by Karen Knops, MD
Each meeting with a physician or other healthcare professional is a shared journey. It can be healing and affirming, or a source of confusion and mistrust. There is increasing evidence that communication often falls short in healthcare. A few thoughtful steps can help: preparing for the visit, having a concise summary ready to share, prioritizing your concerns to make sure they are discussed, exploring anything you don’t understand, getting the clear next steps, and writing or recording the visit. Those steps can be summarized in A-S-C-E-N-D.
An introduction post shares what inspired the ASCEND framework. Read the first blog post of the series, “A” for Anticipation: Tips to prepare for your doctor’s visit.
- a brief statement or account of the main points of something.
If the first moments of the visit have allowed us to see what the visit might consist of, we now have a better sense of how to share our story about the topics at hand, be they single or many. If we’ve found that the clinician needs to give new information, we may need to shift to listening, which is a skill all of its own. The summary of a problem that we bring to an exam room will be influenced by the clinician we are seeing- the amount of time and attention available, their verbal and nonverbal responses, their own questions and interruptions. For each major topic we address, we form a “co-narrative” together. Ideally, it is a process that allows us to organize information and to find a shared meaning – the foundation for making decisions about the future.
Summarizing is the art of knowing what to include and what to leave out as we frame a problem and our theories about what is happening and why:
Be aware of assumptions
Before we delve into detail about an issue at hand, considering what assumptions the clinician may have about the topic (or us) can help us frame how we introduce an issue. If we have specific expectations or fears, we may want to just say that up front. Consider how a clinician would listen differently to the same information if it were framed in each of these ways:
“I do have this problem – I don’t need it fixed, but I just want to make sure it is not dangerous so I know it’s okay to ignore.”
“I want to talk about this problem because I feel like it has not been taken seriously in the past. Right now I feel so strongly about this that I would not want to leave the office today without having a plan.”
“My sister wanted me to ask about this problem – it is not an issue for me, but I said I would ask.”
It makes clear to listeners what we think about the information we are about to present. If they agree that it is no big deal, they know not to waste too much time on it if they have no major concerns, and that allows more time for other topics. If we make clear we feel very vulnerable around some aspect of a problem, a good clinician knows to treat the issue with extra compassion and may be able to lower our anxiety. That is the first step in healing.
All clinicians are balancing the need to be efficient with the desire to connect and show respect, and giving them clues about our expectations helps them do that.
“Once upon a time…” – Where to begin? What matters?
As we delve into an individual topic, we want to summarize relevant background information. This can mean telling your clinician about the timeline of symptoms, what has been tried before, what works and how well, and how, specifically the issue is impacting our lives. Foot pain for a professional soccer player has different implications than foot pain for a professional truck driver, and we can help the clinician understand what measures are going to be most helpful for us.
We often have difficulty remembering details like when things started and how they evolved, especially if we are anxious. Clarity matters. Jumping between topics or time frames increases the risk of misunderstandings. Sometimes a metaphor can help create an image in our listener’s mind and paints a clearer picture than a long list of adjectives. People who find that they struggle to stay on topic or to express themselves clearly may want to bring notes or practice ahead of time. Adding this to our “anticipation habits” can optimize our time with the clinician and increase the accuracy of the information used in caring for us.
For people with multiple chronic illnesses, creating a one-page health summary, described in the last section of this document, is a way to lift the burden of trying to accurately summarize a complex history. While it is not a substitute for conversation, it can helps us organize our thoughts and some clinicians find them to be a great supplement to what they seen in medical records. Electronic medical records are a maze and do little to highlight what illnesses impact our lives the most, so they aren’t always good at “setting the stage” for the discussion.
Asking for a summary. In a hospital setting, where events are happening hour by hour, we may want to ask clinicians to briefly summarize what has been happening before considering new treatments or making choices: “Before we talk about _____, could we summarize what brought us to this point?” Paraphrasing the response back in our own words is a skill that confirms our understanding and helps improve our memory of what was said.
If we are seeing a clinician to receive news about test results or the outcome of treatment, the main skills needed at the opening of the visit may involve listening actively to new information. Even the best clinician can slip and use jargon, so don’t be afraid to speak up if something does not make sense. We can also ask to pause and repeat back what we understand so that we are assured that we are correct in our understanding. To fully pay attention, we may be asking ourselves:
What is the main message here?
How certain is the message? Is it still being determined?
Is this just information, or does it relate to a specific choice?
The goal of the summary around an issue – whether coming from us or coming from our clinician – is to get on the same page about the context for the discussion. It is never possible to cover everything, but ideally we can share the basics of the past before focusing on the future. From brief statements of context to long descriptions of events, we can begin creating a shared story about what is happening and what it all means. Just describing our journey helps us heal and gain perspective.
Learn how to make your own one-page health summary here.