Tuesday, June 7, 2011

The Human Centered Health Home: Reflecting on the Patient Encounter

After Respecting, Protecting, Connecting, Detecting,and Correcting, the last element of the encounter between patients and physicians in the Human Centered Health Home is Reflecting.  This usually occurs at the end of the office clinical encounter or just after it's over.  Reflecting also includes completing the record of the encounter and the information needed to satisfactorally bill for services rendered.

Using the standard S-O-A-P format for recording the note helps immensely with this step.  The note may be written in the room as the patient tells their story and the physician expands and clarifies via mental models, some of which are mentioned in the earlier HCHH writings (see previous posts).  As the physician explores and narrows the possibilities, the note is developed, the assessment determined and the plan is shared.  The P- Plan includes the  diagnostic aspects, therapeutic elements and patient education including the timing of the follow-up for the current situation and continuous care/ prevention.

There may be a lot of probabilistic commentary during this section, as the physician comments on the probabilities that the patient will achieve their goal(s) using various diagnostic, therapeutic and educational strategies.  The patient may clarify their goal(s) as this discussion progresses. The physician may say, "With our findings here, there is a very high probability that you have a kidney stone passing from  your kidney through your ureter toward your bladder." 

"With the CT scan of the abdomen which bills at $2300, there is a 30-50% higher chance you'll know the exact size of your kidney stone (primarily if it's smaller than 4mm, which usually passes spontaneously) than with the renal ultrasound which bills at $550 and accurately shows stone size if 4mm or greater (the size that has a higher chance of not passing spontaneously).  The CT scan involves radiation exposure similar to about 500 chest x-rays and has a 1-2% chance of causing cancer 20 or so years later.  The ultrasound has no radiation and no cancer risk.  Overall it will show stones that may not pass, but less likely to show the size of stones that will pass spontaneously.  Generally, neither imaging study is necessary unless the stone, diagnosed clinically with the history, physical examination and urinalysis, is painful for too long.  What questions do you have about those options?"

The physician helps the patient to frame the situation and explore the options, sometimes shifting into teacher, learner, consumer coach and values clarifier.  Information resources in person or online may be very useful in this segment of the clinical encounter, as contingencies are developed and explored, before final decisions are made.  Sometimes there is further clarification about financial burdens of various medications and testing strategies before  working decisions are agreed to. 

Reflecting also includes context considerations for the physician.  Am I comfortable with this type of patient and this symptom complex?  What is enjoyable about this patient?  How does this type patient and problem inform the physicians career about likes and dislikes in family medicine.  As the physician reflects on the encounter, what did he/she learn?

Reflecting may include a vast array of considerations which will be expanded further in future posts.

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