Families, Systems, & Health 2015, Vol. 33, No. 1, 16 –17
© 2015 American Psychological Association 1091-7527/15/$12.00 http://dx.doi.org/10.1037/fsh0000112
COMMENTARY
Response to Dr. Ventres’ Q-List Manifesto Stephen Schultz, MD and Natercia Rodrigues, MD
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Rochester
Q Is for Questions
Dr. Ventres’ article clearly defines why a checklist approach that is appropriate to procedurally oriented specialties is often not appropriate in primary care. For those of us in primary care who felt uneasy about a checklist approach, it is a welcome reflection on some of the underlying reasons for that unease. Dr. Rodrigues: I recall a patient who I hadn’t seen in a while. It was a busy session and she sat down and told me she wanted to cover “everything. Make sure everything was okay.” I proceeded to attempt to set an agenda by eliciting her spectrum of concerns and we tried prioritizing them together. We’d try to focus on two or three items and we’d get distracted with another concern. I grew frustrated and anxious as the remaining minutes of the visit dwindled. I looked at her. “What else is going on besides the physical stuff? How’s home?” She stopped. “My son just got diagnosed with leukemia. Out of nowhere. My life has been that.” It was then that the visit truly began. Notes constructed by checklists in an Electronic Health Records (EHR) often leave a sense of “but what really happened? What was the patient really like then?” Checklists in the EHR are also a potential source of error. Autopopulated physical exam findings and Review of Systems (ROS) are sometimes overlooked, and the wrong items may be documented out of routine. Checklists within a primary care setting take away the patient narrative which Dr. Ventres emphasizes in his Q-List.
Ultimately the “Q-List” is a manifesto about remaining curious about our patients and their context. For patient care to be truly patientcentered, patients contribute to the agenda, change it, and providers adapt. The Q-List reminds physicians that patients are more than a collection of symptoms and physical exam findings. The notion of treating patients in the context of their health should not be new to providers. Primary care residents are often taught about the importance of psychosocial medicine and are encouraged to explore a patient’s world outside of his or her disease. The Q-List reminds us that these lessons do not stay in residency training but are a part of our growth as physicians. We are in complete agreement with Dr. Ventres when he states “When checklists suggest how I should communicate with patients . . . I cringe.” Primary care cannot be broken down into symptoms and diseases and neither can patients. However, checklists can have an invaluable role in the formative assessment of learners. One such checklist is the PatientCentered Observation Form (PCOF), which allows faculty to break down the intricate process of a primary care visit into directly observable, discreet aspects or behaviors we want to reinforce with learners. It is much easier to teach and improve the process of a visit when it is broken down into discreet actions and behaviors. The PCOF is a tool, and like using a hammer to screw in a bolt, it can be misapplied. The PCOF used as a “check as you complete” checklist of how to conduct yourself in a visit would be an unmitigated disaster.
Stephen Schultz, MD and Natercia Rodrigues, MD, Family Medicine Department, University of Rochester. Correspondence concerning this article should be addressed to Natercia Rodrigues, MD, Highland Family Medicine/University of Rochester, 777 South Clinton Avenue, Rochester, NY 14620. E-mail: Natercia_Rodrigues@urmc .rochester.edu
The Q-List Is Also a Tool Its application seems especially helpful with new patients, patients from other cultures, and 16
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
RESPONSE TO DR. VENTRES’ Q-LIST MANIFESTO
those who speak a different language than the clinician. It will be invaluable for those patients who have uncontrolled chronic illnesses such as asthma, diabetes, or hypertension. The Q-List touches on many of the issues that often underlie an uncontrolled condition. Finally, the Q-List may be especially helpful for those patients many of us care for who we secretly sometimes hope do not show up. Often we feel like we know why—they are drug-seeking, they always have a laundry list of complaints, they seem cold or angry. We just don’t “click.” There are often additional
17
issues we brush by, too busy to examine. The relational issues section of the Q-List is helpful for those patients. It may increase our understanding, which could lead to increased empathy, and our ability to provide good care through caring. Anything that increases our caring will increase the meaning of our work, which in turn will increase our joy of practice—and we can’t say that about any other checklist. Received January 6, 2014 Accepted January 7, 2014 䡲
Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process. If you are interested in reviewing manuscripts, please write APA Journals at [email protected]. Please note the following important points: • To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review. • To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research. • To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, “social psychology” is not sufficient—you would need to specify “social cognition” or “attitude change” as well. • Reviewing a manuscript takes time (1– 4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly. APA now has an online video course that provides guidance in reviewing manuscripts. To learn more about the course and to access the video, visit http://www.apa.org/pubs/ authors/review-manuscript-ce-video.aspx.
