I'm going to begin this session with a discussion on the art and science of a high-quality GI consult. I have no disclosures. I'm not as senior as Dr. Call. I'll start with a couple of polling questions first to establish the idea, the objectives for the talk. So, first polling question is, which of the following are essential components of the art of patient care? A, being caring or being an advocate for the patient. B, listening. C, explaining. D, teamwork. Or E, all of the above. 100%. Oh, look at that. I'll have to tell Dr. Call about that later. But before we move on to question two, I think there are still some attendees looking for the link for session B. Sam, can you repost the link? I still see it in there, but yeah, thank you. Thank you. Those of you who are still looking for session B, the link has been reposted. So, 100%, that's correct. All of the above are essential components to the art of patient care, and this applies to any provider that's providing patient care, whether that's a physician, APP, or other level. And we'll go into the details of what makes that so important. We'll move on to question number two. Sorry, polling question number two. So, patient experience and patient satisfaction are different descriptions of the same process, true or false? Oh, more of a split here. So, we'll talk about what the definitions of each of these mean, how they are related, and whether or not they're the same or different. Slightly different, but we'll get into the details of that. So, we'll start with the objectives of the talk today. So, we're going to start by talking about what constitutes the art of a quality patient visit. We'll focus on discussions on bedside manner and optimizing that provider patient experience. And then we'll move on to some of the more detailed science of the quality patient visit and the essential components of providing a consultation for your provider and for your patient. And then, how do we combine these two? How do we combine the art of the patient visit and the science to really kind of shine for our patients? So, patient experience is defined as the totality of interactions that a patient has with any healthcare entity that influences their perceptions and their outcomes of care. And the Agency for Healthcare Research and Quality has identified these as some of the most important aspects of the patient experience to understand what the patient is looking for in their experience. And that includes such things as their access to care, communication with the clinicians, getting the appropriate information, being involved in shared decision making, being shown courtesy and respect, and culturally appropriate care as well. So, these are all important aspects to understanding what the patient's experience and all those contribute to the patient experience when we're describing that. Patient satisfaction is really focusing on what are the patient's expectations from that visit. What are they expecting to achieve out of that visit? And patient satisfaction goes to, are we meeting or exceeding those expectations? So, the art of the quality GI consult, establishing the foundation for this involves all the factors that we talked about in our first polling question. Showing, being a caring and patient advocate for the patient. Listening to the patient. It's different from just hearing the patient, but actually listening, showing your interest, showing that you care about what their experience is with regards to their symptoms and their background. Explaining at their level, explaining at their level of understanding, both medically and verbally. And then establishing a framework for teamwork, the provider's responsibility, the patient's responsibility, other members that might be part of their team and their care. So, establishing that caring aspect, being an advocate. I always start by introducing myself at the beginning of the visit. I do this at every visit. Obviously, some patients who I've seen more often or more frequently become more familiar with may not be an introduction, but I at least reach out to shake their hand or in the era of non-contact, at least greeting them. And then opening it up to allow them to start to speak. And some patients will take that opportunity to start to provide their history and speak. Some will just say hello and then wait for you to ask questions. But give them the opportunity to start and drive that visit. Maintain eye contact with them while speaking. This really is important in the era of significant technology. We have computers in all of our rooms. Many of us carry our phones or other devices on us while we're in our appointments. But make sure you're maintaining eye contact with your patients while they're speaking. It expresses to them that you're actually interested and paying attention to their history and to their complaints. And also, while you're speaking to them, that direct eye-to-eye contact is a significant component for the patient experience. Ask them questions that are not medical. Understand their background. Understand their family situation. Understand their work situation, their social situation that may actually significantly impact how you provide care and the options for providing care to those patients. And focus on the patient. Again, not the computer. The computer is in the room, yes, and we can use the computer to explain things and show things to the patient. But try to maintain that eye contact and not focus directly on the computer. Use words and language that your patient understands. Understand their literacy level. Understanding their education level. That's how you can properly explain your disease process, explain your plan, explain the thought process that you're going through and help them understand and be involved with their own decision-making, with their medical decision-making. Be nice. Show empathy. Never judge. Never argue with the patient. Use that as an opportunity to nod and and try to understand their perspective. Body language says a lot. Body language is one of the most important things and we don't necessarily always understand or pay attention to our own body language, but