First 5 Minutes® - phaware® interview 530

In this episode, Drs. Victor Test, Deborah Levine and Rodolfo Estrada discuss CHEST’s First 5 Minutes® program, which helps medical professionals build the skills that lead to a positive relationship with patients from the get-go. The goal is to improve patient care, shorten time to diagnosis for complex or rare diseases like pulmonary hypertension, and increase patient compliance and buy-in to their treatment plan.

Victor Test, MD, FCCP:
I'm Dr. Victor Test, Chief of Pulmonary Medicine and Critical Care at Texas Tech University in Lubbock, Texas and Director of the Pulmonary Vascular program.

Deborah Levine, MS, MD, FCCP:
Hi, I am Debbie Levine. I'm a lung transplant and PH doctor and I'm working at Stanford University.

Rodolfo Estrada, MD, FCCP:
Hi, I am Rodolfo Estrada. I'm a UT Health San Antonio pulmonologist and working in pulmonary hypertension, as well. Today, we want to share a little bit about the First 5 Minutes initiative from CHEST, which talks about how do we approach patients in the first five minutes to gather the most amount of information, create trust, and build up empathy to better care for patients.

Victor Test, MD, FCCP:
The First 5 Minutes program was developed in response to our recognition at CHEST about the difficulty that had developed during the period of the COVID pandemic with trust between patients and healthcare professionals, and particularly physicians. As you know, during that time we were all particularly challenged because of lots of information in the media and doubt and fear with patients. The difficulties we faced in ICU care of critically ill patients with isolation and the difficulty that families had with that. So in response to that, we developed something called The Listening Tour where in five different cities of the US, including San Antonio and San Francisco and Atlanta and Chicago, we went out and we recruited patients and we spoke to them about the challenges they had faced with their chronic lung diseases. They ranged from asthma to COPD to pulmonary fibrosis to pulmonary hypertension, and how their patient journey was impacted by their interactions.

What we learned was that there was a significant breakdown in trust. As a physician, usually I go into a room assuming that I have trust. What we really realized is that physicians have to build that trust and develop that trust. It isn't just given to us as an anointment because we're a physician and we're there to try to help. So we developed at CHEST this program called the First 5 Minutes. The concept of it is that physicians and healthcare providers need to develop a rapid rapport and understanding of the patient and develop this trust with active listening, empathetic listening and direct feedback with emotional support while incorporating the patient into the decision-making process.

Deborah Levine, MS, MD, FCCP:
I think really what the First 5 Minutes is an approach to how we as physicians can interact with our patients when we either don't know them or do know them, to kind of build a bridge of trust but also learn to respect each other in terms of being able to understand the best ways to communicate and also understand. I think patient understanding is a big part of it.

Rodolfo Estrada, MD, FCCP:
The beautiful thing about the First 5 Minutes is that you can use it for new patients and follow up patients because it caters to whatever the patient thinks is most important for them for that visit. Sometimes, we pre-chart those patients and have an idea of what we want to talk about, but the patient has new findings and new developments happening. If you take those first five minutes and you take a moment to really elicit that out, most of the times the patient will bring it up but won't be the first thing that they bring up.

One of the tools that the First 5 Minute initiative has is that you ask, “What else? “Then you ask again, “What else?” Then you ask again, “What else?” Maybe by the third “What else,” the real conversation comes on, and then you can develop the rest of the time talking about it and still do your clinical part that you have to do, but in alignment to what's important for the patient for that specific visit. If it's emergent, they'll bring it up quicker than the other ones, but otherwise I think they'll still be able to bring it up.

Victor Test, MD, FCCP:
What we're trying to do is to push this program forward so that we spread it out to physicians at all levels of training as well as post-training, so that it permeates throughout the US healthcare system. We'd really like for it to eventually be part of every training program and post-training program so that our physicians can breach that divide between patients and physicians. It really doesn't have to be physicians, it could be physicians assistants, nurse practitioners, nursing, medical assistants. Anyone can be taught these skills. Sometimes, there's a concern by people when they hear about this, the say, “Well, that's going to take a lot more time.” In fact, studies show that empathetic listening and patient-centered interviews actually take less time and they make the healthcare more efficient. It actually has a win-win solution for most physicians if they're able to use these skills and it helps the patient and develops trust, we believe. This tool set and this educational program can make a big difference for our pulmonary critical care physicians.

Ultimately, the goal here is to improve patient care and to incorporate them into decision making. We believe and we hope that that would decrease time to diagnosis for difficult to diagnose or more rare disorders. Certainly, we wanted to improve healthcare for patients so that we can help identify the obstacles that they face, and improve their compliance and their buy-in to whatever program we develop for them for their care. It aligns the patient and the physician so that they can each achieve the goals that the patient and the physician have, and put them in parallel rather than disparate pathways.

