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.