that is important for the patient being on their side of the table, understanding how does this provider understand what I'm going through, understand my perspective. You want to make sure you're not showing, you're not sitting above their level. If you're sitting above their level, that could show dominance and that raises concerns about exhibiting that to the patient. Patient feels like they're not necessarily threatened, but in a lower position and may not advocate for their own understanding of their disease. Try not to cross your arms. Maintain a relaxed body position. If you lean in, it shows interest, shows that you're listening, shows that you're caring, nodding, smiling, showing understanding or nodding along while they're speaking. These are all ways to optimize your body language and improve that experience for the patient so they understand, they feel comfortable with your discussions. Listening. This is again focusing on the difference between hearing and listening. Yes, we can hear what they're saying, but listening and understanding, focusing on the patients, avoiding those distractions. Put the phone away, leave it at your desk before you come in. Try to avoid speaking or using the computer. Maintain that eye contact both while you're speaking to the patient and while they're speaking. Again, smiling, nodding, showing your understanding, showing that you're listening without even using words, using that body language. Explaining. When we're explaining to the patient, we want to use this as an opportunity to teach them, inform them, inform them about their symptoms, about their medical concerns. Try not to use language that will make them feel like they're being lectured. That again shows that can be portrayed as dominance towards the patient, so you want to try to avoid that. Use your materials. If you have the computer, a lot of times I'll pull up a graph or a picture. Patients like to know that they're up to date on the most recent, most current guidelines, so a lot of times I'll pull up an algorithm to show them why we're making the decisions we're making going through the various levels in that algorithm. They like to know that you're using references and using the most up-to-date material. Again, use language that's at their level. Understand their medical literacy. You'll have some patients that may be at our level, at an APP or physician level, and then others that will be at a lower education level. Understand where their education level is. Use language that's appropriate to them. Use language that suits their level so that they feel like they have an understanding of what you're telling them and they have an understanding of their disease and the plan. Make sure that discussion is transparent, so discussing and reviewing, testing, reviewing the results. Even at the end of the visit, I like to summarize. This was the test. Just briefly, we reviewed your testing and the results. We're going to have this referral. This is our plan. Make sure you have a clear discussion and clear summary for the patient at the end of the visit. Establishing their understanding of the teamwork that's involved. It's important to outline to the patient what they should understand about their experience with your practice moving forward. As being the primary clinician involved, is there a relationship with the physician? Physicians being primarily involved on the endoscopy side, but as the APP, I may still be your primary point of contact or primary clinician organizing your care. There will be other team members involved. There will be your nurses, your triage nurses, the schedulers. We'll coordinate also with your primary care doctor's office. A lot of what we do in GI involves coordinating with surgeons and oncologists or other providers, making them understand how you fit in as part of their medical team, and then also how you fit in as you'll be the primary clinician organizing their care, their GI care moving forward. They'll have access to you, but access to you through your triage nurse, through your nursing team, and however it fits in so that we establish that understanding early on. They may not have – setting the expectation that they may not be getting a direct phone call from you every time they call in, but somebody from the team will be coordinating, will be working with them, working with you as well. Also establishing the understanding for the patient that they're part of the team as well. Every time you see them, you're setting expectations for them. This is what I want you to do. This is what I want you to – this is what my recommendations are. We'll reconvene in a few months and see how that goes. If they're not participating in that care, it's hard to move forward. Understanding that they're also participating and also open up the opportunity for them to say, we'll revisit in a few months, but if this isn't working, feel free to contact my triage nurse in the meantime and we can move on to next steps. Establishing that teamwork relationship with all the providers. Understanding the patient perspective. These are the questions that the patient is looking for and what drives their patient satisfaction. Does the provider care about me? In their body language, they seem distracted. Are they really listening? Are they really caring? Is my provider my advocate from healthcare? Are they focused only on one thing? Are they going to be able to coordinate with my other providers? Are they listening to me when I'm talking about my education status, my work status, and how that affects my life, how that affects my medical care? Is my provider friendly? Are they respectful to me? Do they seem knowledgeable? Are they explaining things in a way that I can understand? And in turn, do I understand exactly what the provider has ordered? Do I understand why they're doing the testing they're doing? This is what the patient is seeing. This is what drives that patient perspective, that patient experience, and patient satisfaction. Moving on to some of the science of the quality visit. So this is where we'll focus a little bit more on the actual design of the visit from a medical perspective, moving