Miller School Professors Publish Practical Approach to Guiding Residents in Patient Interactions

Over the course of 18 years, Heidi Allespach, Ph.D., associate professor of clinical family medicine, medicine and surgery, and Director of Behavioral Medicine, identified specific patterns in the interactions between new doctors and their patients. In particular, she saw how the relationships were strained by persistent paperwork, electronic medical records and obstacles to delivery of care by insurance carriers.

These issues, combined with increased time pressures, contribute to physician stress and burnout, and Allespach wanted to help restore the rewarding and satisfying aspects of patient care. After reviewing more than 700 videos of residents interacting with patients and the extant literature, Allespach developed what she calls the “Rule of Six 2s” — a simple step-by-step protocol for maximizing the efficiency and quality of patient interactions. Each pair of rules is based on the “TAD” — Take, Address, Do — structure:

1. Take 2 minutes.
Reflect on previous notes.

2. Take 2 minutes.
Relax and connect with the patient.

3. Address 2 problems.
Reconcile: Prioritize problems and negotiate with the patient.

4. Address 2 items.
Read aloud while typing notes.

5. Do 2 times.
Wash and rinse hands before and after.

6. Do 2 times.
Review and write down important “homework.”

Erin N. Marcus, M.D., associate professor of clinical medicine and Director for Education at the UM/JMH Academic Internal Medicine Primary Care Residency Training Clinic — a colleague with whom Allespach works closely training internal medicine residents — had observed similar problems and liked the Rule of Six 2s. The two decided to collaborate on a journal article that would offer a practical approach to patient interaction for young doctors who seek rewarding medical careers. The article, “The Rule of Six 2s: Teaching Learners Simple Strategies for Structuring an Outpatient Adult Primary Care Follow-up Visit in the 21st Century,” was published in the August issue of the Postgraduate Medical Journal.

“Our residents at UM/Jackson are topnotch and are dedicated to delivering compassionate care,” said Allespach. “However, like residents everywhere, they are faced with significant challenges, such as heavy patient loads and the integration and use of new technology. Our goal with the Rule of Six 2s is to enhance efficiency while also helping learners maintain strong interpersonal connections with their patients.”

Ingrid Gutierrez, M.D., a first-year family medicine resident, learned the Rule of Six 2s in Allespach’s course.

“This model has helped me tremendously,” she said. “It provides a tangible way to look at time efficiency and patient satisfaction. Also, it promotes professional satisfaction and physician wellness. It helps prevent burn out, because it sets realistic expectations for the patient and for the provider.”

Marcus, who has more than two decades of experience in primary care, said, “Our plan provides a structure to things that we do routinely, such as look through the record and write notes. Clinic encounters with patients can be a bit overwhelming to novice doctors because they are bombarded with lots of information that they have to integrate right away. You have to learn to think on your feet while remaining calm, cool, and collected. A key component is a moment of reflection and mindfulness before seeing the patient, which helps the practitioner be fully engaged in their brief but intense interaction.”

She calls the electronic medical record, in particular, a ubiquitous presence in the exam room that often negatively intrudes into physicians’ interaction with patients.

“The stress of using the computer while keeping up with a tight schedule contributes to physician burnout,” she said. “The Rule of Six 2s is our attempt to provide a straightforward strategy for using the EMR in daily practice while being efficient and maintaining a meaningful connection with patients.”

Meredith Turner, a second-year family medicine resident, said, “The Rule of Six 2s is critical in the primary care setting in which we are only given a short time to see complex patients with multiple medical problems. Following the rule allows me to connect with the patient while addressing their medical problems.”

Looking ahead, Allespach and Marcus plan to continue to disseminate this model to their trainees and to the broader medical community at national and international conferences. In addition, they hope to rigorously study the effects of this model on patients’ satisfaction with their visits as well as doctors’ career satisfaction.

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