405 - General Health Checks, Compassionate Communication With PPE
Take 3 – Practical Practice Pointers©
From the Literature
1) General Health Checks in Primary Care – Redux
The value of general health checks (health maintenance visits, etc.) has been vigorously debated. Three previous systematic reviews have attempted to solve the issue with conflicting results, but the authors of this review charged once again into that breach to try to give us an answer. They used the references from the three previous reviews and updated the search since the last review was published. They included published randomized controlled trials from any time, and included observational studies published since 2000. They excluded small studies (N<200 subjects) but tried to include studies that were more relevant to the US primary care system (some of which had been excluded in previous reviews). The authors looked at a broad array of outcomes: mortality, quality of life, chronic disease outcomes, preventive service delivery, etc.
Thirty-two studies were found (19 RCTs). They were a very heterogenous collection – they differed by geography and presence of a national health care system, whether a physical examination was included, whether one or more providers were involved, whether they were single exams vs. yearly exams. No meta-analysis could be performed, so the results are described narratively.
- Overall mortality was reduced in older populations only [in a US study of Medicare enrollees (9% vs 22%; P = .02, NNT~33) and in a Swedish study (10% vs. 11%, hazard ratio [HR], 0.93 [95%CI, 0.88-0.98], NNT~100)], but not for studies in the general population.
- Cardiovascular outcomes were generally not reduced.
- Chronic disease detection was generally increased – new diagnoses of hypertension, diabetes, and chronic kidney diseases as well as prescriptions of antidepressants and statins.
- Risk factor modification was achieved in several studies – mostly small improvements in blood pressure, cholesterol levels, and weight.
- Preventive services delivery – more patients undergoing health checks receive the indicated preventive services. This was shown for Medicare Annual Wellness Visits as well as non-Medicare populations. Preventive services delivery goes back down when the health checks are stopped (seen in follow-up studies).
- Health behaviors improved – but mainly for diet and exercise. Tobacco and excessive alcohol use were not affected in the studies, but it is unclear if recommended methods of addressing these behaviors (such as motivational interviewing) were consistently employed.
- Patient-reported quality of life improved and health anxiety decreased with routine health checks.
- Adverse events – increased mortality was seen in one trial (Medicare population) but was explained post-hoc by increased advanced care planning resulting in fewer unwanted life-prolonging interventions for some patients. Two other studies (Scandinavian) showed increased cancer mortality, lifestyle-related mortality, and stroke incidence. These were thought to be due to over-medicalization (supplement use, hospitalization, etc.). In another Scandinavian study, a decline in cardiovascular mortality was accompanied by an increase in hospitalization for COPD and stroke. The authors hypothesized that treatments begun during those hospitalizations led to the reduced mortality.
The authors conclude that health checks probably confer an overall benefit, especially in our fragmented US healthcare system. Physical examinations were not demonstrated to be necessary as part of these visits.
The evidence here is mixed but is more positive that previous reviews have suggested. Overall mortality reduction is a high bar for a single intervention and the time frames for most of these studies are likely too short to definitively measure an effect on this outcome. General health checks reinforce the essential beneficial characteristics of primary care: first contact, accessibility, longitudinality, and comprehensiveness; these outcomes are not well-measured in our system or in these studies. An accompanying editorial notes the Choosing Wisely recommendation against routine health checks from the Society of General Internal Medicine and highlights the differences between the currently in-vogue “executive physicals” vs. health checks driven by evidence.
I personally like to use general health checks as an opportunity to get to know my patients better and establish relationships outside the complaint-driven visit. If you don’t use health checks, then it is important to establish reminder and recall systems to ensure that your patients get the recommended screenings and preventive services.
