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Appendix C Examples of Effective and Ineffective Patient–Clinician Discussions As noted in Chapter 6, the foundation of a treatment plan for a veteran who has chronic multisymptom illness is the establishment of an effec- tive patient–clinician relationship. The basis of an effective relationship is proper interview technique. To assist with clinician training to improve interviewing skills, the Department of Veterans Affairs may want to con- sider developing videos based on the illustrative scripts in Boxes C-1 and C-2 that demonstrate ineffective and effective patient–patient discussions. There are several observations to address in the conversation in Box C-1. First, there was no eye contact when the doctor greeted the patient; the doctor was reviewing the chart. The flow of the discussion was not effective in gathering information, because the doctor asked closed- ended, multiple-choice questions and interrupted the patient twice while the patient was attempting to say something. There was no opportunity for the patient to tell the story, and the communication was passive. In addition, toward the end of the conversation it was difficult to follow the flow of the conversation because the doctor and patient were working from different agendas. Then the doctor seemed to close the discussion by offer- ing to order tests, perhaps in an effort to reassure the patient. When the patient raised concern about the diagnosis and whether it was Gulf War syndrome, the doctor did not address this concern. Furthermore, the doctor disregarded the validity of the diagnosis, focusing more on seeing that the tests would be done to exclude other conditions as a means of reassuring the patient. Finally, the doctor indicated an interest in placing the patient on an antidepressant if the tests were negative but gave no explanation as 207

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208 GULF WAR AND HEALTH BOX C-1 Example of an Ineffective Patient–Clinician Discussion Doctor. “How can I help you?” (looking at chart) Patient. “I developed another flareup of whatever I have . . . the fatigue, muscle aches, stomach pain, and terrible nausea, when I came back from vacation . . . (pause) . . . (pensive) I . . .” Dr. “Was this like what you had before?” (interrupting) Pt. “Yes . . . well, almost . . . I think.” Dr. “Was it made worse by food?” (looks up) Pt. “Yes, I think so.” Dr. “Did you have fever? or chest pain?” (leaning forward) Pt. “Well, yes, I think, . . . but I didn’t take my temperature” (looks down) Dr. “So you had fever and chest pain?” Pt. “Uh no, well, the pain wasn’t bad . . . I guess. . . . Dr., I’m really wor- ried about this.” Dr. “Let me go ahead and schedule you for some blood work and maybe another X-ray. It’ll probably be ok, but this way we’ll be sure there is nothing to worry about.” Pt. “But what do I have? I saw on the veterans website that some other people had the same things, and they called it Gulf War syndrome. Is that what I have?” Dr. “Most people aren’t sure whether that’s a real medical condition, so I want to rule out anything else that we can treat. If the studies are negative, I’d like to put you on an antidepressant to make you feel more comfortable.” Pt. (looking confused) “I’m not depressed. . . . I just can’t deal with the pain and nausea. I . . .” Dr. (interrupting) “I didn’t say you were depressed. It can help the symp- toms. Let’s see what the tests show.” to why. The doctor’s comment led the patient to infer that the medicine was being used for depression, which he did not think he had. It is noteworthy that although the number of verbal exchanges is the same in both conversations, the content and the messages communicated are richer in the second one (Box C-2), with far more clinical content and probably greater effectiveness in building the patient–clinician relation- ship. It is clear that the doctor is fully engaged in helping the patient. The d ­ octor listens actively, gives the patient the opportunity to tell his story, and responds to the patient’s comments and concerns. Validating statements are used (for example, “I can see how much this is really affecting your

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APPENDIX C 209 BOX C-2 Example of an Effective Patient–Clinician Discussion Doctor. “How can I help you?” (concerned, looking at patient) Patient. “I developed another flareup of whatever I have . . . the muscle aches, stomach pain, and terrible nausea, when I came back from vacation . . . (pause) . . . (pensive) I . . .” Dr. “Yes?” Pt. “I was about to start my new position as floor supervisor, and . . . and then all this happened.” Dr. “Oh, I see . . .” (pause) Pt. “(Continues) I started getting those muscle aches and that fatigue, then the cramps came on right here (points to lower abdomen), and it got worse after eating. It felt like the flu. I felt warm but didn’t take my temperature. So I knew it was getting worse again, so I came in to see you. I’m really getting worried about this.” Dr. “Hmmm . . . how so?” Pt. “Well, it’s really starting to cut into things. I’m afraid to do any sports or go out to eat, and I’m worried about my job. I’m irritable and don’t think I’m doing a good job at home. But my wife is really terrific. Then you know I got this promotion, but what am I going to do if I can’t do the job because of this?” Dr. “I can see how much this is really affecting your life.” Pt. “That’s right; sometimes I don’t think anyone understands. Doctor, what do I have? I’ve been reading this veterans website, and some of the people have the same problems. They’re calling it Gulf War syndrome.” Dr. “Yes, it’s gotta be hard when it seems that no one really understands what you’re going through. You know, there is a lot of discussion about Gulf War syndrome, or what we now call chronic multisymptom illness, or CMI. You are not alone with this, and medical researchers and the VA medical system are working to understand the causes and find treatments. I can see from your records that you have had a full medical evaluation on a couple of occasions, and since the symptoms haven’t changed I believe you do have CMI. So I’d really like for us to focus more on ways to manage your symptoms.” Pt. “That sounds good, so what do you want to do?” Dr. “Well, the first thing is that I want to work together with you on this. There is no magic pill, but I have several ideas that we can discuss that may help you get back to the life you want. I can see that these symptoms are so bad that they also affect your emotional well-being, your family relationships, and your quality of life. So, while we are continued

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210 GULF WAR AND HEALTH BOX C-2 Continued working on getting some relief for the symptoms, I want you to also see a colleague of mine, a psychologist who will work with you to develop coping strategies and help you find ways get back to a more normal lifestyle. I also would like you to put you on a certain type of antidepressants that can help reduce some of the pain and discomfort you are experiencing. They act on nerve pathways from the brain to your body to help block pain signals, and they often can be used in lower dosages than are used for depression.” Pt. “So, it’s not because I’m depressed?” Dr. “Well, medicines have different effects. Aspirin can relieve pain and also prevent a heart attack. Certain antidepressants are also used to treat a variety of painful conditions like body pain, irritable bowel, and even pain from diabetes. Also, if all of this is making you feel depressed, it can help for that as well.” Pt. “Okay. I’ll give it a try. Thank you, doctor.” Alternative ending: Dr. “Well, the first thing is that I want to continue to work with you on this. There is no magic pill, but I have several ideas to help reduce the symptoms and work to get you back to the life you want. There is a VA program that is designed to provide a team approach to the treatment that addresses not only your physical symptoms but also your emotional well-being and your quality of life. I’d like you to sign up with that program, and then you would come back to see me in 3–4 weeks to go over your progress. How does that sound?” Pt. “That sounds great. Thanks so much for your help.” life”), and the patient is informed that he is not alone in his experience. This allows the patient to say more about how the illness is affecting his life and about the stress of getting a promotion while being uncertain about how well he can do the work. Then the doctor validates the illness, and the conversation moves toward working collaboratively with the patient on the treatment. Finally, the recommendation for the psychologist and antidepressant (or the VA program) is addressed in a fashion that will be understandable and relevant to the patient’s interests and needs.