Sunanda Kane, MD, on Physician as Educator in IBD
In this video, Dr Kane reviews her presentation at the Advances in Inflammatory Bowel Disease 2020 virtual meeting on how best to inform and educate patients with inflammatory bowel disease to help ensure patient understanding, compliance, and the best outcomes of treatment.
Sunanda Kane, MD, is a professor of medicine at the Mayo Clinic in Rochester, Minnesota.
Hi, I'm Dr. Susie Kane. I'm a professor of medicine at the Mayo Clinic in Rochester, Minnesota. I was asked by my colleagues to give a presentation on physician as educator, how to teach patients about IBD as part of the advances in IBD conference.
In thinking about how I talk to my patients about IBD, there are some basic things that you have to remember first before you even start thinking about, talking about the science. Thinking about some of these things that I'm going to bring up are what are going to make or break that visit or that meeting with that patient.
The first thing that I recommend is that, if at all possible, have someone else there at the visit. Now, a lot of us are doing phone visits or video visits. It's much easier to have a family member or a household member there. If you're doing it in clinic, that if somebody can come with, that would be great, so it's an extra pair of ears.
Number 2, you want to assume that your patient has either read up or at least googled the diagnosis that they have been given or that they think that they have.
If you are about ready to tell them that they have Crohn's disease, or they thought maybe they have ulcerative colitis, or they think that they have leaky gut, that you better be ready to switch gears, make sure that you have addressed why they don't have celiac, or an allergy, or leaky gut syndrome, and what they really have is Crohn's disease.
You want to consider that the patient might be downplaying symptoms or isn't even cognizant of them, so you may say, "Oh, well, you have very mild disease based on your symptoms." That's why it's also helpful to have someone else there.
The patient may say, "Well, yeah, I go to the bathroom once or twice a day," and the family members sitting there shaking their head saying, "Yeah, well, you may only go twice a day, but you're in there for 40 minutes." Then, it's suddenly a much different story.
Or, "Oh, yeah. You know, I do fine and I eat 3 meals a day," The family member may say, "Yeah, but you pick and you don't eat half of what you're used to, and you tell me that I can't eat salad or popcorn anymore." Then, that changes the scenario.
Fourth, be open minded about their position. You are giving them a diagnosis that is incurable and chronic. They may have to deny it first. They may have to question it. They may have a very emotional or dramatic response to what you're telling them, so give them the time to absorb.
Don't try to tell them everything that they need to know in one visit, which you might think is a good thing that you're giving them all this information, but you know that any lecture you go to, you're not going to remember more than 3 things from that lecture. Don't assume that your patient is going to remember more than 3 things.
If you tell them that they have an increased risk for cancer, that's the only thing they hear. Be open-minded about their position. Next thing is, pick your battles. Again, that goes back to the thought that you have to give them all of the information all at once.
Certainly, if the patient wants to treat their disease with diet, and/or supplements, or more natural things, be ready to have that discussion and pick which battle you want to have in terms of the importance of medical therapy, versus getting a flu shot, versus annual colonoscopy, or whatever it is, make sure that you've picked your battle.
Just a couple of other things, then just to keep in mind. Again, we haven't even talked about the science of what you're going to tell them. This is how you're going to tell them. Don't just hand them a pamphlet.
"I don't have time to sit down and talk to them for an hour like you do, Dr. Kane." I don't have an hour to talk to them, necessarily, but I've picked my battles. I've picked the top 3 things that I want them to hear, and that is Act 1, or even scene 1 of Act 1, that this is an ongoing conversation.
If you hand them a pamphlet, that's fine, but you want them to understand that the pamphlet is a better source of information than Dr. Google, or that it's going to reinforce all of the things that you have talked about, or are going to talk about.
This is a big one that I talk to my fellows about. I say, "Talk in English. Do not use medical terms." It drives me nuts when I hear my fellows use the term mucosa. Nobody knows what mucosa is, unless they are a gastroenterologist. It's the lining of the colon.
When you start talking about anti‑TNF, nobody's going to understand what that means. “Biologic” is going to be something that you're going to have to explain and heaven forbid that you have to explain a biosimilar, so just talk in English.
Use analogies and mental pictures when possible. What do I mean by that? What I do is when I'm talking about the difference between a CT enterography, a regular CT that they may have at an outside hospital or in an ER, and a video capsule study, and a colonoscopy.
A CT is flying over the Grand Canyon in a commercial airliner. You're seeing the Grand Canyon, but there's not a lot of detail. It's just a big gorgeous hole. That's what's meant to look for very obvious gross things.
A CT enterography is where you're flying over the Grand Canyon in a helicopter. You're much lower down. You're getting a lot more detail. A video capsule study or colonoscopy is the riverboat on the Colorado River, so you're actually inside the Grand Canyon, and you're looking at it from that perspective.
All of these different modalities present a different way to look at the same thing. They all add a different dimension to what you're looking at. That's awfully helpful to a patient to understand that kind of mental picture or analogy.
Something that we learn from communication skills and leadership is the, talk, ask, talk system where you say something. You stop and you ask the patient, "Did you understand what I just said?" You give them the chance to ask or repeat what you just said so that you know that, "OK, they got it."
Then, you can go on to your next point because patients are intimidated. They're fearful. They're overwhelmed. They don't want to look like they're stupid, so they are going to just sit there and nod their heads.
These are intelligent people. They may have PhDs in rocket science, but they're not medically trained, so they're just going to nod their head. They say to themselves, "I'll go look this up later," but you don't want them looking up stuff on Google.
You talk. You make a point. You stop. You make sure they understand. If they don't, then you have to think of another way. That's why it's good to have somebody there, because they may understand and be able to help get it to a form that the patient understands.
The last thing to remember is that this is a marathon, not a sprint. If you need to see the patient back, it takes a village to take care of these patients, dietician, nurses, PAs, NPs, psychologists, trainees, so that you don't have to do it all.
You want to make sure that they leave with some basic understanding that is in English, so that when they go home they can explain it to their family. Not everything has to be explained on that first day.
Certainly, you want to maybe think about not talking about their risk of cancer right away, because that's the only thing that they're going to focus on. With that, is the structure for how you want to talk to patients, what you're going to tell them is based on all of the other information that you've heard here at this conference during these 3 days?