4 General Approach to Treating Patients
As previously stated, the committee is charged with three tasks, one of which is to identify already validated models of treatment for conditions of interest. Before reporting effective treatments for individual conditions, however, the committee determined that there are certain general principles of a patient-centered approach to medicine that form part of the effective evaluation and treatment of any patient. Even though this approach is one that will benefit any patient, it may be of particular value for patients like the Gulf War veteran who is experiencing symptoms that impact his or her daily life, who is concerned that these symptoms may signal some major health problem, and for whom no diagnosis can be made. This chapter discusses such a general approach to diagnosis and treatment.
Part of the evaluation and treatment of any patient, regardless of condition or diagnosis, is an appropriate framework or pathway for diagnosis, treatment, and, if necessary, referral for specialty care (IOM 1998a). For Gulf War veterans, the first step in evaluating persons deployed to the Gulf War is to construct an accurate history through a careful interview. The patient's history is a critical basis for assessing his or her symptoms. The history should be followed by a comprehensive physical examination.
As with any assessment, the approach taken for this interview should be patient centered. Patient-centered care has been defined as care that recognizes the patient as a person with a unique life history and needs (McWhinnney 1981). Henbest and Stewart (1990) defined patient-centered care as care in which the physician responds to the patient in such a way
as to allow him or her to express all of the patient's reasons for seeking care, including symptoms, feelings, thoughts, and expectations. Patient-centered care requires positive interaction or communication between the patient and the physician, interaction during which the physician actively seeks the patient's point of view.
Owens et al. (1995) studied the effect of physician-patient interaction on the long-term prognoses of patients with irritable bowel syndrome. They found that a positive physician-patient interaction may be related to reduced use of ambulatory health services by such patients. Daltroy (1993) studied the effect of doctor-patient communication on patients with rheumatological disorders. He found that effective communication results in increases in patient knowledge, in desirable behaviors (especially compliance with prescribed treatments), in self-confidence, and in functional status.
A review of the literature by Ong et al. (1995) reported that information giving, time spent in discussion of preventive care by the doctor, and greater interview length were positively associated with patient satisfaction while a dominant, controlling style of communication on the part of the physician produced less satisfaction. They also found that in the ideal medical interview the patient leads in areas where he or she is the expert (symptoms, preferences, concerns) and the physician leads in his or her domain of expertise (details of disease, treatment).
Stewart (1984) found that physician behavior is crucial and that a positive outcome depends on physician behavior that is facilitating rather than dominating. Kaplan et al. (1989) found that better health status was related to more patient and less physician control, more affect (i.e., expression of both positive and negative emotions) expressed by physician and patient, and more information provided by the physician in response to effective patient information seeking.
In following this patient-centered approach to care, physician questions should be asked in a manner that conveys genuine interest and does not make the patient feel that he or she is under interrogation. Once rapport is established, questions can become more detailed or specific, focusing on the patient's problems, blending open-ended questions with others that can be answered easily with a yes or no.
The goal of evaluation is to define the problem that the patient identifies with Gulf War deployment through relatively nonintrusive inquiries about the patient's problems and symptoms, only then moving on to more specific questions. Patients may need reassurance before disclosing their thoughts and behaviors; clinicians should reassure them about the confidential nature of the doctor-patient relationship. Family members and friends can be important informants, able to fill in the gaps in the patient's history or to describe behaviors they may have witnessed. Pa
tients may not always be accurate in describing the extent of their symptoms, though relatives may be able to do so.
Comprehensive assessment of persons with symptoms attributed to Gulf War deployment would benefit from an understanding of the types of symptoms and problems that such patients experience. The evaluation begins by gathering a thorough history of signs and symptoms, which the subject attributes to Gulf War experiences, such as when the problems began in relationship to deployment, their nature and onset, and their course over time. Have the symptoms been chronic? Episodic? Has their severity fluctuated? Physicians should try to determine the onset of the symptoms and how the patient became aware of his or her symptoms, should inquire about diagnostic techniques or treatment measures used by clinicians he or she may have seen, and should document the patient's response to these interventions.
