The doctor of the future will give no medicine but will instruct his patient in the care of the human frame, in diet and in the cause and prevention of disease.

Thomas Edison, 1902

Every patient interaction should conclude with a structured end of the interview that usually consists of sharing the information you have obtained with the patient, collaborating with her or him to arrive at an acceptable plan and, where necessary, motivating the patient to act on it. The skills used in the beginning and middle of the interview allow you to gather information from the patient, primarily by asking questions, and establish a relationship with her or him. At some point in the interaction, usually after an appropriate physical exam and/or review of laboratory data, you will need to share your impressions and engage in a conversation about the next steps of diagnosis and/or treatment. You can be tempted to educate and/or motivate patients earlier in the interview, but this vital activity is usually best done after data gathering is completed. A successful end of the interview leads to better health outcomes, because patients are more likely to agree with plans and carry them out. Patients take the pills we prescribe, go for X-rays and tests, and keep their appointments. We do not do it for them. Therefore, the end of the interview is a key element in successful health outcomes.1–6 See also doc.com Modules 10–12.7–9

The structure of the end of the interview depends on the needs of the patient. Consider these patients during a single clinic morning. The first patient, new to your care and similar to Mrs. Jones, requires information on your findings from the history and physical examination, answers to questions, and diagnostic and treatment plans for the future. The second is a patient making a follow-up visit to discuss the results of a recent test. Unfortunately, you have discovered a life-threatening disease and you need to deliver bad news to this patient. In this case, you devote a large part of the interaction, following the middle of the interview and physical examination, to delivering the bad news and making subsequent plans. The third patient asks for no information but you want to discuss a topic that the patient does not ask about. You first listen to the patient’s needs using patient-centered interviewing skills and elicit necessary details using clinician-centered skills. Having learned that the patient smokes cigarettes you want to discuss smoking cessation and you devote the end of the interview to motivating the patient to consider smoking cessation.

The end of the interview thus involves issues stemming from either the beginning or middle of the current interview, or from a previous interview; and requires effective skills in delivering information, motivating, and sharing decisions with patients.10,11 The end of the interview guide that follows, outlined in Table 6-1, provides a pathway for ending most clinical interviews. Sections “End of the Interview—Giving Bad News” and “End of the Interview—Motivating Patients for Behavioral Change” describe steps to deliver bad news and motivate patients to adopt healthy behaviors, respectively.

Orient the Patient to the End of the Interview and Ask for Permission to Begin Discussion

This can be done with a simple statement, such as, “We have about five minutes left; I’d like to share my thoughts about what may be causing your symptoms and then discuss where to go from here. Is that all right with you? Seeking permission before sharing information increases the patient’s receptivity to it.6

Iteratively Explain Diagnostic and/or Prognostic Information; Incorporate Patient’s Informational Needs

Sharing information with patients can be a difficult task as they often do not understand the information provided and forget up to 40% of it.12 Equally problematic, most clinicians underestimate their patients’ desire for information, especially when the patients are shy, reticent, or inarticulate. As a result they spend very little time explaining their findings to patients.4,5,13–15 Sharing information effectively does not mean you have to turn the patient into a “mini expert” on the topic under discussion.10 Rather, provide enough information until the patient has a conceptual understanding or ‘gets it’.10 Seeking permission before sharing information increases the patient’s receptivity:6 “Would it be OK if I shared my thoughts about what’s causing your symptoms?” After sharing the diagnosis and before presenting details or plans, use ask-tell-ask to (1) establish the patient’s baseline knowledge and help you tailor your message for maximum benefit (ask). See also doc.com Module 10.7

Once you have better understood the patient’s informational needs, (2) tell her or him what she or he needs to know. Categorize data where possible; for example, “First let’s talk about what migraine is and then …” Depending on their expectations, health beliefs, previous experiences, or general disposition, some patients can perceive as “bad news” diagnostic data that you consider routine.16,17 One way to mitigate this may be to deliver good prognostic information before you declare the diagnosis,18 for example “After reviewing all the information I feel confident that we have an excellent chance of controlling your headaches. I believe you have migraine headaches.” In any case, it is important to monitor the patient closely as you discuss diagnostic and prognostic information. Always be prepared to express empathy using naming, understanding, respecting, and supporting (NURS) and answer questions. Use the steps outlined in Section “End of the Interview—Giving Bad News” and Table 6-2 in the cases where you anticipate strong negative reactions to the news you are about to deliver.

