Tien V. V. Nguyen - Clinical Cases in Psychocutaneous Disease

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Patients are often asked by their practitioners and the practitioners medical society to create a list so as to have all of their concerns resolved in the most efficient way possible. The problem with Mr. Hawthorne list is its length, causing you to worry about being able to address them fully and comfortably in a single visit. It is important to take a step back and explicitly acknowledge that this patient has been proactive about taking care of his health. This well-intentioned effort on Mr. Hawthornes part and the ultimate product, the list, are not meant to purposefully control the visit or create unreasonable demands on your time but to save time during a seemingly short dermatologic visit. Of note, there might be other possible explanations for a patients list, including insurance reimbursement issues and conflicts with the patients personal or work schedule, etc. Therefore, it is important to wait until the patient finishes his opening statements in order to find out his motivation for making a long list.

When it is your turn to speak, the authors suggest beginning with: Mr. Hawthorne, thank you for taking the time to make this thorough list. Patients like to be complimented by their practitioners for doing something good, and here is your opportunity to gain favor with Mr. Hawthorne, even though you might feel apprehensive about the lists length. Second, ask politely to look at the items on the list with him, keeping in mind that he most likely expects you to have an infinite amount of time to address all of his concerns in a single visit.

A useful intention on your part would be to assume that Mr. Hawthorne composed his list in innocence, not realizing that some signs or symptoms may require lengthy conversations and exams. In order to make the patient more amenable to shortening the list, remind him gently: Mr. Hawthorne, I would love to spend time addressing each item on your list in a careful, thorough manner. However, if I were to do that, it would take up more time than what I have scheduled for you today. I understand that you might not have realized this before. Would it be okay if we look at the list and choose the three most pressing concerns to take care of in this visit?

If the patient was successfully persuaded to shorten the list, consider yourself lucky! However, the authors of this book are less optimistic about this happening with the average long list patient. Therefore, we will prepare you for the case where Mr. Hawthorne does not agree to accept your request. You can start the argument for a shorter list by saying, Im afraid that if we completely evaluate all of your concerns today, we will not be able to focus on the most important problems requiring a lot more time and attention than the others. In addition, if we address every item on your list, I might overwhelm you with too much information. Im sorry.

Occasionally patients might not accept the above explanation and continue to insist that you deal with every item on the list, even if this means information overload. Some practitioners employ the tactic of guilt-tripping patients by saying such things as, Im sorry that we cannot accommodate all of your needs today, Mr. Hawthorne. As you can see, there are other patients waiting outside to be helped. I cannot spend all of my clinic time with you today because it means that I would have little or no time to see those patients.

The authors are not sure of the success of this tactic. You are essentially setting boundaries with Mr. Hawthorne by saying I do not have enough time to help you with all of your problems. Such an approach requires much experience and can backfire, resulting in an angry patient. Only you can determine whether or not it is worth possibly sacrificing a long-term relationship with a patient to stay on schedule, by limiting what you will and will not discuss from the list. Sometimes you might decide to acquiesce in the request of the long list patient so as to get through the visit and part on an amiable basis.

It might be helpful to reinforce your compassion for the patient by looking directly at him and saying in a warm tone, Mr. Hawthorne, I understand that getting an appointment to see me is difficult. I would love to see you again and again, and take the time to get all of your skin problems under control. So if we cannot get to a couple of problems on the list today, I promise that we will take care of them promptly at the next visit. I am here for you! You really have to mean what you say Mr. Hawthorne expects you to follow your own words with strong actions.

If it is within your capacity, you may also suggest that a phone call be scheduled later that day or the next day to deal with non-urgent issues on the list. In our experience, given the opportunity to call, most patients do not embrace it. However, it is reassuring and comforting for the patient to be offered such an option, and your chance of convincing these patients to shorten their lists might be made more favorable. Before ending the visit, it might be wise to go over the list again and show him that you took note of the items not addressed in this visit. Mr. Hawthorne may become more confident about your ability to deliver the high-quality, compassionate care that you promise him.

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