Do You CAPE?

I am going to mock this article in Medical Economics because that is what I do. In its essence, I always think we physicians can improve how we communicate with patients. My issue is that if the environment is poisoned by metrics and clicks then these recommendations are like pissing in the wind.

The article talks about:

One approach many experts encourage physicians to use is motivational interviewing (MI), a series of techniques to get at the root of patient concerns and help encourage them to make healthy behavior changes.

“At this point in my career, I was quite burnt out,” she says, explaining that her population was quite sick, yet patients continued to keep drinking, smoking, or failing to take their medications. “When I learned motivational interviewing, I changed the way I was with my patients, and as a result my patients changed.”

So how do you do it? Here are two ways:

The concept of OARS offers a snapshot of the skills involved in MI:

O – Open-ended questions
A – Affirmations of the patient’s inner strength
R – Reflective statements
S – Summary statements

and CAPE:

Compassion. The entire interaction is driven by the best interest of the patient.

Acceptance and respecting autonomy. Individuals have the right to change or not change, says Gutnick. “If somebody is not ready, you respect that and you don’t push. You might use some skills to try to guide them toward change, but if you’re hearing a lot of resistance and you have four patients waiting, you don’t push that visit,” she says.

Partnership. The physician is not telling the patient what to do. Instead, “You’re helping the patient move toward change, but you’re equals,” Gutnick says.

Evocation. This means pulling ideas for change out of the patient. “As a doctor, I know a lot of reasons why you should quit smoking, but only you know what’s most important to you,” Gutnick says.

Remember, you first need to do all those clicks to get your payment metrics down. After that you have other problems to deal with because the patients always have more than one complaint. With the last minute you can CAPE or OARS to your heart’s delight. Do you see my point?

I have a realistic mnemonic:

H – hurry the hell up

E – get stuck doing your work every EVENING

L – get out of the system or you will LOSE your mind

P – Pray you will survive a few more years in the job

Can anyone else come up with some so that the ivory tower idiots (academics) can pad their resume? Please share them below.

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  13 comments for “Do You CAPE?

  1. Stephen J Rockower
    September 7, 2019 at 4:57 pm

    Open ended questions? Am I suppose to have all month to do this? Not on your life!

    As to Pat and her professor: I get that all the time, and do that much of the time.
    Them: “I don’t like medicines, and I didn’t do the exercises you prescribed, and I don’t want that shot.”
    Me: “So what do you think I can do for you?”

  2. Jerry
    September 7, 2019 at 3:44 pm

    I don’t care how open ended and empathetic we are, people will not eat better, exercise, stop smoking, stop drinking, and stop using drugs. Most of them had mothers who tried to get them to do these things and failed, how are we to do differently?

  3. Rick
    September 5, 2019 at 6:40 pm

    Priceless, Celia, just priceless! LOL

  4. Rick
    September 5, 2019 at 6:36 pm

    God help me but the bureaucratic bullshit is so deep I’m drowning.
    I SO resent these suggestions from cretins who have no idea what it is like on the ground.

  5. Steve O'
    September 5, 2019 at 2:30 pm

    We see one of the myths that we live by in 21st Century America. Look at the educated professions – doctor, nurse, lawyer, minister, policeman. When perhaps once there was a standard of respect and pride to these, they have been commercialized, bureaucratized and made contemptible.
    Each is at varying stages of a transformation where one must become, to some degree, morally compromised to continue in these professions. Practitioners of these professions have been held in contempt, for the only people who can survive in them are those worthy of contempt.
    Nursing has been ruined long ago. Medicine is only following the path to ruination used on nursing. Psychopathic and immoral monsters are allowed to roam unscathed in the ministry and courthouses.
    The citizenry itself is a hothouse of lies, criminality and betrayal. Women decry the rape culture, narrowing a universal phenomenon to a representative act of betrayal. We do not make each others’ worlds better or safer; the underpinning of civilization.
    Faceless machines execute the medicine and the law upon the people in an impersonal and faceless manner.
    I wouldn’t agree that most patients are childish, ignorant dolts who can be easily manipulated by 15 seconds of fake sympathy. Rather, only the most successful ones can do this effectively.
    de Tocqueville warned long ago:

    Above this race of men stands an immense and tutelary power, which takes upon itself alone to secure their gratifications, and to watch over their fate. That power is absolute, minute, regular, provident, and mild. It would be like the authority of a parent, if, like that authority, its object was to prepare men for manhood; but it seeks on the contrary to keep them in perpetual childhood: it is well content that the people should rejoice, provided they think of nothing but rejoicing. For their happiness such a government willingly labors, but it chooses to be the sole agent and the only arbiter of that happiness: it provides for their security, foresees and supplies their necessities, facilitates their pleasures, manages their principal concerns, directs their industry, regulates the descent of property, and subdivides their inheritances — what remains, but to spare them all the care of thinking and all the trouble of living?