- General Health Checks in Adult Primary Care: A Review | Cancer Screening, Prevention, Control | JAMA | JAMA Network [Internet]. [cited 2021 Jun 21]. Link
- Brett AS. The Routine General Medical Checkup: Valuable Practice or Unnecessary Ritual? JAMA. 2021 Jun 8;325(22):2259. Link
From the Literature
2) Compassionate Communication as We Emerge from COVID
COVID-19 introduced several barriers to effective doctor-patient communication. Personal protective equipment (PPE) complicated our ability to read and understand one another’s nonverbal cues, and often made verbal communication more difficult as well. Physical distancing and isolation removed the role of physical touch from patient visits. These barriers often contributed to poor attitudes, ineffective communication, and emotional fatigue.
Even as we begin to “open up” more, most are still wearing face masks, and this will likely continue on and off in some form over the next year. As such, reminding ourselves how to optimize communication during this time is imperative (as well as when we’re no longer masking).
Research is clear that compassionate caring as manifested in therapeutic communication techniques is essential for patient care. Such techniques help the clinician establish effective rapport and have been shown to improve patient adherence, increase favorable medical outcomes, improve efficiency, increase patient satisfaction, and lower the chances of malpractice claims.
Research on the neuroscience of compassion has also revealed the process of neuroception, which means that human beings have a rapid, unconscious neural ability to assess safety, stress, or mortal danger in any interaction by reading verbal and non-verbal cues. Our PPE has interfered with this ability and has contributed to a patient’s sense of lessened safety and a diminished sense of empathy in the clinical encounter.
Even under these less than ideal conditions, clinicians can improve communication with patients by emphasizing nonverbals that are not hidden behind PPE, such as hand gestures, posture, head nodding, eye contact, and even physical position within the exam room. The limitations of nonverbal communication increases the importance of verbal communication as well. Verbally validating patient emotions and building rapport throughout the patient interaction are ways to overcome nonverbal communication challenges presented by PPE and make the patient feel safe. Speaking slowly and distinctly, enunciating, and facing patients when talking to them with a face mask on ensures they can better hear your empathic verbal communication.
Clinicians should also not make the mistake of considering facial expressions to be less important. For example, smiling is communicated not only by the mouth and lips, but also by the crinkling of the skin around the eyes and the tone of voice. Exaggerating facial expressions can help overcome some of this limitation.
Serious conversations have been especially difficult during the pandemic. Telling patients that they might have a serious illness is always hard to do, but even more so with masks and distancing. The patient is left vulnerable in the presence of the physically distanced clinician, amplifying the isolating effects of the moment.
To compensate for physical distancing, clinicians must find other ways to achieve emotional closeness with their patients during these conversations. Carefully chosen verbal communication coupled with good listening skills help give patients the sense that they are cared for. An acronym that can be a helpful reminder to achieve this expression of compassion is SPIKES:
- S = Setting up the appointment meaningfully
- P = checking the patient Perception of any concerns
- I = Inviting the patient to ask questions
- K = having Knowledge of medical facts and explaining them clearly
- E = Exploring and responding to emotions
- S = establishing a strategy for Support
Being open and honest with the patient about COVID-19 precautions can also be helpful. For example, saying, “I’m sorry we have to wear these masks. They are intended for everyone’s safety, including both you and the entire team helping to take care of your health.” Every intentional step you take toward better communication during this unprecedented time can make all the difference in the physical, emotional, and psychological well-being of your patients.
As PPE requirements and other public measures are being relaxed but not yet eliminated, I thought this was a helpful reminder. Though I absolutely understand the reasons why, I’ve even found myself increasingly annoyed and impatient at having to continue to wear a mask when I’m not wearing one most other places, and therefore I need to regularly remind myself to “check my attitude” before I enter an exam room so I don’t spread any negative emotional contagion.
Be sure as well to check in regularly with your care team to see how they are handling these ongoing challenges. We’re not at the “finish line” yet, and there is a real possibility that there may not be one for quite some time yet, if ever.
Zabukovic BW, Wisniewski NG, Vachon DO. A Compassionate Communication Refresher for Clinicians Experiencing COVID Fatigue. Fam Prac Mgt published ahead of print July/August 2021. Link
Mark and John
Carilion Clinic Department of Family and Community Medicine
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