The clinician should attempt to exclude medical conditions suggested by the patient's symptom profile. This will involve recording detailed information about current and past medical illnesses, medications used, surgical procedures, typical allergies, previous diagnostic workups and treatments, and the patient's pattern of medical care utilization. Obtaining past medical records is especially helpful, particularly when the patient is a poor historian or the past history is confusing. Evaluation of a patient must also include the patient's psychiatric history since the presence of psychiatric comorbidity may suggest particular treatment strategies or approaches, as well as a possible explanation for some of the reported symptoms.
The committee recognizes that alcohol and other substances are frequently used as a self-medication strategy by patients who learn, through experience, that these drugs alleviate some of their symptoms, particularly depression, stress, and anxiety. While the committee did not choose to examine effective treatments for use and misuse of alcohol and other substances, such use, if undetected, will complicate the management of any underlying conditions. This is especially true in those situations where alcohol is in some way synergistic with the medication being prescribed.
It is very important, therefore, that health care practitioners explore these issues with all patients, including Gulf War veterans. Commonly used screening tools such as the CAGE and AUDIT interviews about alcohol use are excellent, well-validated tools for measuring the degree of alcohol use.
The patient's history should be followed by a thorough physical examination and routine laboratory testing. A physical examination and screening laboratories could help uncover a diagnosis that may explain, in part or in full, the patient's symptoms attributed to Gulf War deployment. The assessment should include routine laboratory tests such as a complete blood count, serum electrolytes, serum glucose, and urine analy-
sis. A veteran who presents with specific complaints should also receive targeted testing.
If the results of the initial examination and testing are consistent with a diagnosis that explains the complaints, that patient's diagnostic evaluation would stop and he or she would receive treatment for the diagnosed problem. If, however, the results are not consistent with the complaint, or if something unexplained appears as a result of the tests or the examination, the patient should continue on the diagnostic pathway for additional evaluation and testing that would be guided by the patient's signs and symptoms (IOM 1998a). Patients with prominent respiratory tract complaints, for instance, may need referral for pulmonary function tests to rule out the presence of reactive airway disease. Neuropsychological testing may be useful in some patients, particularly when the predominant complaint involves memory impairment or poor concentration.
Results of the physical examination and laboratory testing may well be within normal limits for most patients and will help to exclude the presence of well-defined illness. If a diagnosis cannot be determined, the provider must decide whether (1) the symptoms or problems are serious enough to cause disruption in the patient's life and therefore warrant continued evaluation at a special center or (2) the symptoms and complaints are not causing disruption in the patient's life and therefore the patient should receive periodic reevaluations to determine if his or her condition changes over time (IOM 1998a). Throughout the evaluation, however, positive communication is essential.
According to Ong et al. (1995), there are three purposes of physicianpatient communication: creating a good interpersonal relationship, exchanging information, and making treatment-related decisions. Daltroy (1993) has identified three primary communication goals for the physician: to elicit the patient's problems and history with an eye toward making a diagnosis, to negotiate a treatment regimen that the patient will accept and that is congruent with recognized medical practice, and to teach the patient about managing his or her disease and treatment regimen so that it may be effectively implemented. The physician views empathy and building patient self-confidence as supportive rather than primary goals.
Much has been written about the effect of physician-patient communication on patient outcomes. Evidence indicates that physician-patient interactions have a substantial impact on health-related outcomes (Stewart 1984; Kaplan et al. 1989; Daltroy 1993; DiMatteo 1994; Gordon et al. 1995; Owens et al. 1995; Joos et al. 1996). Outcomes measured include patient satisfaction with care, adherence to treatment regimen, understanding of medical information, coping with disease, quality of life, and functional status. Kaplan et al. (1989) wrote that effective physician-patient communication may lead to better health outcomes for the patient because:
Patients need information to manage their disease.
Communication can motivate, encourage, and reassure as well as provide an opportunity for the patient and physician to change their expectations.
Physicians may be able to change patients' perceptions about their health status as well as their beliefs about and self-confidence in their ability to influence their health status.
But what does this mean in terms of specific behaviors for the patient and the physician? Based on attribution and decision theory, Daltroy (1993) identified the following nine tasks for effective physician-patient communication:
- 1. The patient must express all of his or her concerns during the clinical encounter. To ensure that this happens the physician should ask the patient about his or her concerns and should listen and probe until he or she is confident that all concerns have been expressed. One technique is to encourage patients to bring lists of their concerns to the appointment.