    Blockheads transmute the real risk of loss of freedom into a slavish obedience to any party, organization or institution which rails at governments’ doing such things, while simultaneously enabling the grifting of power, money and influence for the myriad parties, entities, corporations and bureaucracies that do the very same thing. Thanks, AMA, and here’s to you, ABIM.
    The problem is that so many are willing to be infantilized and liberated from the burden of having a mind or conscience which takes up too much attention.
    We prefer to yell at the doctor, “I’m going to speak with your MANAGER and call my CONGRESSMAN!” little realizing that they are wanting a few kibbles from someone running their kennel. In a prison, one can still be human; in a kennel, in which many comfortably reside, not so.
    “None are more hopelessly enslaved than those who falsely believe they are free.” JW von Goethe
    Hateful patients and hate-filled doctors; that’s what American 21st Century Medicine is well on the path to actualizing.

  6. Steve O'
    September 5, 2019 at 2:00 pm

    #1) Diligence. Avoid practice in a position where one’s diligent professional skills are not genuinely honored and encouraged. It takes attentiveness and diligence to provide excellent care. If this is not valued by those who surround and support the clinic, deliberate and diligent care cannot exist.
    #2) Patience. It is impossible to care for other human beings in an environment which disrupts one’s ability to engage in longstanding partnerships in care, rather than the furtive and impersonal urgent care setting where no progress is achieved. Patience with one’s self as well as one’s patients will reap a delightful reward.
    #3) Courtesy & Compassion. Set one’s value in being an honorable professional, a genuine adult and a dignified human being, and expect no less from one’s patients. Your compassion comes from your own affirmation of being valuable to the patient you are caring from. If they cannot value you, let them find someone else who tolerates abuse.
    I apologize it’s not a snappy acronym, but DPC is the only path to self-fulfillment in medicine.

  7. HJR
    September 4, 2019 at 2:23 pm

    Bingo. These people obviously don’t actually practice medicine.

  8. SP
    September 4, 2019 at 11:12 am

    M for mirror your patients’ words to keep them on track about the chief complaint and not discuss the rash their neighbors” kid had last summer

    O order the tests quickly while they’re telling you about how they tried an alcohol free February (shortest month) but couldn’t do it all 28 days

    V for Vindictive as in how you feel when you are subjected to mandatory seminars on “value-based” care and when patients ask you whether you read the recent article in the NYT about “top 40 diagnoses that doctors frequently miss”

    E for exasperation when you battle with your ehr which has a “glitch” and keeps signing you out and for when your assistants knock to tell you that they had to double book you through lunch because it so crazy today and your nurse is out sick and IT is on the phone and wants to review with you how to follow your ehr sign in protocol.

    While you MOVE, just remember:

    “A little less conversation, a little more action, please
    All this aggravation ain’t satisfactioning me”…

  9. Pat
    September 4, 2019 at 8:38 am

    Or….OR, you MedEc dimwits…we could aspire to be like an internist from my med school days. He was an old timer, grabbed the chart, walked in, asked the pt how the med he prescribed was treating her headaches.

    She said she hadn’t really taken them yet, because…

    He cut her off: “You came to me with a problem. I wrote a prescription for your problem, which you elected not to take. What else can I do for you today?”

    Of course, this was in an academic setting…

  10. Pat
    September 4, 2019 at 8:31 am

    S – STATE why you only have 5 min for this visit
    C- COMPLAINTS: you get one (see above)
    R – REVIEW the EMR to make sure you entered family history
    data for a stubbed toe or cold
    E – ENTER every detail possible to reach a Level 3; and
    rush the nurse to ESCORT the patient the hell out
    W – The only WELLNESS within your power is your own,
    which will be a hard workout and a double on the rocks
    at the end of this slog…
    U – …until you can retire or become disabled.

  11. R Stuart
    September 4, 2019 at 8:11 am

    “Acceptance and respecting autonomy. Individuals have the right to change or not change”

    Just remember that in the new world of “value-based care,” it’s your paycheck they’re screwing with if they don’t change.

    Better to just kick them out of the practice.

  12. R Stuart
    September 4, 2019 at 7:59 am

    The underlying assumption is that most patients are childish, ignorant dolts who can be easily manipulated by 15 seconds of fake sympathy.

  13. Celia Entwistle
    September 4, 2019 at 6:50 am

    The last time I asked an open ended question–I think I was a third year medical student doing a handwritten 6 page admit note back in another century. After 15 minutes of some wandering/pointless/unclear answer, I no longer needed my intern to tell me that was a losing proposition.

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