Coach Your Physicians to Care, Listen and Connect with Patients.
Developing strong physician/patient relationships isn't easy when doctors are pressed for time, forced to see more patients and overburdened with paperwork. Yet, successful organizations realize that the physician/patient relationship is the most valuable asset for the hospital or practice. Learn ways to cultivate the relationship and make it grow even stronger.
SOMETIMES IN THE frenzy of a workday, I will stop and ask myself: How can I help ACPE help physician executives help physicians help patients?
Why do I do that? For the most part, the answer is selfish. I was hospitalized two times in the last five years and my mother has been a patient in the last year. During these times, physician/patient relationships were the center of my world.
Maintaining and improving these relationships is critical. Consider this excerpt from a recent issue of JAMA:
"Encounters between physicians and patients are increasingly marred by a mismatch between what patients need and want and what the physicians are able to provide. Patients want enough time to tell their story, to be listened to, and to be cared for as individuals. Patients have few criteria by which to judge the appropriateness of the technical aspects of care, but they are exquisitely sensitive to its interpersonal aspects." 
The physician executive's job is to make sure physicians develop strong, positive relationships with their patients. A physician will not accept the advice from an executive who has not been "in the trenches" delivering health care. That's why five years or more of clinical experience is one of the basic requirements for physicians to move into management and be seriously considered by recruiters and organizations.
In their book, Communicating with Today's Patient; Essentials to Save Time, Decrease Risk, and Increase Patient Compliance, Joanne Desmond and Lanny R. Copeland, MD, provide:
* A well-researched discussion of patient expectations.
* Ways to reduce the threat of malpractice claims.
* Specific words to say to patients to be sure you have communicated clearly.
Their suggestions can help physician executives coach other physicians to change behaviors.
"Although we can't increase the amount of time you have with patients, we can show you how to use that time to greater advantage--and in a way that helps your patients perceive their time with you as longer than it actually is," the authors write in their introduction.
Let's examine some other ways to build a solid physician/patient relationship.
Slow down a bit
Before you enter the exam room, "slow your inner clock before greeting your patients, and, if you have been in a fast-paced mode all day, be sure to slow your speech when talking with them. If you don't, patients may quickly sense that you are in a hurry and resent the fact that you seem to be rushing them through the visit." 
David Whyte, a poet and lecturer on how to make work more meaningful, says "the faster we go, the harder it becomes to stop.... The great tragedy of speed as an answer to the complexities and responsibilities of existence is that very soon we cannot recognize anything or anyone who is not traveling at the same velocity as we are.
"...On the personal side as slaves to speed, we start to lose sight of family members, especially children, or those who are ill or infirm, who are not flying through the world as quickly and determinedly as we are." 
Invite patients to tell their stories
In the beginning of the patient interview, ask open-ended questions. Begin with who, what, when, where, how but leave out the journalist's why question when you can. The word "why" often becomes a harsh judgment.
"When did you stop taking the antibiotic?" or 'What was occurring that caused you to stop the medication?" is less harsh and can get you better information than our often knee-jerk reaction of "Why did you stop taking it?" 
Later in the visit you can switch to closed questions that require a simple yes or no. But it is desirable to announce what you are doing, "Mr. Gusak, I'd like to ask you a series of questions now, which will help me determine more precisely what we're dealing with. Does this pain...?"
Starting with open-ended questions allows patients to tell you their stories. Switching to closed questions later helps you get more specific information.
"A team of researchers led by Wendy Levinson, MD, found that primary care physicians with no malpractice claims used specific communication approaches more frequently than did physicians who had a history of claims. These communication techniques included checking for understanding, educating patients about what to expect during their visit, and encouraging patients to talk." 
About three fourths of the way though the visit ask the question, "What other concerns do you have?" According to research, the main reason for coming to see the clinician may be something other than the patient's presenting complaint in 42 percent of visits.
This question can help eliminate the frequent "By the way, doc" at what you think is the end of the visit. 
Most physicians strive to keep routine patient visits to 10-15 minutes. How you spend those minutes can make you seem either rushed or attentive.
"Even though you have a tight time schedule, your patients probably perceive the time with you as being longer and far more caring if you pause a few beats now and then to wait for their response." 
If you listen to patients, they feel you truly care. Body language accounts for almost 90 percent of the quality of interaction between people. You need to move the muscles in your face to indicate that you are listening.
"Your facial expressions are an important part of your nonverbal communication and are being constantly and carefully monitored by your patients."  If you just sit there stone-faced or look at the chart, patients don't think you are listening or worse they think you don't care about them.
"You might include a slight widening of the eyes or a lift of the eyebrows to show interest, or a frown or slight wincing motion of the eyes if the patient describes a painful situation."  Desmond's research shows what patients are thinking when the physician behaves in certain ways.
Connecting with the patient on an emotional level can be therapeutic.
A simple, "I'm sorry to hear that." or "It must be very difficult losing your wife after so many happy years together. I can certainly understand why you'd feel sad, Mr. ______," lets patients know that you are concerned about them personally rather than just interested in fixing their various body parts. 
"Keep all movements to a minimum if the patient begins to tell you something deeply emotional. This is not the time to write in the chart or do any other medical task... Stay with the feeling. The patient will usually perceive you as caring and feel that you are spending more time than you actually are." 