away from the art. So when you're taking your history of present illness, it's important to get an introduction. What's the purpose? What's the background of the patient? Use the old carts mnemonic, and we'll get into the details of that in a second. Doing a targeted review of systems. So we want a GI review of systems, and then relevant other review of systems that might be important to that patient's presentation. Any interval history. Let's say it's a three-month follow-up or six-month follow-up of a patient. What has happened in that interval? A summary of that experience for the patient, the medical history. In the introduction, that may include things such as the age, sex, major medical history. For example, this is a 72-year-old male with a past medical history significant for atrial fibrillation on chronic anticoagulation with Sirelto, and stage three chronic kidney disease who presents for … This helps to answer the questions establishing the background of the patient briefly, but also in your mind you should be thinking, okay, what are my options? Is this somebody, particularly in our field, when we're considering endoscopy, colonoscopy, various procedures, can I offer an endoscopy safely? Can I offer an endoscopy for this patient now? Do they have other active medical issues that might interfere with that plan? The old carts mnemonic. It's a mnemonic that allows us to get further detail about the patients, particularly when they're describing, trying to understand their pain. They're describing stomach pain, abdominal pain, trying to understand the character of that pain, asking about when did this start? What's the onset? Where is it located? Ask them to point on their abdomen. Where does this bother you the most? How long has this been present? When you have the symptoms, are they always there? Are they constant? Are they waxy and waning? How long do they last when they are present? What's the character of that? Is it sharp or dull? Is it throbbing or burning? Giving them the opportunity to describe, and sometimes they can't describe, and then I might offer these as examples of ways that they may be able to describe the character of their pain. I was asked, what makes the symptom worse? Are there certain factors? Is it related to meals? Is the pain related to bowel movements? Is it related to position? What are things that they've tried that make the symptoms better? Have they tried over-the-counter medications? Have they tried a heating pad? Have they tried changing their position? What are the factors that seem to improve their pain? Is it occurring at specific times of day or night? Again, is it related to meals? Is it happening an hour after a meal? Is it unrelated to meals? Does it wake them up at night? These are important factors that will drive your differential diagnosis and subsequent testing. Expanding on our patient, another patient, 82-year-old man with a past medical history for atrial fibrillation on chronic anticoagulation with Xarelto. They also have congestive heart failure with a depressed EF of 15%. They have chronic obstructive pulmonary disease on chronic oxygen at 2 liters and at stage 3, chronic kidney disease. Setting a more complex patient history, understanding this patient baseline has some significant cardiopulmonary comorbidities. Who presents for evaluation of rectal bleeding? Setting the stage, okay, now I'm thinking, okay, rectal bleeding, we may need to be considering a colonoscopy or a sigmoidoscopy. And then getting further detail on that history. He was in his usual state of health until 3 days ago when he developed mild lower abdominal cramping. After 30 minutes, he had an urgent bowel movement mixed with bright red blood mixed with a stool. Cramping initially resolved but returned an hour later. He is having 3 to 5 bowel movements per day, which is different from his baseline of 1 to 2. He has stool mixed with the bright red blood. He has not tried any anti-diarrheal medications. He denies any correlation with oral intake. So that gets to that mealtime symptoms. Then taking that targeted review of systems. What's pertinent to the chief complaint? What's pertinent to the primary symptoms? This is important to understanding how sick the patient is now. So this will commonly include such things as fevers, chills, trying to understand is there an infectious process going on. Weight loss, whether that's intentional or unintentional. Do they have associated symptoms of anemia like dyspnea, dizziness, lightheadedness, chest pain? And then, of course, the GI review of systems. Understanding that interval history. Again, getting the latest developments. What has the clinical course been? Maybe it's been 6 months since I've seen the patient. Have they been hospitalized in the interval? And what were those hospitalizations for? Have there been major medical changes, medication changes during that time? What's their clinical course been? Has it been stable or have symptoms progressed or improved? Have we done testing in the interval that we need to get updated on? Have we had any lab work that's completed, stool studies that have been completed, CT scans, endoscopy? Understanding all that interval history and any prior GI evaluation. If this is your first consultation and they are explaining that previously they've had endoscopy and visits elsewhere, obtaining that historical data is important. And then summarizing that in your notes. Physical exam. Of course, vital signs, abdominal exam, focused remainder of the physical exam, heart and lungs when appropriate. But for other patients or patients with cirrhosis, whether or not asterixis is present, is edema present, ascites, other features on the skin exam that indicate stigmata of chronic liver disease. These are features to potentially examine for and explain in your physical exam. And then in your assessment, you want to briefly restate the history of present illness, the introduction. Again, setting the stage for that patient, understanding their baseline illness. And then what are their primary complaints? You want to list or explain your differential diagnosis. This helps to provide for other