While giving information, speak as plainly as you can, avoiding medical jargon, for example, saying “pain killer” instead of “analgesic” and “cancer” instead of “carcinoma.” Use clear, short statements with simple words about just one bit of data at a time. Encourage and answer questions until the patient understands the information. Periodically ask (to complete ask-tell-ask) the patient to “teach back” information,19 for example, “Just to be sure we are on the same page, can you tell me what you understand so far?” or, “When you get home your spouse is going to ask, ‘What did the doctor say?’ What will you tell him?” Correct any misunderstanding and repeat the most important messages if the patient does not mention them. It may be necessary to ask additional questions to check the patient’s understanding of major points. “Closing the loop” using ask-tell-ask enhances patient understanding and adherence.19 Do not provide more data until the initial material is clarified and assimilated. Remember to assess and address the patient’s emotional reaction(s) to the information given.

Invite the Patient to Participate in Shared Decision Making

Clinicians are increasingly expected to involve patients in decisions about their care.10 For example, the 2010 Affordable Care Act includes provisions that foster shared decision-making in clinical practice. A clinician may order the right tests and prescribe the best treatments, but these will do no good if a patient is not be able or willing to follow the clinician’s recommendations. Many patients are not aware that they can or should participate in decision making; so, explicitly invite patients to participate11 by saying, for example, “I’d like us to make this decision together,” or “I want to make sure whatever we decide works for you; so, I want you to be sure to let me know your preferences and concerns about where to go from here.”

Iteratively Explain Testing and/or Treatment Options and Incorporate Patient Preferences until the Patient Understands and Agreement Is Reached

Some clinical decisions, such as whether or not to order a routine blood test, only require a clear statement of what you would like to do and why, for example, “I think we should check your iron level to see how much blood you have lost. Does that seem reasonable to you?” Typically, these basic decisions have clear, singular outcomes. Other decisions, like starting a new medication have moderately uncertain outcomes but are not controversial. These decisions usually require discussion of alternatives with their pros and cons; for example, “We need to control your blood pressure better. We could increase the dose of your water pill or add a medication called a beta blocker. The higher dose of the water pill might make you urinate a lot but the beta blocker might make you fatigued. Are you clear about the pros and cons of these choices? What would you like to do?”11

Decisions that are controversial require explanation of the associated uncertainties; for example, “We should talk about your desire for a prostate specific antigen (PSA) test. The test can detect very small cancers, but it can also be abnormal if you have large prostate with no cancer. Unfortunately, finding prostate cancer early is unlikely to help you live any longer, and we do know that there can be serious side effects from testing and treatment such as erectile dysfunction and incontinence. However, different men have different preferences so, I would like to hear your views. Do you have any questions about the test? Would you still like me to order the test?”11 Regardless of the complexity of the clinical decision, be sure patient understands pertinent information and decisions by asking her or him to “teach [them] back.”19

Decisions that require patients to significantly change their behaviors often require more active engagement from the clinician than just explaining and inviting patient participation. The section “End of the Interview—Motivating Patients for Behavioral Change” describes a method that has been effective for motivating behavioral change in some of the most difficult patients in clinical practice.20–22 See also doc.com module 31.23

Summarize Decision(s) and Provide Written Plans/Instructions

Summarize the conversation and be prepared to provide a handout if necessary; be sure the patient can read and understand the written information. “We have decided that you will take one pill every morning and every evening until the bottle is empty, that will be 7 days. We also agreed that you would come back in … Here is a handout of the exercises we talked about … Do you have any problem reading it? If necessary, have patient “teach back”19 the discussion one last time.

Acknowledge and Support the Patient before Saying Goodbye

“It was good to see you again.” “Please call if you think of any other questions before our next visit.” “Take care of yourself and say hello to your spouse for me.”

Conclusion of Mrs. Jones Visit