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The Fifteen Minute Hour: Efficient and Effective Patient-Centered Consultation Skills Sixth Edition Lieberman
The Fifteen Minute Hour: Efficient and Effective Patient-Centered Consultation Skills Sixth Edition Lieberman
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SIXTH EDITION
The Fifteen
Minute Hour
Efficient and Effective
Patient-Centered
Consultation Skills
http://taylorandfrancis.com
SIXTH EDITION
The Fifteen
Minute Hour
Efficient and Effective
Patient-Centered
Consultation Skills
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Forewordviii
Prefacex
Authorsxvi
Acknowledgmentsxviii
v
vi Contents
Appendix A: Twelve good questions and three good answers for all seasons 193
Index199
Foreword
Health systems across the globe are confronting a wide variety of issues, rang-
ing from controlling rising health care costs associated with increased disease
burdens of aging populations to containing new epidemics with the potential
of rapid spread worldwide. The importance of primary care in contributing
to the reduction of disease burdens and maintaining health in populations
is now recognized worldwide. At this level, the delivery of health care services
in most countries remains fundamentally a relationship-oriented interaction
between providers and patients. Yet, many systems of care continue to be
afflicted by an organizational and cultural pathology of Cartesian dualism
that separates the care of the mind and body.
The challenge for health care practitioners on the front lines of delivering
services has been in bridging this divide. As primary care practitioners know,
patients most often do not present with discrete singular problems, but rather
with a mélange of inter-related and connected biomedical and psychosocial
problems. Ascertaining the status of and connecting with patients’ affective
domains remain two of the fundamental skill challenges for all practitioners,
and are absolutely essential to achieving beneficial therapeutic effect.
Fortunately, this new edition of The Fifteen Minute Hour provides health care
professionals with the necessary knowledge and skills to accomplish this
daunting task. Building on the strengths of previous editions, this update
weaves contemporary knowledge and practical skill techniques into the fabric
of a well-written, readable text. The result provides the practitioner with an
efficient and time-effective set of practical approaches to building the thera-
peutic relationship to achieve beneficial results for the patient.
Whether it’s providing background material on the mind-body link, the
time-tested method of BATHE in extracting psychosocial data, or concrete
examples of cognitive behavioral therapy, this book illustrates the knowledge
and skills in straightforward coherent prose with many useful examples and
viii
Foreword ix
vignettes that bring the material to life. New material on wellness and liv-
ing with chronic conditions enhances this edition and fits with practitioner
goals of meeting the needs of increasing longevity in populations in many
countries.
I know you will enjoy reading this text as much as I have and will benefit
from the many pearls of practical advice contained herein. Drs. Stuart and
Lieberman have again provided healthcare professionals with another out-
standing contribution to improving the care of those we serve. Happy read-
ing and learning!
The publication of the sixth edition of The Fifteen Minute Hour is a source
of great satisfaction to us. Our purpose in writing this book, which has
not changed since the original 1986 edition, is to convince you that by
routinely incorporating therapeutic talk into your medical practice,
you can solve and often prevent many problems. During the years since
publication of the first edition, many things have changed. In earlier
editions we speculated about a number of mind-body connections now
substantiated by research. The increase in terrorism around the world
has compromised people’s basic sense of safety. Evidence-based medicine,
electronic communications, the plethora of information on the internet,
cost control, cultural diversity, and other societal trends have affected the
delivery of medical care. In spite of all these changes, the importance of
the practitioner-patient relationship remains a constant. With electronic
records, and computers in the exam room, the need to relate to patients
in a personal and empathic manner has become more critical than ever.
The approaches described in this text are designed not only to enhance
the therapeutic relationship, but also to make your practice more produc-
tive and pleasurable.
The book has grown out of our combined 80+ years of clinical practice and
experience in teaching doctors training in the specialty of family medicine,
practicing physicians, nurse practitioners, and other primary care providers
in the art of therapeutic talk. In the 31 years since the publication of the
first edition of The Fifteen Minute Hour, we have heard from many enthusias-
tic practitioners in the United States, Australia, Brazil, Canada, Denmark,
Israel, Malta, the United Kingdom, and elsewhere who have assimilated our
techniques into their practices. We were delighted when the second edition
was translated into Japanese, and the third and fifth editions were translated
into Korean, because this attested to the multicultural relevance of our tech-
niques. The overwhelming consensus is that the strategies work: patients
x
Preface xi
There are many schools of therapy. We are not preaching a dogma, nor do
we have the need to establish a true religion in this area. We are quite com-
fortable with practical eclecticism because it works, and primary care prac-
titioners desperately need techniques that work. We invite you to apply our
techniques and empirically confirm their usefulness for yourself. In essence,
we are saying, “Try it; you’ll like it.”
John Godfrey Saxe, a Vermont lawyer and humorist, wrote “The Blind Men
and the Elephant” over 100 years ago.7 This poem was based on an Indian
tale thought to date back thousands of years. It still seems most applicable.
Different schools of psychology and psychiatry view the patient and the
patient’s problems from different perspectives. Each provides a small piece
of useful insight. Collectively these fragments form a tool kit which can be
used to reduce patients’ suffering, prevent many physical and psychological
illnesses, and help patients structure more satisfying lives for themselves and
their loved ones.