providers your thought process as to how you determined your plan. And then for continuity visits as you're going every three months or every six months that you're seeing your patients, is the disease well controlled? Is it poorly controlled? Has there been modest improvement in the interval? That sets the stage again for our patients, particularly our chronic patients with inflammatory bowel disease and other disease processes. Generating your differential diagnosis. This is another mnemonic that we like to use when we're thinking about the various etiologies for a presentation. And typical language in your differential diagnosis based on our assessment. The most likely diagnosis is X. However, given the patient's age, medical history, we need to consider or exclude other conditions such as Y, Z, etc. It is otherwise unlikely that another A is in the differential for this patient. Based on this assessment, our plan, and after discussion with the patient, our plan is to pursue this endoscopy. We'll obtain updated lab tests, etc. Explaining all that in a language that describes your thought process and your priorities in your differential diagnosis is helpful and it's important. This is a 72-year-old man with a past medical history. Significant for atrial fibrillation on chronic anticoagulation with Xarelto. Again, congestive heart failure with an EF of 15%. COPD, stage 3 chronic kidney disease. Presents with abdominal cramping and rectal bleeding for three days. Recent labs demonstrated acute anemia. He also has symptoms of fatigue and dyspnea on exertion. Last colonoscopy in 2014 was normal and as above. So, our differential diagnosis, we're considering hemorrhoidal bleeding and infectious diarrhea are potential diagnoses. However, based on his presentation age, other medical comorbidities, chronic anticoagulation, we also have to consider malignancy and ischemic colitis. Inflammatory bowel disease is unlikely considering it's only a three-day history of symptoms. So, this is laying out for providers who will be reading your notes. Otherwise, the endoscopist or others, particularly further down in the road as you're understanding your differential diagnosis and your thought process. So, this is all part of the science of establishing a good notes, a good plan for your patient. So, outlining the next steps in your evaluation, again, detailed based off of my assessment and our discussion with the patient. We've developed the following plan. We're going to update lab work this week. We had a discussion with the patient's other providers, cardiologists, regarding the risks and benefits of holding anticoagulation, whether that's just for the procedure or for chronic care moving forward. We're going to plan a colonoscopy. We're going to plan this procedure to be done under moderate sedation with a specific prep. We have coordinated with the cardiologists regarding their anticoagulation holds and detailing all of this in the plan. We've discussed the risks and benefits and obtained informed consent. He is agreeable to proceed. This is all important to lay out in your plan, in your notes, so that you have a detailed visit. And this is helpful also for billing purposes as well. Instructing the patient to go to the emergency department if he has new signs or symptoms of anemia. And then we will plan follow-up here in four weeks after the colonoscopy is completed to review those results and move forward with the plan. This is all detailed in a very scientific approach to the care, to the visit, and then to the note that goes into that visit. So, combining these…oh, actually, and then one more slide on the plan. If the patient has multiple complaints, it's also helpful to separate those complaints out sometimes. So, patients coming in for follow-up of gastroesophageal reflux disease and chronic constipation. GERD is well-controlled under PPI. We'll continue dietary and lifestyle modifications and try tapering that off. And then as a separate entity, constipation, this persists despite making dietary changes. The next step is going to be to add MiraLAX, so that way you're keeping your different problems separate but having a proper plan for each of those. So, finally, some practice pearls. Again, focusing a little bit on the…mostly on the arts, but a little bit on the science of this. Being caring and showing advocacy for your patient, listening to your patient, explaining in a language that the patient understands, establishing the foundation for a relationship, establishing an understanding for the patient as to how…what their role is in the team, and other team members as you move forward with your clinical care. Body language is just as important as our vocal language, as our spoken words. Be transparent, show caring, be empathetic towards our patients, listen, listen, listen to our patients, understand what they're trying to say, understand their perspective, understand their background and their history, which will drive your decision-making. Try and teach and educate them, use materials, use algorithms, show them pictures, help them understand, but try not to lecture to them. This is all important in developing a successful rapport with your patient and optimizing that patient experience, optimizing that relationship to make it a successful relationship moving forward. Use guidelines, as I said, understand the patient's medical literacy level and speak at that level, teach at that level, so that they can understand that you're understanding their experience. And the science, again, setting up that note, the introduction, the purpose, using the old-cards mnemonic to detail the patient's symptoms, targeted review systems and review of their history, establish a nice differential diagnosis, prioritize that differential diagnosis and prioritize the management plan. This is all important for detailing for other providers, as now patients have access to their notes as well. They'll be looking at some of these notes as well, so seeing that detailed out will help. Thank you very much. That's the end of my talk.

GI consultation

empathetic care

clinical precision

patient education

medical guidelines

teamwork