© Geriatric Times. All rights reserved.
Using the BATHE Technique With Older Patients
by Joseph A. Lieberman III, M.D.
| Geriatric Times |
 |
May/June 2000 |
|
Vol. I |
|
Issue 1 |
One of the problems frequently encountered in medical practice is the perceived
difficulty associated with effectively interviewing elderly patients. Seasoned
physicians, residents and medical students have all articulated this problem.
This difficulty may arise, in part, from the environment in which we have
trained. Since the Flexner Report (1910), the medical education process has
been largely housed in hospitals and tertiary care medical centers. These
latter institutions have become the backbone of the medical education
enterprise. Much emphasis is placed on the science of medicine and the process
of dealing with the acutely ill patients with traditional organic illnesses,
usually requiring aggressive intervention. This has led Robert Lowes (1998) and
others to conclude, "The medical education system has taught doctors to view
patients as disease puzzles to solve rather than as peoplex to listen to." The
acute care environment, with its sharply delineated subdivisions, clearly
housed in bricks and mortar, is almost antithetical to the poorly
differentiated symptoms and problems besetting the typical elderly patient.
Complicating the issue are the personality qualities of our current elderly
patients as opposed to those of their "Baby Boomer" and "Generation X"
caregivers. Today's seniors survived the Great Depression and fought in WWII
and Korea. As mature wage earners, they witnessed the tumultuous 1960s, and
they experienced the national angst over the Vietnam War and the Watergate
scandal. They have experienced privation, shortages and insecurity. Their
caregivers, on the other hand, frequently are a product of the 1960s who have
largely known peace and prosperity. They are used to asking for what they want
and getting it. Contemporary seniors are generally more cautious and willing to
settle for less in life because that historically has been their lot. They are
accustomed to giving and self-sacrifice as opposed to self-indulgence. If one
ponders this, the problems are both chronological and attitudinal.
Into this mix we add the clinical difficulty of dealing with the
psychodynamic complications of organic dysfunction as well as organic symptoms
that emanate from a psychological source. Getting at these issues is difficult
for the organically oriented clinician, as the psychodynamic is perceived to
get in the way of making a proper diagnosis and instituting appropriate
therapy. This is precisely the environment in which many of us work, however,
and it is particularly so for those of us who frequently care for the
elderly.
Marian Stuart, Ph.D., and I (Stuart and Lieberman, 1993) make the point,
"The primary care physician who incorporates psychotherapy into everyday
medical practice is in a unique position to make a meaningful impact here." In
other words, if we reconnect the mind and the body by exploring these systems
and symptoms concurrently, we can have a far greater impact and be of greater
assistance to all of our patients, particularly the elderly. This is true
regardless of the age and/or attitudes of either the patient or the
caregiver.
How do we do this in the fast-paced environment in which we work and with
our limited resources, particularly time? I propose adopting the BATHE
technique to supplement the problem-oriented medical record's SOAP format.
Larry Weed, M.D., (1971) developed the SOAP (Subjective data; new Objective
data; Assessment of the new data and new Plans that are determined by the new
data) format for conducting a medical interview and composing a medical record.
It is in widespread use in primary care medical practice today. As Weed
explains:
The medical record need not be simply a static, pro forma
repository of medical observations and activities grouped in the meaningless
order of source-whether doctor or nurse, laboratory or X-ray department-rather
than with respect to the problems to which they pertain; it can be
problem-oriented, and thereby it can become a dynamic, structured, creative
instrument for facilitating comprehensive and highly specialized medical
care.
By adding BATHE or BATHEing the patient, clinicians can supplement the
information gathered using the problem-oriented approach to determine the
patient's psychosocial status. The BATHE acronym stands for the following:
Background: A simple question will elicit the context of the patient's
visit: "What's going on in your life?"
Affect: Questions such as "How do you feel about that?" or "What's your
mood?" allow the patient to report the current feeling state.
Trouble: The question, "What about the situation troubles you the most?"
helps both the physician and the patient focus on the situation's subjective
meaning.
Handling: The answer to, "How are you handling that?" gives an assessment of
functioning.
Empathy: A statement can legitimize the patient's reactions: "That must be
very difficult for you."
The BATHE technique enables the practitioner to get at critical elements in
the patient's presentation that are not readily accessible through standard
interview techniques. It also has the advantage of being very focused, quickly
employed and nonthreatening to the majority of elderly patients. The
information helps to make a much better assessment of the patient's situation,
the forces acting on the patient and the patient's perception of their state of
affairs.
Armed with this information, the health care practitioner can more
intelligently assist the patient in the resolution of the problems with which
the patient is wrestling. Stuart (Lowes, 2000) summarized the technique by
stating, "BATHE not only gathers information, it engages the patient in true
psychotherapy…it eases negative feelings, such as anxiety, and
strengthens the patient's sense of connectedness as well as competence."
I recommend trying the BATHE technique, not just on an occasional troubled
patient, but on all patients. It provides valuable insights with a minimal
expenditure of time and effort. In addition, it can go a long way toward
enhancing doctor/patient relationships and improving the quality of care
available to our elderly patients. BATHE builds a lasting rapport with
patients. Winthrop Dillaway, M.D., a family practitioner in New Jersey,
explained (Lowes, 2000), "It's a quick way to win over patients. They're
pleasantly surprised-and gratified-when I ask about things that really matter
to them."
Dr. Lieberman is chair of the department of family and community medicine
at the Christiana Care Health Services. He is a member of the American Academy
of Family Physician's Health Care Services Commission, vice speaker of the
House of Delegates of the Medical Society of Delaware and a member of the
Delaware Health Care Commission.
References
Flexner A (1910), Medical Education in the United States and Canada. New
York: Carnegie Foundation for the Advancement of Teaching.
Lowes R(2000), Want to uncover a patient's real problem? BATHE him! Medical
Economics 77(2):117-126.
Lowes R (1998), Patient-centered care for better patient adherence. Family
Practice Management 5(3):46-57.
Stuart MR, Lieberman JA III (1993), The Fifteen Minute Hour: Applied
Psychotherapy for the Primary Care Physician. 2nd ed. Westport, Conn.: Praeger,
p188.
Weed LD (1971), The problem oriented record as a basic tool in medical
education, patient care and clinical research. Ann Clin Res 3(3):131-134.