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| 50th Annual Meeting of the American Headache Society |
Boston, Massachusetts June 26-29, 2008 |
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Headache Care Providers urged to use open-ended
Questions |
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BY MAURY M. BREECHER
Contributing Writer |
BOSTON — Many physicians fear that asking
“open-ended” questions of patients will significantly
increase the length of office visits, but data from the
American Migraine Communication Studies (AMCS-I & II)
refute that concern, said Dr. Richard B. Lipton at the
50th Annual Scientific Meeting of the American Headache
Society on June 29.
“Despite headache care providers’ concern that
open-ended questions would lead to significantly
increased length of office visits, AMCS-II visits were
shorter than AMCS-I visits (an average of 9 minutes, 36
seconds vs. 11 minutes),” stated Dr. Lipton of Albert
Einstein College of Medicine and the Montefiore Medical
Center in New York.
The AMCS-1 & II Studies were two-stage collaborations
between specialists in medical communication and
clinical providers who focus on headache treatment and
management.
Both studied “real world” interactions between headache
care providers and patients, said Dr. Lipton. Both
studies were funded by Ortho-McNeil Neurologics.
“It is important to focus studies on migraine and
communication because migraine remains underdiagnosed,
undertreated, and misunderstood,” said Dr. Lipton,
citing his own research. “Surveys of migraine patients
reveal that only 29% are ‘very satisfied’ with their
treatment.” (Headache. 1999;39:S20-S26; Neurology.
2002;58:885-894).
AMCS-I was an observational study with the purpose of
understanding what actually goes on between health care
professions and migraine patients and to identify
barriers to efficient communication.
AMCS-II was an intervention study to assess the benefits
of specific communication strategies designed to
overcome these barriers. First, primary care physicians
and neurology practices were identified and then
patients likely to discuss headache were flagged in the
waiting room. The medical visits were videotaped and
recorded and afterward the patients were interviewed
about their visit.
“The reason this study was exciting to me was that we
actually had the opportunity to see what was happening
in the room between clinicians and headache sufferers
and then debrief them so we could get a handle on their
perceptions,” said Dr. Lipton.
Participating in AMCS-II were 28 clinicians and 66
patients. Their average age was 42 years, 83% were
female and had headache histories of an average of 14
years. Participating patients averaged five migraine
episodes per day, 60% required bed rest or were severely
impaired by migraines.
AMCS-I revealed that clinicians asked predominantly
closed-ended questions about headache frequency,
symptoms, and triggers rather than open-ended questions
such as, “Tell me about your headaches” or “How do your
headaches affect your life.”
Most clinicians asked an average of 12 to 13 questions,
but patients did not get to tell their stories, said Dr.
Lipton. There was a lack of attention to the extent of
patient disability and impairment and patient education
efforts were made without assessing existing
understanding of the issues.
Recommendations from AMCS-I for improving communication
included asking open-ended questions to let patients
tell their story and to encourage communication about
impact. Also, clinicians should use “ask-tell-ask”
methodology for patient education and to assess
frequency.
The first “ask” question reveals current understanding
and identifies whether correct information has been
gathered, allows correction of incorrect information,
and identification of missing information.
The “tell” portion of the protocol is based on the ask
and allows doctors to reinforce and add the most
important next piece of critical information, identify
and correct misunderstandings, but not waste time on
what is known.
The second “ask” tests for understanding, controls the
information provided with each “tell,” and repeats the
sequence in an iterative process.
Dr. Lipton offered an example of the ask-tell-ask
system:
Ask patients the following questions to assess headache
frequency: How many migraines do you get per month and
how long do they typically last?
Tell the patient what you understood: “So you get three
migraines that last two days each for a total of six
days of migraine per month.”
Ask “Is that correct?” to make sure you understood
correctly. (Hahn SR, Poster presented at Diamond
Headache Clinic’s 20th Annual Practicing Physician’s
Approach to the Difficult Headache Patient, Feb. 2007,
Rancho Mirage, CA). |
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