Want to uncover a patient's real problem? BATHE him!

Primary care doctors are adapting a simpletechnique to address emotional problems that may underlie patients'physical symptoms. And it won't make office visits longer, proponentssay.

By Robert Lowes, Midwest Editor

As FP Jamie Reedy of North Brunswick, NJ, hovers over a patient in the exam room, peering into his ears and throat, she nonchalantly asks, "So, what's going on in your life?"

First-time patients don't realize that Reedy has just commenceda five-step procedure called BATHE that squeezes psychotherapyinto a 15-minute office visit. What begins so casually, say Reedyand other BATHE practitioners, frequently builds to a dramatic,almost wondrous finale. Patients disclose upheavals in their lives—divorce,job agonies, the death of a child—that either trigger diseases,exacerbate them, or interfere with treatment plans.

Patients who've been "BATHED" usually leave the officemore hopeful, these doctors say, all because they've shared theirfeelings with another person and gained confidence that they cancope. In the process, the physician-patient connection is strengthened.FP David Nutter in Redlands, CA, quotes one comforted patientas saying, "No doctor has ever talked to me like this before."

BATHE was devised by members of the family medicine departmentat the Robert Wood Johnson Medical School in New Brunswick, NJ,to help doctors link the patient's body with his mind and emotions."We're trained to be body mechanics," says FP JosephLieberman III, a BATHE proponent who chairs the family medicinedepartment at Christiana Care Health System in Wilmington, DE."But patients are telling us they want to be treated as wholepeople. Look at the popularity of alternative medicine."

Can BATHE work for you? Some doctors write off the techniqueas too time-consuming for a busy practice. But Lieberman and otherssay BATHE not only fits into the average office visit, but oftenshortens it. Indeed, insurance giant Aetna US Healthcare offersits primary care physicians a booklet on BATHE that they can studyfor CME credit.

BATHE is to the mind what SOAP is to the body

BATHE an acronym, consists of four questions and a statement:

Background: "What's going on in your life?" The answer gives some context to the conversation.

Affect: "How do you feel about that?" This makes the patient think about his feelings— at least enough to label them. He may not have done that before.

Trouble: "What is it about the situation that troubles you the most?" This pinpoints what the situation means to him.

Handling: "How are you handling that?" Here, you try to assess how the patient is or isn't functioning, and what resources he can muster to manage his problem.

Empathy: "That must be very difficult for you." Your response reassures the patient that his reaction is understandable.

Psychologist Marian Stewart and family physicians at the RobertWood Johnson Medical School developed BATHE in the late 1970sto plug a perceived hole in physician training. Medical studentsand residents were learning to record physiological informationin the traditional SOAP-notes format. But so-called psychosocialinformation such as marital strife never got into the charts.

"We told ourselves that we needed a bigger cake of soap,like bath soap," says Stuart, who together with Liebermanwrote a book titled The Fifteen Minute Hour: Applied Psychotherapyfor the Primary Care Physician. To drive that point home,they fashioned an acronym from the word "bath," andlater added the "E" to create a verb.

BATHE became part of the curriculum for Robert WoodJohnson students such as Jamie Reedy, who also trained there asa resident and now serves on the faculty. She continues to relyon the technique, which readily lends itself to puns. Reedy, forexample, says, "It gets me into the soap opera of the patient'slife."

Reedy recalls a woman in her late 30s who came to the officecomplaining of abdominal pain, diarrhea, and fatigue. The patientwondered whether she had a viral infection, or worse. "Iasked the B question," says Reedy. "She said her husbandhad just left her and was planning to file for divorce. Then sheburst into tears."

"I asked her how she felt. 'Alone,' she replied. Whattroubled her the most was the prospect of living alone for therest of her life. It was her second marriage. When I asked herthe H question, she said she was handling it poorly. She wasn'teating or getting enough sleep. I told her she must be going througha horrible time."

The upshot? There was no need for extensive gastroenterologicalstudies. The woman's complaints were classic symptoms of stress.Reedy prescribed an antidepressant and referred her to a psychologistwhile continuing to see her. "Without BATHE, the divorceissue might never have surfaced," says Reedy.

