radical
hysterectomy.
“SPIKES” Protocol: How To Deliver Bad News
Cervical Cancer Screening Guidelines

Bethesda system for Pap test screening:
 ASC-US,

ASC-H, LSIL, HSIL
Histologic evaluation of cervical biopsy obtained
during colposcopy
 CIN
I, II, III

Age 21-29  Pap test only

Age 30-65  Pap test every 3 years OR
 Pap test + HPV co-test every 5 years
http://wcs-stl.com/wp-content/uploads/2011/09/cervix_exam.327131242_std.gif
http://www.arhp.org/publications-and-resources/quick-reference-guide-for-clinicians/managing-hpv/Screening
“SPIKES” Protocol: How To Deliver Bad News
Clinical Scenario
Patient is 36 yo nulliparous female who is monogamous with her
husband of 4 years. She initially went to her ob/gyn PA to discuss her
desire to become pregnant. However, a routine Pap test report came
back as abnormal and ultimately led to a diagnosis of cervical
cancer. Over the following year, she has yet been unable to become
pregnant due to the aggressive nature of her cancer. Her PA has
scheduled an appointment for today to discuss her most recent workup, which indicates endocervical tissue margins are still positive for
microinvasive carcinoma, and the best option is now radical
hysterectomy.
“SPIKES” Protocol: How To Deliver Bad News
S.P.I.K.E.S.


Setting:

Private location with adequate time to deliver news

“Is there anyone else you would like to be here?”
Patient’s Perception:


Patient knowledge: “What do you know about your disease?”
Invitation for Information

“Would you like to know more about your illness/your treatment options
right now?”
“SPIKES” Protocol: How To Deliver Bad News
K.E.S.
S.P.I.



Knowledge

Warning shot: “Unfortunately, I do have bad news to discuss with you
today.”

Give information in small chunks and “signpost” when moving to new
topics
Explore Emotions and Empathize

“How are you feeling?”

Non-verbal cues
Strategy and Summary

“Can you tell me what I told you about your disease today?”

Schedule follow-up visit
“SPIKES” Protocol: How To Deliver Bad News
Patient Response To Bad News
“We came back and he told me it was cancerous. It
was just like my whole body went dead. I went completely
numb. The doctor sat and told us things. I never heard
another word he said.”
“Your mind is racing like, ‘How long am I going to be
out of work?’ I am going to have to make lesson plans for
8 weeks. It also raced through my mind, ‘How did I get it?
Was it because of stress or just luck?’ You want to know
why you have it when there is no answer.”
Slide courtesy of Marcy Rosenbaum
Overview: 2 Strategies For Today

“SPIKES” protocol

How to break bad news – a method for relaying the message of a negative
diagnosis
 Motivational
Interviewing
How to strengthen your patient’s
commitment to change a behavior
adversely affecting their physical or
mental health
Motivational Interviewing: Commit To Change
A Provider’s “Typical Approach”

How do we typically try to convince a patient to
change problematic or unhealthy behaviors?

Explain what he/she could do differently

Warn them about what will happen if they don’t change

Counsel them about how to change their behavior

Refer them to a specialist

Be frustrated by your non-compliant patient!
Motivational Interviewing: Commit To Change
A Patient’s “Typical Response”

How do patients respond to being told what to do?

“Paradoxical effect of coercion”:


We tend to believe and act on what we hear ourselves say


When a provider takes up the “good” side of an ambivalent
behavior, the patient is more likely to argue the other side
The more we hear ourselves defending our behavior, the more
committed we become to it
New approach: Actively try to guide the conversation
so that it is the client rather than the clinician voicing
the argument for change
Motivational Interviewing: Commit To Change
4 Steps To Learning MI
Understand the spirit of MI
2. Learn how to ask
3. Learn how to respond
4. Learn how to really listen
1.
Motivational Interviewing: Commit To Change
The Spirit Of MI
Collaboration
With Patient
Compassion
Acceptance
And
Honesty
Of Stage
Make
A Commitment
Motivational Interviewing: Commit To Change
Your Patient’s Stage Of Change
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Motivational Interviewing: Commit To Change
Mnemonic To Ask And Respond
 OARS
Open
questions
Affirmation
Reflection
Summarize
Motivational Interviewing: Commit To Change
Learn How To Ask: Open Questions

