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Table 1 Watchful Waiting to Avoid Inappropriate Testing (WAIT): intervention model with key skills and criteria for fulfillment

From: Watchful waiting as a strategy to reduce low-value spinal imaging: study protocol for a randomized trial

Step

Key skills

Criteria for fulfillment with examples (to guide intervention content and coding)

1. Set the stage for deferred imaging by building trust

1. Demonstrate openness and interest

2. Avoid interruptions

3. Identify the patient’s motivating concern or expectations

1. Non-verbal openness and engagement

• Sits, orients toward the patient

• Maintains open body position, leans in

• Frequent, attentive eye contact

• Engaged facial expressions or gestures (e.g., nodding)

2. Clinician does not interrupt early on. Allows patient to “tell their story” without cutting them off.

3. Clinician probes or asks for more information when patient signals a major underlying or motivating concern or expectations: “It sounds like you are worried that you seriously injured your back. Is that right?” or “You seem to be concerned that you need an MRI. Can you tell me more about that?”

2. Convey empathy

1. Legitimize patient’s concerns

2. Name and explore patient’s emotions

3. Express your understanding

4. Make supportive statements

5. Praise patient’s attempts to address pain

1. Legitimizing statements: “I can understand why you are concerned.”

2. Naming and exploring emotions: “You said you are afraid. Can you tell me more about what you are afraid of?”

3. Expressing understanding: “This is obviously a tough thing to go through. I can see that it’s really impacted your work life.”

4. Supportive statements: “I’m committed to helping you find a workable solution.”

5. Praise: “I think it’s great that you have been trying to get out and walk.”

3. Communicate optimism and openness while advocating a plan without imaging

1. Convey optimism when sharing your assessment and suggested plan, emphasizing reassuring aspects of the history and physical examination and the patient’s favorable prognosis.

2. Advocate a conservative treatment plan without imaging

3. If a patient asks about imaging, recommend a watchful waiting approach

4. Communicate your availability if the patient’s pain does not improve.

1. Frames diagnosis and treatment recommendation in an optimistic, positive frame: “Overall, I’m actually quite reassured by your history and physical. I do not see any signs of a disc problem or nerve involvement, and I’m confident that your back pain is very likely to improve markedly over the next couple of weeks.”

2. Confidently endorses an initial treatment plan that does not include imaging

EX: “Given your reassuring history and exam, I’m confident that you’ll improve with conservative treatment, and in these cases, I do not recommend imaging at this time.”

3. If the patient asks about imaging, clinician advocates a “watchful waiting” approach:

EX: “I do not recommend imaging at this point, but I’d consider it in a few weeks if your pain did not improve substantially, as I expect it to.”

4. Articulates a follow-up, contingency plan for what the patient should do if the pain or other symptoms worsen or do not improve. Plan should address how the patient should contact the clinician, when they should do so, and what the clinician is likely to do in response. (The follow-up plan may or may not include a plan for deferred imaging.)

EX: “If you are pain is not substantially improved within two weeks, I’d like you to contact me via MyChart. I can then order you an x-ray and then we can have a either a phone call or a video visit.”