Harpham, Wendy S. MD
Mnemonics aid your efforts to provide expert, compassionate care. They jog a weary brain and focus attention in chaotic settings. At visit's end, they provide reassurance that you've covered the essentials, freeing you to shift your full attention to the next patient.
WENDY S. HARPHAM, MD
I'd like to offer my mnemonic, BEST MED, for an approach to helping patients overcome the emotional obstacles to dealing with complex, upsetting information and/or making the best treatment decision. While you likely do—or try to do—these things already, pulling them together with a mnemonic may make it easier when guiding patients through difficult treatment decisions. The goal is to help patients make the best decision, by which I mean an informed decision in keeping with their values.
B = Best
E = Empower
S = Support
T = Tool
M = Manage uncertainty
E = Encourage
D = Decide
The BEST MED approach begins with verbalizing the mission of “best” before mentioning any treatment options: “My number one goal is to help you determine the best treatment path for you.” In seconds, professing commitment personalizes the interaction and fosters trust, which calms patients' fears, including that of being pressed into a treatment choice (especially if discussing clinical trials).
For patients with anxieties and/or misperceptions about various treatments, a sense of striving for “best” may help them keep an open mind as you discuss options and offer recommendations.
Importantly, the notion of “best” lays the groundwork for helping patients take advantage of support, manage the uncertainty, and, finally, develop confidence in their ability to make a wise decision and handle whatever happens.
Empowering patients can enhance communication. For example, instructing patients to ask questions and tell you to slow down as needed can help as much by engaging their active listening as by ensuring that your pace matches their needs.
Affirming the power of their stories to help you determine both prognoses and best possible outcomes may facilitate the history-taking: “Your accurate reporting enables me to make an accurate assessment of what you can expect with each treatment, so you can compare your options. Your reporting also helps me assess what you can hope for with each option, which helps you determine the best path for you.”
In our culture of shared decision-making, some patients don't want a lot of medical details and prefer to have you make the final decision. Even here, words of empowerment may enhance communication, especially if patients feel tempted to hold back information they find embarrassing or too (whatever): “For me to make the best recommendations for you, I'm depending on your candor about both your symptoms and your priorities.”
In seconds, you can provide a bounty of support in a handout that outlines key insights and tips about decision-making (such as the one offered in my April 25, 2014 column), along with a short list of patient-centered resources. To keep this bounty from being tossed into the garbage, unread, you can prescribe it with the same authority as a medicine: “Common, normal thoughts and feelings can interfere with making the best decision. Your reviewing this handout helps me prevent that from being an issue for you.”
Another form of support is to invite patients, in the absence of physicians, to talk with nurses (or other members of the health care team) about their treatment options. This may be the only place some patients are willing to ask certain questions and share some information that ultimately proves essential to making the best recommendations and decisions. This really shouldn't take a lot of time, if incorporated into routine care.
A tool for decision-making is a form of support that merits its own letter, because for some patients it's essential to making the best decision. Tools can serve you, too, by providing a compact way to validate that patients are processing medical information properly and to learn about patients' values.
M: Manage Uncertainty
Helping patients manage uncertainty—another form of support—warrants a separate letter because a heightened sense of uncertainty can threaten sound decision-making.
For example, bringing up the uncertainty related to the risk of unexpected problems can ignite patients' imagination with horror-movie images. You can relieve that anxiety by explaining: “Unexpected medical problems are usually familiar, treatable problems—such as unexpected rashes or unexpected diarrhea.”
With no way to foretell a patient's outcome with each option, you can relieve patients of the burden of searching for certainty: “The best decision is always the best decision. We can make the best decision based on all information available.” If appropriate, you can add, “Cancer doesn't make life uncertain... cancer only makes life feel more uncertain by exposing the uncertainty of life.”
Words of encouragement matter. I remember times that my physicians' off-the-cuff comments reverberated in my head for days, helping me in ways no one else in my life could. It can be a simple “You can do this.”
At decision time, you can bolster patients' confidence: “You have the information and tools you need to make the best decision. I will support whatever you decide.” Then, having used the BEST MED approach, you can let go and expect patients to continue to benefit from your guidance and support as they make their final decision.
The BEST MED approach reflects my belief that a shared mission to determine the best treatment path for each patient is the best medicine—not only for patients, but also for clinicians. At the end of each day, you'll enjoy the satisfaction of having used the art and science of medicine to help patients live life their way.
Whatever patients ultimately decide and whatever the medical outcome, you'll know you did your best to provide expert, compassionate care.