Living stories

Question: How might I employ the BATHE technique in my future practice?

This week in our Principles of Clinical Medicine (PCM) class we discussed the BATHE technique. BATHE is a mnemonic that stands for background, affect, trouble, handling, and empathy. The technique is an interviewing tool designed to elicit more and better information from patients. As students, it helps us understand how psychosocial issues can have great bearing as we diagnosis and treat the people in our care. As I listened to our instructors and began to consider its value, I realized it was something I wanted to keep in my toolbox for future practice.

About an hour after I left the PCM class that afternoon, my wife and I climbed into the car in order to attend a speaking engagement in downtown Portland. The speaker was Dr. Atul Gawande, a nationally-known surgeon and author interested in improving healthcare in our country. He spoke about his experiences and a number of topics, but one of the stories he related was of a hospital and a particular doctor who specialized in the treatment of patients with cystic fibrosis. Dr. Gawande had travelled to their institution to try to understand why they were having better outcomes than other CF units while spending far less money. This particular hospital, as led by this doctor, had average survival rates that exceeded national averages by almost 42%. Their patients typically lived to be 47 years old as opposed to 34.

Dr. Gawande proceeded to tell the story of how he was observing the doctor with a patient, a 17-year-old girl, whose numbers had taken a turn for the worse. The girl was not disclosing some relevant information as to when and how she had been taking her medications, so the doctor needed to employ a more novel means of questioning in order to elicit her full story. Using a blackboard and Dr. Gawande as his foil to direct the focus off of the girl, he calculated the odds ratios for folks who take their meds and for those who don’t. He told Dr. Gawande that, given irrefutable statistics, it is quite clear that outcomes are poor for patients who do not take their meds and that it is quite obvious when meds are not being taken when poor outcomes are occurring. He cleverly persisted at inquiring in third person as to the relatively sudden change in the girl’s status as she listened from the sidelines.

The girl then joined the conversation again and finally revealed why she wasn’t taking her medicine. Her reasons were two-fold: a new boyfriend with his own apartment and some new school rules for taking medications only at the nurse’s office. He continued to question the girl and found out what was happening in her life and how she was dealing with it. He discovered more clearly the impediments to her progress. He offered workable solutions and found support from friends and family to help her stay on track. Indeed, the doctor considered her failure a personal failure of his own, and he helped her realize that she needed to see it as a failure, so she could admit where she had gone astray and choose a better path for herself.

About halfway through the story, I realized this doctor was using the BATHE technique to a large degree, and I became convinced I needed to take his attitude and methods to heart. Of course, the point of Dr. Gawande’s story was simply that the reason this doctor had such remarkable results was that he cared deeply about his patients and was willing to spare a small amount of time to gather a complete picture of how their health was being effected by the events in their lives. We need context, and we need the truth if we’re going to truly make a difference for our patients. Of course, I want optimal outcomes for my patients, and I’ll need to use every tool at my disposal. By emulating this doctor’s methods, I can begin to effectively employ the BATHE technique as I enter a practice of my own.