Deborah Levine, MS, MD, FCCP:
The idea that we as a community, I'm talking all physicians whether it be PH or anything else, we are limited often in time. If you are in a busy pulmonary clinic where you're seeing 30 patients in the morning and 30 patients in the afternoon, you may have some type of preconceived notions or preconceived ideas about what this patient has. So leading that patient, you may be leading him or her to say what you believe they have. This way, I think it is more efficient, because you can then say, "Hey, listen to the story.” Take the five minutes and listen to the story. It may not be asthma and it may not be COPD, which is what many of our patients are diagnosed with instead of whatever they have. I think this can help that bridge to understanding what the patient has, but also it can do it in a way that also kills two birds with one stone. You maybe get a more efficient trajectory in terms of getting a diagnosis, but also you make them feel so much more comfortable.

Rodolfo Estrada, MD, FCCP:
I think that's something that's important within the rare disease space with PH being one of them, is that, as humans, we're prediction machines. When we see someone with shortness of breath, we're going to go and think about what's the most likely diagnosis from what we've seen in the past. In the rare disease space, that becomes challenging, because then we have to pause. Having that pause initially when you're first going to see the patient and checking if your biases, if your assumptions, are correct. That can be taught and doesn't need a lot of time. So a nurse that sees a patient before the provider goes into the room can have that same approach of pausing, and making sure that what we're seeing and what the patient is saying are congruent things.

Victor Test, MD, FCCP:
One of the things that has been observed in medical interviews is that patients often are interrupted quite frequently by healthcare providers to try to facilitate their story. When in fact, when patients are left to tell their own story they often give a more complete and thorough story than we as healthcare providers would like to ask.

So the PEARLS is an acronym to remind us of important points in interacting with the patient. They range from personal to support, and empathy, acknowledgement. When you use those in a patient interview, you don't have to use them all in every interview. In fact, if you did, you probably would defeat the purpose of them. But to use those different points to help you to connect with the patient and help each other understand the healthcare that they're receiving is actually a team between them, their family and the healthcare providers that they're seeing.

Deborah Levine, MS, MD, FCCP:
I learn a lot more about patients, their families, and their life. There's no question that that comes organically. Empathy isn't something you have to think about, it just happens, because if you hear these patient stories, if you hear their families talking about them and their past, it's there. You automatically become very involved and included into their life. That's what I think it does. It makes that easier to make it more than just the patient-physician relationship. It makes you feel empathetic. I think that's a big deal. I don't think you have to do it. It happens on its own with this process.

Rodolfo Estrada, MD, FCCP:
Another aspect I think is important is that the patients when they show up to a provider, they have an expectation of something from that visit. Sometimes, the provider may give medications, but with the First 5 Minutes, you can also give them a space for the patient to actually share their journey and share their experience. The patient visit becomes complete when the patient is fulfilled. I think the providers will be more comfortable at times not prescribing medication because their role has been fulfilled through that visit. I think that will actually allow for these patients with pulmonary hypertension to be recognized earlier on, because the symptoms are pretty characteristic once their story is allowed to come to life. I think that's what the First 5 Minutes allow to do.

Victor Test, MD, FCCP:
We really want to develop this program so that it improves patient communication and trust so that we shorten this time to diagnosis. When I first began working in pulmonary hypertension, the average time to diagnosis was two and a half years from the onset of symptoms. In registries that are published after that, despite the increasing technology and awareness of the disease that time has actually increased into nearly three years. We need to actively work to change that from a pulmonary hypertension standpoint. But the First 5 Minutes is not just for pulmonary hypertension, it's for all lung diseases or really any disease. We want to shorten the time to diagnosis of complex lung diseases.

Deborah Levine, MS, MD, FCCP:
Where I think it's going to help the most is, obviously, with PH doctors or whatever the specialty is, asthma doctors or something. But actually with more generalized care either in the ER or the primary doc or even a community physician that is not in a specialized practice. I think that's where it starts and that's where a lot of the delay is, because patients come to us on inhalers that don't need inhalers because they don't have asthma. My thought is yes, I think it will help all of our teams. I think even more than that, it will help us if we can get this type of practice out to more of the general community. Even in the ER, you can take five minutes and get a good history, because maybe this is not what they have and maybe this is.

Rodolfo Estrada, MD, FCCP:
What I think about the First 5 Minutes in the pulmonary hypertension space is that these patients go through a lot for a very long time. It's not just the patient, but their community, their work, their families. The First 5 minutes allows the provider and the priority system to understand that dynamic a little bit better. It's not only the outcome of being able to walk more or mortality, it's what is the day-to-day looking like and how do we make that day-to-day better with interventions that we have available? Sometimes, those interventions are listening and being part of the journey with our patients, that conversation of empathy. Empathy is something that the provider and the system will feel once you start getting into a personal note with these patients that our system sometimes doesn't allow us as much. This is a tool to really bring that story to life and bring it into the space of conversation.

Thank you for listening. My name is Rodolfo Estrada…

Victor Test, MD, FCCP:
I'm Dr. Victor Test…

Deborah Levine, MS, MD, FCCP:
I'm Dr. Debbie Levine, and we are aware that our patients are rare.

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