Patient-Doctor Communication Lacking in Chronic Migraine Treatment
One of the most essential elements of migraine management is effective communication between us and our doctors.
Research presented at this year's scientific meeting of the American Headache Society indicated that many patients with chronic migraine receive suboptimal medical treatment even when they seek medical care. Researchers found that the majority of clinical encounters between CM patients and physicians were missing essential components of effective communication.
"Effective medical communication is vital to accurate diagnosis, optimizing treatment plans, and facilitating patient adherence. Recording actual physician-patient encounters is an ecologically valid and powerful approach for studying communication, not previously applied to chronic migraine (CM)."1
- 20 neurologists recorded routinely scheduled headache/migraine visits and submitted 67 encounters with patients the physician felt had CM.
- Dialogues from those appointments were anonymized and transcribed.
- Several communication parameters and strategies indicative of good migraine-related medical care were investigated. This included the “ask-tell-ask” strategy, which is an interactive communication strategy that elicits information, allows for a response, clarifies/rephrases, and then offers the opportunity for the pattern to continue.
- The dialogues were subsequently coded in the following areas:
- communication methods (visit duration, use of ask-tell-ask, and use of open ended questions),
- headache/migraine history content areas (headache and migraine frequency, headache related disability), and
- communication from the doctor to the patient (diagnosis and treatment).
A total of 35 out of 67 encounters were eligible for analysis based on robust headache/migraine discussions (i.e., multiple physician"patient exchanges during the dialogue). Analysis of these visits revealed:
- On average, encounters lasted 11 minutes and included 17 headache/migraine-related questions
- Open-ended questions (e.g., "How do your headaches affect your life?"), which are recommended to initiate a dialogue about chronic migraine, were used in just 4 percent of encounters.
- Determining the number of headache/migraine days each month is crucial to distinguishing between episodic and chronic migraine. Although migraine frequency was discussed in 70 percent of encounters, migraine attacks (which often last more than a day) and days with migraine were distinguished just 4 percent of the time.
- Headache/migraine-related disability, a critical determinant of treatment needs, was discussed in only 30 percent of encounters.
- The diagnosis "chronic migraine" was mentioned in just 9 percent of visits.
- Treatment plans were discussed in only 37 percent of visits.
"The majority of CM physician-patient encounters were missing elements judged to be crucial to effective CM diagnosis and treatment. Improving communication between neurologists and patients may facilitate more effective CM diagnosis and treatment."1
Richard B. Lipton, MD, director of Montefiore Headache Center and vice chair of neurology, and the Edwin S. Lowe Chair in Neurology, Albert Einstein College of Medicine, commented:
"The study shows we can do much better. Effective medical communication is vital to accurate diagnosis, optimizing treatment plans, and facilitating patient adherence. We found that recording actual physician-patient encounters provides a powerful tool for evaluating communication. The next step is to see if improving communication will improve treatment outcomes."
Comments and Implications for Patients:
Especially given that Dr. Lipton has been writing and talking about the "ask-tell-ask" approach for several years, I find these results very disappointing:
Open-ended questions were used only 4 percent of the time. Although many patients with chronic migraine have migraine attacks that last more than one day, Migraine attacks and days with migraine were distinguished just 4 percent of the time. Chronic migraine diagnosis was mentioned in only 9 percent of visits. Treatment plans were discussed in only 37 percent of visits.
It's also disturbing that the average appointment was only 11 minutes long when the impact of chronic migraine on our lives can be so enormous and devastating.
We must not, however, place the entire burden of effective communication on our doctors. We can help maximize the effectiveness of the communication with out doctors by doing several things:
- Making a list of questions and topics to be discussed at our appointments, leaving space between them for notes, then taking two copies to our appointments - one for us, and one for our doctor.
- Expressing our concerns about the length of our migraine attacks.
- Discussing our diagnoses with our doctors until we're certain of them.
- Making sure we bring up the subject of our treatment plans.
Continuing to work with our doctors as treatment partners is the best thing we can do to improve our migraine management and quality of life. We can also work with our doctors to improve communication to accomplish more during our appointments.
1 Lipton, Richard, MD; Buse, Dawn, PhD. "Communication Patterns in Physician and Chronic Migraine Patient Dialogues during Routine Office Visits." Research Abstract. 57th Annual Scientific Meeting of the American Headache Society. June, 2015.
2 American Headache Society. "Study Shows Opportunities to Improve Communication Between Doctors and Patients with Migraine." Press Release. Washington, D.C. June 17, 2015.