BATHE not only gathers information, it engages the patientin true psychotherapy, says Marian Stuart. It eases negative feelings,such as anxiety, and strengthens the patient's sense of connectednessas well as competence. "The A question is therapeutic becausepeople usually are relieved when they can label their feelings,"she says. "The H question also is therapeutic because itsuggests that the patient can indeed handle the situation, thathe can make things happen."

FP David Nutter says the therapeutic results are easy to spot."Patients come in worried, and they leave visibly relaxed."

BATHE your way toward accurate diagnoses, compliance, andrapport

By uncovering the emotional turmoil that influences a patient'soverall health, BATHE helps doctors diagnose and treat. Just asJamie Reedy used BATHE to determine that her patient's GI problemswere psychosomatic, the technique can reveal a link between chronicillness and stress. The knowledge that an asthmatic began wheezingafter an argument with his boss may prevent needless tests, prescriptions,and return visits. "You spend less time on wild goose chases,"says Winthrop Dillaway, an FP in Sparta, NJ.

Among BATHE's other benefits, Joseph Lieberman touts it asa means to improve patient compliance with treatment plans. "AnFP once referred a middle-aged woman with a heart condition toa cardiologist," says Lieberman. "The cardiologist wantedto admit her to the hospital for tests, but she refused. So thecardiologist called the FP and complained to high heaven abouther uncooperative attitude.

"When the FP saw the woman again, he asked, 'What's goingon in your life?' She replied, 'I've just made arrangements formy funeral.' She was convinced that her heart ailment would killher, so why should she bother with the hospital visit? BATHE uncoveredthat."

Primary care doctors also can use BATHE to screen for mentalillness. That's no minor mission, given the troubled state ofthe American psyche. A landmark government study published inthe 1980s showed that mental illness afflicts 32 percent of theadult population at some time in their lives. Lieberman and Stuartcite other studies indicating that primary care doctors fail todiagnose psychological disorders more often than not. "Ifyou pick up on depression early, it's easier to treat," saysStuart. Depending on the severity, you may decide to refer.

BATHE even helps in delivering bad news, Marian Stuart notes."Let's say you've just told someone he has multiple sclerosis.You pause and let it sink in. Then start with the A question:'How do you feel about that?' And go through the rest of the sequence.You'll build his confidence to face the future as well as makehim feel he's not fighting this by himself."

Finally, BATHE advocates prize the technique as a rapport-builderbetween patient and doctor. "It's a quick way to win overpatients," says Winthrop Dillaway. "They're pleasantlysurprised—and gratified—when I ask about things that reallymatter to them."

Doctors tailor BATHE to suit their practice needs

Admittedly, BATHE isn't appropriate in certain settings. Forgoit, for example, if patients are psychotic or in severe pain,say Lieberman and Stuart. And if a patient responds to the firstquestion or two with hostility or suspicion, stop right there.Barring such exceptions, however, BATHE is recommended for everypatient encounter, even with someone you saw only two weeks ago."Just tailor the B a little," Stuart suggests. "Youcan ask, 'What's happened since your last visit?' "

But do doctors with go-go schedules have the time to routinelyemploy this technique? Lieberman replies with an emphatic Yes."It takes me only about a minute and a half to do BATHE;it's second nature by now," he says. He tells the followingstory at medical conferences to illustrate his point.

Back when Lieberman taught at Robert Wood Johnson, he saw afemale patient who needed a driver's license physical. The visitwas being videotaped so students could watch BATHE in action.Lieberman anticipated an easy interview.

He asked the B question: "What's happening in your life?"

"Nothing," she said.

Relieved that the patient didn't appear to be in any crisis,Lieberman then dutifully asked how she felt about it.

"Terrible," the patient replied.

Baffled, Lieberman asked what troubled her the most about thesituation.

The facts quickly emerged. The woman, raised in Iowa, had justearned an MBA and taken a job in New York City. She had expectedthe work to be energizing and challenging, but the people shesupervised hated her. And she'd begun to hate New York. "Shesaid it was cold and dark, and people were so rude they'd as soonpush you in front of a bus as walk around you."