Closed questions invite brief answers, e.g. yes or no:
 OLDCARTS
– “When did you start smoking?” or “How
many ppd?”
 Open
questions evoke more elaborate
responses:
 “What,
if anything, has been your experience with
cigarette smoking?”
Motivational Interviewing: Commit To Change
Learn How To Respond: Affirmations
 An
affirmation is a genuine statement that
emphasizes a strength of the patient.
 Notice
and appreciate a positive action
 Express
positive regard and caring
 “I
see you have tried to quit smoking before, which I
think is a great starting point.”
Motivational Interviewing: Commit To Change
Learn How To Respond: Reflections
A
reflection is a statement of inference, or
hypothesis, about what your patient has
told you
 Attempt
to extrapolate the essential meaning of
what the patient has told you back to them
 The patient must respond by confirming, correcting,
or elaborating on your comment
 “You say you don’t see yourself quitting. So you plan
to smoke for all the rest of your days.”
Motivational Interviewing: Commit To Change
Learn How To Respond: Summarize
A
summary wraps up what the patient
has told you
 Shows
you have been listening carefully
 Allows
you to end the conversation and make
recommendations for follow-up
 “This
is what I heard you say. Now let’s plan to
address that again next time.”
Motivational Interviewing: Commit To Change
Learn How To Really Listen
 RULE
Resist
the righting reflex
Understand their motivations
Listen to your patient
Empower your patient
Motivational Interviewing: Commit To Change
Video Scenario
Motivational Interviewing: Commit To Change
Mnemonic To Ask And Respond
 How
did the clinician do?
 OARS
Open questions
Affirmation
Reflection
Summarize
Motivational Interviewing: Commit To Change
Clinical Scenario
Patient is 55 yo with a history of poorly-controlled
hypertension (170/90) who has an appointment with
you, their family practice PA, for a discussion about
lifestyle modification. The patient is obese (BMI = 35),
eats a high-salt diet, does not exercise, and refuses to
take medications regularly.
Use the OARS approach to begin a conversation with
your patient about making healthy changes.
Motivational Interviewing: Commit To Change
2013 ACC/AHA Blood Cholesterol
Guidelines

Atherosclerosis is a primary risk factor for cardiovascular
disease, including MI or stroke

Preventative statin therapy should be initiated in most
patients with the following risk factors for atherosclerotic
Cardiovascular Disease:

Clinical atherosclerotic CV disease

LDL ≥ 190 mg/dL

Type 1 or 2 diabetes + 10-year ACVD risk ≥ 7.5%

10-year ACVD risk ≥ 7.5%
http://jama.jamanetwork.com/article.aspx?articleid=1791497#Results(Recommendations)
Motivational Interviewing: Commit To Change
Clinical Scenario
Patient is 55 yo with a history of poorly-controlled
hypertension (170/90) who has an appointment with
you, their family practice PA, for a discussion about
lifestyle modification. The patient is obese (BMI = 35),
eats a high-salt diet, does not exercise, and refuses to
take medications regularly.
Use the OARS approach to begin a conversation with
your patient about making healthy changes.
Motivational Interviewing: Commit To Change
Discussion
 OARS
Open-ended
Affirmations:
questions: not yes/no
positive attributes
Reflections:
infer patient’s ultimate view
Summarize:
show you’re listening
Conclusion:
Your Role As A Patient Educator

Soon you will be a practicing PA

Patient education is a part of your job

Understand the impact good communication skills
can have on the well-being of your patients

Use SPIKES and OARS to address difficult but
common! clinical scenarios with your patients

Be confident in your ability to meet the healthcare
needs of your patients
Additional Resources And Information

Next session: more on your role as an educator in your profession!

Future opportunities to learn about PA education:


SPIKES information


Future Educator Fellowship - November 2015: small number of students +
scholarship to attend Education Forum in Washington DC
http://www.each.eu/teaching/resources/breaking-bad-news-experientialmodule-curriculum-iowa-120613/
Motivational Interviewing information

Miller, W.R.; Rollnick, S. (2002). "Motivational Interviewing: Preparing People to
Change'". Guilford press.
A special thanks to Marcy Rosenbaum, PhD and Dr. Michael Flaum, MD for
their contributions of time and materials in the making of this presentation.