VO Artist: The following program has been created and paid for by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., and is intended for health care professionals in the United States.
Dr. Shepherd: Hello, and welcome to Conversations in Contraceptive Care, a podcast all about counseling patients on contraception. I’m Jan Shepherd. A Clinical Associate Professor in Obstetrics and Gynecology at the University of Colorado School of Medicine. And I’m here with Dr. Jeff Levine, who is a Professor and Director of Women’s Health Programs in the Department of Family Medicine and Community Health at Rutgers Robert Wood Johnson Medical School.
Dr. Levine: Hi, and so it’s so great to be joining you today!
Dr. Shepherd: Today we’re talking about the importance of an effective dialogue between us as healthcare practitioners, and our patients. It’s well established that engaging in a patient-centered dialogue helps identify the contraceptive needs and preferences of our patients. Just as important, it can also enhance the trust patients have in us as their healthcare practitioners. So, Jeff, why is an effective dialogue important? In your practice, how do you approach the contraceptive dialogue?
Dr. Levine: I think it’s critically important. If you look at unintended pregnancy rates in the US they’re still quite significant. And not only do you have a number of women who get pregnant who aren’t using a contraceptive method, but also a number who are using a method, but maybe not just consistently or correctly. So, I think that for a lot of the reasons um that you mentioned and I think we’re going to discuss, when you engage in a patient-centered contraceptive dialogue with your patients, you’re not only going to increase patient satisfaction, but also gonna increase the likelihood that they’re gonna use their method properly, consistently, and hopefully for at least as long as they desire to prevent an unintended pregnancy. I think all because they really felt that they shared in the decision that—to choose that particular method.
Now, in my practice, I try to seize on any and every opportunity to assess pregnancy intention of my reproductive-age patients beyond just their annual visits. Because, if we wait, we’re missing opportunities to prevent unintended pregnancy.
Dr. Shepherd: Yes, I agree. The more we can do to bring this up the better, and I think it’s important to do so with open-ended questions. Just trying to figure out where she is on all of this, avoiding any preconceptions about where she might be, and making sure she is listened to and understood.
Dr. Levine: Oh, absolutely. In fact, you know, I really try to include pregnancy intention as a vital sign. I even take a step before that and I routinely ask all my patients one, are they sexually active, or if not, do they intend to be in the near future. Then I try to assess are their partners men, women, or both, how do they identify themselves and their partner, and what, if anything, they use for contraception. And then I ask open-ended questions. Instead of asking, “Do you have any concerns?”, I’ll probably start by saying, “What concerns do you have relating to your sexual health or preventing pregnancy?” Cause I find when you ask open-ended questions, patients feel more comfortable bringing up concerns they don’t feel that you’re either going to have the time for or the intention to validate those concerns.
Dr. Shepherd: That’s a very good point, Jeff. There are also a number of guidelines and frameworks out there that can help us engage our patients effectively. Among them are the CDC recommendations for quality family planning services. Within these guidelines, the CDC recommends a collaborative approach to help improve the healthcare provider-patient dialogue. This includes, first and foremost, the patient- centered approach, and then, of course, the effectiveness and safety of the contraceptive method. Also important are the timeliness and efficiency of our appointment with that patient.
Let’s start with the patient-centered approach. This means that we, as healthcare providers, must respect the patient’s primary purpose for the visit, ensure confidentiality, offer a broad range of contraceptive methods, and deliver services in a culturally competent manner to meet the needs of all patients. Jeff, how do you work with patients collaboratively to select an appropriate method? What kinds of questions do you ask that narrow down your discussion to help identify what would be the best fit for that patient?
Dr. Levine: Well I think, the first thing you want to do is establish that your patients’ concerns and questions regarding contraception are important to you. The way you utilize your body language that demonstrates effective listening, such as leaning forward, nodding, making good eye contact. And make sure they understand that the conversation you’re gonna have is between you and them, because it’s important that they feel that they’re in a safe environment. I then ask about their pregnancy intentions. Do they want children? And if so, do they want to delay pregnancy more than a year? And how would pregnancy impact their life? The next thing I try to do is, I try to assess the contraceptive features that are important to them—not that are important to me, what’s important to them. Did they have an issue in the past when they tried a certain method before? What are their concerns about side effects and the safety of a product? I’d also have to consider medical conditions and assess the patient’s lifestyle. Are they smokers? Do they engage in high-risk sexual behaviors? All of these things may impact the contraceptive benefits and risk that might be the best fit for the patient.
Dr. Shepherd: I certainly agree with you there. Another part of taking the patient-centered approach and one that’s more difficult, I think, is to be able to discuss all of this in a timely and efficient manner. How do you ensure your conversations are timely and efficient, Jeff?