Lieberman asked how she was handling it. The woman repliedthat she was drinking a pint and a half of vodka a day. A patientwho had come in for a driver's license physical had suddenly shownherself to be a candidate for Alcoholics Anonymous.

"All of this happened in less than a minute," saysLieberman.

Other doctors offer similar testimonial about the technique'sefficiency. "BATHE doesn't slow me down," says DavidNutter. "I still manage to see 20 to 30 patients a day."Jamie Reedy, who's just as busy, stays on schedule by proceedingthrough the BATHE sequence while simultaneously examining thepatient. Like Nutter, she says the technique sometimes shortensvisits because it cuts to the chase. "You avoid having thepatient ramble for five to 10 minutes," says Reedy.

Not all disciples of Lieberman and Stuart employ BATHE as religiouslyas the masters might wish, however. Some doctors skip one or moreof the questions, or use the technique only when they suspectthe patient has a hidden emotional problem, says psychiatristLawrence Obsorn, medical director of behavioral science at AetnaUS Healthcare.

Reedy estimates that she omits BATHE in about 40 percent ofpatient encounters. "If they have the flu, all they wantis to get a prescription and rush out the door," she says."Or I may know the patient's situation well—I just saw her severaldays earlier." Winthrop Dillaway applies BATHE only whenhis instincts suggest someone needs it.

Look beyond lab tests, say BATHE supporters

Joseph Lieberman doesn't guarantee that doctors who adapt BATHEwill experience one-minute miracles right away. "It's likeanything else," he says. "The more you practice it,the faster and more facile you become."

There are definitely fine points to master. One of the mostcommon mistakes doctors make is to get stuck on the backgroundquestion. "Doctors get engrossed in the details and ask formore," says Lieberman. "The patient will go on and onand on. The hardest thing is to move through the sequence. OnceI know the basics, I wait for the patient to catch his breathand ask the A question—How do you feel about that?"

Another mistake is to render the questions ineffective by rewordingthem. "If you start with 'How are things going?' or 'How'severything?' people will usually say 'Okay' and no more,"says Lieberman.

Many doctors simply omit the T question—What troubles youthe most about the situation?—because they don't understand itsimportance, says Marian Stuart. However, this stage of BATHE iscritical because you need to know how patients interpret theircircumstances. She recalls a woman who revealed during BATHE thather husband had been carrying on an affair with her sister for18 months. The woman's feelings about the adulterous relationship—angerand depression—were predictable. But her response to the T questionwasn't. "She said she didn't want to become a single parentof two children," says Stuart. "That was her main reasonfor trying to save the marriage."

Novices also trip up on the empathy component, says Lieberman."Don't say, 'I know how you feel.' That statement can turnpeople off, because it assumes you've experienced the same problem.They'll think to themselves, 'How the hell does he know how Ifeel?' "

Give some credit to the doctors who mess up on the empathystatement, though. At least they're trying. BATHE supporters saya shortage of exam room empathy explains why many doctors resistusing the BATHE technique in the first place.

"Some physicians want to focus strictly on the biomedical,"says Jamie Reedy. "They define disease only in terms of labtests. The psychosocial aspect of medicine—emotions, relationships,lifestyle issues—is hard for them to grasp.

"I remember residents rolling their eyes and getting angrywhen they had to attend a BATHE lecture. They viewed it as a wasteof time."

Lab-test junkies also may reject BATHE simply because they'reafraid of unearthing a problem they might not be able to fix."I once asked a resident if an elderly patient who was broughtinto the ER in a fetal position might be depressed," saysLieberman. "He said, 'I don't want to open that can of worms.'"

Lieberman and Stuart's message is that primary care doctorsshould open that can of worms. By virtue of their professionalrole, frontline physicians have great power to influence how patientsthink and feel about themselves. And BATHE gives them a meansto do so.

"Psychotherapy is a medical procedure, the same as anyother," says Stuart. "You're just using words insteadof instruments."

Robert Lowes. Want to uncover a patient's real problem? BATHE him!.

Medical Economics

2000;2:117.