In writing this book, we have tried to present a coherent whole. Each chapter
builds on the previous one, and illustrative clinical examples appear through-
out the text. The case material, including all new examples, is based entirely
on actual encounters, although we have changed names and altered some
details to guarantee patients’ confidentiality. In revising the text for the cur-
rent edition, we have considered the many thoughtful critiques of The Fifteen
Minute Hour; we have cited numerous new studies, clarified important sec-
tions, and eliminated extraneous material.
In Chapter 1, we introduce the BATHE technique, the basic structure
of this text, for obtaining psychosocial data while supporting patients
and building a therapeutic relationship. We have moved this material to
xiv Preface
In Chapter 2, we detail how patients react to stress and provide the sci-
entific background and theortical material that explain the efficacy of
our interventions. Chapter 3, focusing on healthy lifestyle interventions
and pain management, is brand-new in this edition. Behavioral strate-
gies can be employed for successfully preventing or managing disease and
promoing wellness. Chapter 4 provides examples of small interventions
that have large benefits. This material is drawn primarily from cognitive
behavioral therapy (CBT) and other modalities that lend themselves for
use in a brief office visit. We discuss the elements common to all schools
of psychotherapy and bring in several new concepts to simplify the process
of inducing positive change. Chapters 5, 6, and 7 provide a rich variety of
techniques that can be used in brief, follow-up counseling sessions with
patients. We have included material dealing with hypochondriasis, anxi-
ety, depression, grief, potential suicide, and issues related to children and
teens.
Chapter 8 presents material from the field of positive psychology and shows
how to potentially enhance patients’ health by focusing them on the affir-
mative aspects of their lives. We introduce the Positive BATHE, which has
received enthusiastic response. Chapter 9 suggests ways that incorporating
our material will improve the office environment, increase patient satisfac-
tion, and prevent staff and practitioner burnout. Throughout the book, we
have added new evidence-based material related to behavioral medicine.
Chapter 10 projects our vision of what is possible for primary care practice,
given widespread acceptance and application of these ideas. It is our hope
that the techniques and applications we outline will enrich the experience of
both practitioners and patients.
We hope you will enjoy reading The Fifteen Minute Hour. Please have fun with
it. Your patients will thank you many times over.
REFERENCES
1. Planck M. Scientific Autobiography and Other Papers. New York: Philosophical Library;
1949.
2. Jones KMG, Marvel K. Counseling patients for lifestyle change: a comparison of two
methods. Proceedings of the Society of Teachers of Family Medicine; Seattle, WA: May 1998.
3. Leiblum SR, Schnall E, Seehuus M, DeMaria A. To BATHE or not to BATHE: patient
satisfaction with visits to their family physician. Family Medicine. 2008;40(6):407–411.
4. Kallerup H. Patient’s and doctors’ considerations about using communication strate-
gies. Proceedings of the 24th Annual Meeting of the North American Primary Care Research
Group; Vancouver, BC: Nov 3–6, 1996
5. Pace EJ, Somerville NJ, Enyioha C, Allen JP, Lemon LC, Allen CW. Effects of a brief
psychosocial intervention on inpatient satisfaction: a randomized controlled trial.
Family Medicine. 2017;49(9):675–678.
6. DeMaria S, Jr., DeMaria AP, Silvay G, Flynn BC. Use of the BATHE method in the
preanesthetic clinic visit. Anesthesia and Analgesia. 2011;113(5):1020–1026.
7. Saxe JG. Clever Stories of Many Nations: rendered in rhyme. Boston, MA: Ticknor & Fields;
1865.
8. Vikram Gupta, MD. Personal e-mail to M. Stuart, June 1, 2014.
Authors
xvi
10 The BATHE technique: Key to making your practice patient-centered
The physician then asks how she feels about this. The patient seems slightly
uncomfortable disclosing her feelings and focuses instead on discussing the con-
tent of her college program. The physician listens intently for a brief while. Then he
patiently asks again how she feels about that. Ms. K.’s shoulders appear to relax
as she admits to feeling rather stressed out concerning the challenges of returning
to school later in life. The physician then comments that that must be very difficult
for her. The patient nods her head in agreement and seems relieved to have her
feelings validated.
The doctor then asks what troubles the patient the most about her situation.
The patient discloses that she finds the workload and associated stress and anxiety
most disconcerting. The doctor then inquires how she has been handling the anxi-
ety. At this point, the patient shares laughter with the doctor as she replies that a
lot of prayers have been getting her through.
The physician acknowledges the helpfulness of prayer and then introduces the
importance of exercise as a further means of reducing stress. Ms. K. reports that
she used to exercise but has not lately. The doctor then explains, “The reason
that I am asking about your stress is that there is a mind-body connection, and
often psychological issues can manifest as or exacerbate physical problems, such
as with your scalp.” This appears to strike a responsive chord with the patient as
she relates, “Oh, yes, Doctor; in fact, a few years ago when I was going through a
stressful divorce, I remember having similar problems with my scalp.” The discus-
sion then returns to the topic of exercise, and with the patient’s eager collabora-
tion, together they formulate a daily exercise regimen that can realistically be
implemented given the rigorous demands of Ms. K.’s scholastic program.
In this situation, the physician weaves BATHE into the encounter and is able
to use it to help the patient make sense of her symptoms as well as prescribing
and getting agreement for an effective management plan.