Dr. Levine: Well, first thing I do again, is I try to see how relevant or important the issue of pregnancy intention and subsequently contraception is to the patient. We really have to respect that the patient’s primary purpose for the visit may not be pregnancy prevention or contraception. Contraception might not be important to them at that time, or they just might not have time to have a focused discussion on contraceptive options that might be the best fit for them. And if not, we have to arrive at a mutually agreeable time to bring them back to discuss those things.
I also have visual aids readily available, I think it helps them to clarify patients’ concerns and understanding. I have also unbranded handouts in different languages, uh, not just in English but in the primary, secondary-second languages that a lot of my, uh, patients, uh, speak. Uh, I think having those aids helps in terms of being more efficient, and if you don’t have the time to initiate the method during a patient visit, you have something for the patient to take home and remember and review. It also might help them make a decision even before they come back for the next visit.
Dr. Shepherd: Those are great ideas. I think it’s also worth pointing out that asking open-ended questions, although it might seem instinctively that it would take more time, in my experience actually takes less time. Because, if we ask open-ended questions, the patient often zeroes in on what her concerns are without us even pursuing them, and then we have a lead in to begin our discussion.
Dr. Levine: Absolutely. I mean, certainly, the extra investment of a little time really goes a long way because when patients get adequate advanced counseling they’re more likely to be satisfied with their contraceptive method and to continue that method. So, to me, it’s time well invested and actually, it’s in the end, time saved.
Dr. Shepherd: I agree, Jeff. Other points the CDC recommends talking with our patients about are accessibility, value, and equity. How do you integrate those into your patient dialogue?
Dr. Levine: I think making those aspects practical and implementing them into your practice can actually be very challenging. One of the things we want to do ideally, is to be able to help our patients have access to any method of contraception that we both decide to initiate them on. It may mean stocking certain methods in your office, so you can facilitate a “quick start”, and the patient doesn’t have to wait for the method to come in. It could also mean providing your patients with one-year refills for whatever method they choose to minimize the risk of them running out of that method, say over the weekend when their pharmacy may be closed, which would increase their risk for pregnancy.
Dr. Shepherd: Yes, I couldn’t agree more with those points. I also think, and you touched on this, another important thing is whenever possible to provide the contraceptive method on the very day we’re seeing the patient, not timing things so far apart
Dr. Levine: Absolutely. Most methods can be started the same day as requested if pregnancy can be reasonably excluded.
Dr. Shepherd: Absolutely. And I would point out that the criteria for determining whether a patient is likely to be pregnant are in the CDC recommendations for Family Planning Services. There’s a list of requirements and if your patient meets the requirements on that list, you can be reasonably sure that she isn’t pregnant already and you can go ahead and provide the contraceptive method.
Dr. Levine: Yeah. And if I could provide a little, parting gift for our audience, there are plenty of readily available resources, including great ones on the CDC website, for practitioners to use in counseling their patients.
Dr. Shepherd: Sounds good. Thanks, Jeff, for sharing your thoughts and joining me today.
Dr. Levine: It’s been my pleasure. And thank you so much for inviting me.
Dr. Shepherd: From our collective experiences, it’s quite clear that engaging in an effective dialogue with our patients can really enhance contraceptive care. To our listeners, I hope we were able to provide some useful insights into the healthcare provider- patient dialogue, that you can apply them in your own practices. Talk to you next time on Conversations in Contraceptive Care!
VO Artist: The preceding program has been created and paid for by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. The information in this presentation is intended for health care professionals in the United States. The references for the information discussed today are available in the transcript which can be accessed on the site where you have listened to this podcast.
- Gavin L et al. Providing quality family planning services: Recommendations of CDC and the U.S. Office of Population Affairs. MMWR Morb Mortal Wkly Rep. 2014;63:1‒54.
- Gavin L et al. Update: Providing Quality Family Planning Services - Recommendations from CDC and the U.S. Office of Population Affairs, 2017. MMWR Morb Mortal Wkly Rep. 2017;66:1383‒1385.
- Wysocki S. The state of hormonal contraception today: enhancing clinician/patient communications. Am J Obstet Gynecol. 2011;205(4 suppl):S18–S20.
- Finer LB et al. Declines in Unintended Pregnancy in the United States, 2008–2011. N Engl J Med. 2016;374:843–852.
- Sonfield A et al. Moving forward: Family planning in the era of health reform. Guttmacher Institute; March 2014. https://www.guttmacher.org/sites/default/files/report_pdf/family-planning-and-health- reform.pdf, Accessed January 17, 2019.
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