Five years ago when I had surgery, I was given too much postoperative pain medication and spent a night in the intensive care unit. It was a terrifying night for my physician husband, but I knew nothing until I finally woke up with a nurse pounding on my chest and asking me if I knew my name and what day it was.
It was my primary care internist who leaned over my bed with empathy and said, "Doctors' wives--if anything can happen, it will." The surgeon, the ICU nurses, and nurses on the floor acted as if I had done something wrong. The hurt caused by their reactions was hard to shake.
A simple: "I'm sorry you had a rough time of it" would have helped and seemed appropriate.
Talking to the patient
As an opening to the interview, "Invite your new patient to tell you about his or her family, career, or other general information that is not directly related to the medical task." 
Thirty to 60 seconds is enough. Then, give an overview of the visit: 'Right now, I'd like to hear about your health concerns. Then I'll examine you, and after that we can talk about where we go from there--what would be best for you.'" 
"Avoid jargon. To a physician or other clinician, it makes perfect sense to say, 'I recommend this medication regimen because, left untreated, your hypertension could increase your risk of renal failure, myocardial infarction, and cerebral hemorrhage.'" 
To understand you, the patient needs to hear: "Your high blood pressure can cause kidney damage, a heart attack, or a blood vessel to burst in your brain."
"If you give an explanation heavily infused with jargon and then ask, 'Is that clear?' or 'Do you understand how you'll be taking your medications?' few patients will say, 'Gee no, I just didn't get it, Dr. Smith. Could you go through it all again--slowly?'"
"jargon can cause resentment in some patients. They feel angry when they hear polysyllabic medical terms, perceiving the speaker as showing off or trying to sound superior. To them it sounds patronizing and... distances you from them." 
"Patients are already emotionally taut because of their illness, and if they face any surgery or other invasive procedures, it compounds their fear. Why add even more stress through something as controllable as your choice of words?" 
Check for understanding
"Ask for the patient's reaction to the treatment plan you have suggested. Questions such as: 'What are your thoughts on this approach?' 'Are you comfortable with this plan?' 'What were you hoping I could do for you today?' If the patient is not satisfied with the visit, they might not do what you have prescribed, and they may not come back."
You need to know if the patient has understood what you have told them to do, but you can't say, "Now, tell me back what I told you." You could say, "We've covered a lot here. Just so I'm sure I was clear in my explanation, let's go over how you'll be taking these medications."
"...If they are nervous or concerned about their health, people of all ages and backgrounds have trouble remembering.... Research tells us that the patient forgets about one-half of the clinician's statements almost immediately.... As you sum up at the end of a visit, write down the key points you want the patient to remember when he/she gets home." 
Give hope if at all possible
My mother moved from her home of 44 years to a retirement community in my city in October 2000.
She had fallen, broken her sacrum, and had to enter the skilled nursing facility. Her new doctor came to the facility, was friendly and caring. The first time he visited her she was sitting at a table eating with the other people in the unit.
He walked up to her, smiled and said, "Hello, Mrs. Johnson, I'm Dr. White. Why don't you come with me?" He took her by the arm, walked her to her room, and listened to her tell her story. He told her the physical therapist would be starting with her tomorrow.
After one week of working with her, the therapist said, "You will be out of here in a month and in your own apartment." They gave her hope. Her spirits soared in spite of all the fear she felt after being moved 350 miles by ambulance to a new place.
They listened to her and cared.
Patients want to feel that their physicians care about them no matter what the diagnosis. How physicians listen and talk are the only ways to convey that message. Excellent quality and competence are already expected.
I recommend reading the Desmond and Copeland book and passing it on to physicians who need coaching on physician/patient relationships.
Barbara J. Linney, MA, is the vice president of career development at the American College of Physician Executives in Tampa, Fla. and a member of its faculty.
(1.) Eisenberg, Leon. "Good technical outcome, poor service experience: A verdict on contemporary medical care?" Journal of the American Medical Association, May 23/30, 2001, 285(20).
(2.) Desmond, Joanne and Lanny R. Copeland, MD. Communicating with Today's Patient. San Francisco: Jossey-Bass, 2000.
(3.) Whyte, David. Crossing the Unknown Sea, Work as a Pilgrimage of Identity. New York: Riverhead Books, 2001
Clinician Body Language Patient Translation Examining x-rays as the patient "I'm ignoring your emotional divulges deep-seated fears nonsense. Hmmm, what can we fix here?" Rapid and frequent nodding while "OK. OK. Let's get through this! the patient is talking I haven't got all day." Jargon Translation When coronary angiography When special X-rays of the heart reveals severe obstruction in the show that the main blood vessels coronary arteries, then coronary to the heart are clogged, then bypass grafting or percutaneous those blood vessels need to be transluminal coronary angioplasty unclogged, or else they need to be may be indicated, rerouted. If we take the first approach and unblock the vessels, that's called angioplasty. If we take the second method, we reroute the vessels, which is called a coronary bypass. Both approaches have a similar goal: to help your blood flow more easily, more freely, into your heart. 
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|Date:||Sep 1, 2001|
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