- 2. The physician addresses all of the patient's concerns. While it may not be possible to immediately respond to all of the concerns, the physician should work with the patient to decide which items should be addressed immediately and which must be deferred. Even though the patient might have a diagnosed problem, it is important not to neglect unexplained symptoms. For patients with chronic symptoms it is important that the provider communicate his/her understanding of the patient's physical distress and the intent to work with the patient to maximize functioning and quality of life.
- 3. The physician and the patient share models of disease and symptoms. Patients frequently have a different understanding of the cause and course of their disease or symptoms. The physician can discover the patient's beliefs and understanding by asking the patient to explain in his or her own terms the causes of the disease and the symptoms. It is then possible to address misconceptions, reinforce accurate understanding, and provide reassurance to patients through education and advice that address the patient's beliefs.
- 4. The physician and patient must share goals for treatment. Patient's goals for treatment frequently relate to how well they function, to their loss of functioning in areas important to them. They may not always understand how the recommended treatment relates to achieving their own goals. The physician should share his or her goals for treatment, explaining what is possible. Discussion should also include the treatment's limitations.
- 5. The physician and the patient should agree on treatment goals, state them explicitly, and set priorities. Provider-patient collaboration on setting spe
cific, incremental, realistic, and achievable goals helps the patient achieve a feeling of ownership of the treatment goals. Such goals may address occupational, household, or social tasks, as well as other areas such as physical activation, sleep hygiene, or medication adherence. Negotiation of the goals and priorities indicates respect for the patient's preferences and can increase patient commitment to a mutually agreed upon regimen.
- 6. The physician and the patient should share their respective ideas about the purpose and course of treatments. That is, specifically what is the medicine or other treatment for (e.g., pain, drowsiness, reduction of swelling) and how long might it take to work (days, weeks, months). It may be the case that the provider will have to prepare the patient for a shift in emphasis from the expectation of a full cure to one where the aim is improvement in functioning and quality of life. Such mutual understanding may affect the patient's adherence to the treatment regimen.
- 7. The physician and patient should identify potential difficulties in the care plan. It may be the case, for example, that a patient will not be able to tolerate a particular medication or will be unable to adhere completely to a rigid diet. It is important to explore the patient's home environment and social network in order to identify potential impediments or supports that could assist in maximizing the effectiveness of the care plan. Anticipating problems in order to deal with them before they interfere with the effectiveness of therapy is also very important. It may also help for patients to understand that some patients do have problems.
- 8. The physician and the patient should plan how to overcome anticipated compliance difficulties.
- 9. The physician should provide written information on the disease and treatment regimen. This information should include the diagnosis (or possibilities), each treatment with the name, purpose of treatment, instructions for use, how to evaluate its effectiveness, key drawbacks or side effects, and what to do if it fails.
No matter what the disease or condition, all evaluation and treatment of patients must involve caring, investigation of all complaints, respect for the patient's perspective, avoidance of excessive testing, and joint decision making regarding treatment, to the extent that is possible. Such an approach is important to maintain excellent communication with the patient. Patient-centered care may require more initial time spent with the patient but may, in the end, decrease the total amount of time required for effective treatment, especially for those patients with difficult-to-diagnose or unexplained conditions.
As an example, patient-centered care has been used to clinically manage patients with somatization disorder. The approach involves the scheduling of regular but brief appointments with the primary care physician; a
brief physical exam at each visit, the physician seeking signs of disease rather than taking symptoms at face value; the physician avoiding hospitalization of the patient and minimizing the use of diagnostic procedures, surgery, and laboratory evaluations; and the physician viewing the development of symptoms as an unconscious process, rather than being “all in your head.” Use of this management approach lowered annual medical care costs and improved physical functioning for the subjects (Smith et al. 1990). Following this patient-centered approach to medicine, one can then proceed to implement validated treatments for specific conditions.
The committee recommends that the VA provide specific training to health care providers caring for Gulf War veterans to ensure that they are skilled in the principles and practice of patient-centered care.
Further, the committee recommends that the VA ensure that health care practitioners serving Gulf War veterans are allowed sufficient time with patients to provide patient-centered care.
The preceding pages describe an approach to patient care that can be used regardless of diagnosis or condition. Chapter 5 will explore condition-specific treatments.