© 2015 American Psychological Association 1091-7527/15/$12.00 http://dx.doi.org/10.1037/fsh0000112
COMMENTARY
Response to Dr. Ventres’ Q-List Manifesto Stephen Schultz, MD and Natercia Rodrigues, MD
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Rochester
Q Is for Questions
Dr. Ventres’ article clearly defines why a checklist approach that is appropriate to procedurally oriented specialties is often not appropriate in primary care. For those of us in primary care who felt uneasy about a checklist approach, it is a welcome reflection on some of the underlying reasons for that unease. Dr. Rodrigues: I recall a patient who I hadn’t seen in a while. It was a busy session and she sat down and told me she wanted to cover “everything. Make sure everything was okay.” I proceeded to attempt to set an agenda by eliciting her spectrum of concerns and we tried prioritizing them together. We’d try to focus on two or three items and we’d get distracted with another concern. I grew frustrated and anxious as the remaining minutes of the visit dwindled. I looked at her. “What else is going on besides the physical stuff? How’s home?” She stopped. “My son just got diagnosed with leukemia. Out of nowhere. My life has been that.” It was then that the visit truly began. Notes constructed by checklists in an Electronic Health Records (EHR) often leave a sense of “but what really happened? What was the patient really like then?” Checklists in the EHR are also a potential source of error. Autopopulated physical exam findings and Review of Systems (ROS) are sometimes overlooked, and the wrong items may be documented out of routine. Checklists within a primary care setting take away the patient narrative which Dr. Ventres emphasizes in his Q-List.
Ultimately the “Q-List” is a manifesto about remaining curious about our patients and their context. For patient care to be truly patientcentered, patients contribute to the agenda, change it, and providers adapt. The Q-List reminds physicians that patients are more than a collection of symptoms and physical exam findings. The notion of treating patients in the context of their health should not be new to providers. Primary care residents are often taught about the importance of psychosocial medicine and are encouraged to explore a patient’s world outside of his or her disease. The Q-List reminds us that these lessons do not stay in residency training but are a part of our growth as physicians. We are in complete agreement with Dr. Ventres when he states “When checklists suggest how I should communicate with patients . . . I cringe.” Primary care cannot be broken down into symptoms and diseases and neither can patients. However, checklists can have an invaluable role in the formative assessment of learners. One such checklist is the PatientCentered Observation Form (PCOF), which allows faculty to break down the intricate process of a primary care visit into directly observable, discreet aspects or behaviors we want to reinforce with learners. It is much easier to teach and improve the process of a visit when it is broken down into discreet actions and behaviors. The PCOF is a tool, and like using a hammer to screw in a bolt, it can be misapplied. The PCOF used as a “check as you complete” checklist of how to conduct yourself in a visit would be an unmitigated disaster.
Stephen Schultz, MD and Natercia Rodrigues, MD, Family Medicine Department, University of Rochester. Correspondence concerning this article should be addressed to Natercia Rodrigues, MD, Highland Family Medicine/University of Rochester, 777 South Clinton Avenue, Rochester, NY 14620. E-mail: Natercia_Rodrigues@urmc .rochester.edu
The Q-List Is Also a Tool Its application seems especially helpful with new patients, patients from other cultures, and 16
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
RESPONSE TO DR. VENTRES’ Q-LIST MANIFESTO
those who speak a different language than the clinician. It will be invaluable for those patients who have uncontrolled chronic illnesses such as asthma, diabetes, or hypertension. The Q-List touches on many of the issues that often underlie an uncontrolled condition. Finally, the Q-List may be especially helpful for those patients many of us care for who we secretly sometimes hope do not show up. Often we feel like we know why—they are drug-seeking, they always have a laundry list of complaints, they seem cold or angry. We just don’t “click.” There are often additional
17
issues we brush by, too busy to examine. The relational issues section of the Q-List is helpful for those patients. It may increase our understanding, which could lead to increased empathy, and our ability to provide good care through caring. Anything that increases our caring will increase the meaning of our work, which in turn will increase our joy of practice—and we can’t say that about any other checklist. Received January 6, 2014 Accepted January 7, 2014 䡲
Members of Underrepresented Groups: Reviewers for Journal Manuscripts Wanted If you are interested in reviewing manuscripts for APA journals, the APA Publications and Communications Board would like to invite your participation. Manuscript reviewers are vital to the publications process. As a reviewer, you would gain valuable experience in publishing. The P&C Board is particularly interested in encouraging members of underrepresented groups to participate more in this process. If you are interested in reviewing manuscripts, please write APA Journals at [email protected]. Please note the following important points: • To be selected as a reviewer, you must have published articles in peer-reviewed journals. The experience of publishing provides a reviewer with the basis for preparing a thorough, objective review. • To be selected, it is critical to be a regular reader of the five to six empirical journals that are most central to the area or journal for which you would like to review. Current knowledge of recently published research provides a reviewer with the knowledge base to evaluate a new submission within the context of existing research. • To select the appropriate reviewers for each manuscript, the editor needs detailed information. Please include with your letter your vita. In the letter, please identify which APA journal(s) you are interested in, and describe your area of expertise. Be as specific as possible. For example, “social psychology” is not sufficient—you would need to specify “social cognition” or “attitude change” as well. • Reviewing a manuscript takes time (1– 4 hours per manuscript reviewed). If you are selected to review a manuscript, be prepared to invest the necessary time to evaluate the manuscript thoroughly. APA now has an online video course that provides guidance in reviewing manuscripts. To learn more about the course and to access the video, visit http://www.apa.org/pubs/ authors/review-manuscript-ce-video.aspx.
