Pave the way – a big benefit for teammates and patients

Posted on June 25, 2012 by Helane Fronek

A medical assistant brings a patient into a room. Then, the physician enters. Perhaps a technician follows to perform a test. A nurse might be the last person the patient interacts with, explaining the treatment and followup plan. It can be difficult for patients to make so many adjustments and develop trust, over and over again, as they interact with so many different people.

No matter which role we play in patient care, we are a member of a team. What each of us does reflects on the other members of our team. Similarly, what we say about our team members does a lot to color the perception that our patients will have of them. For this reason, the Studer Group, a healthcare management consulting company, suggests that we utilize a skill they refer to as “managing up” and “managing down” to insure that our patients begin with the very best impression of each of our team members.

The medical assistant can share with the patient some of the positive comments about the physician that she has heard from other patients. The physician can explain the technical expertise of the technician and the importance of the test that will be performed. The technician can comment on how thorough and compassionate the nurse is. Each of these brief comments puts the patient at ease by introducing the next team member in a positive way and demonstrating the efficient collaboration of the many people who are participating in his care.

As we enter the new phase of ACO’s and Patient Centered Medical Homes, the team aspect of medical care will become even more widespread and important. However, regardless of whether we are in a large, multidisciplinary healthcare group or a solo medical office, the skill of managing up and down is an easy and effective way of positioning each team member in the very best light, reducing our patient’s anxiety, and improving morale in the group. A simple idea, easy to implement, and full of powerful benefits.

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There’s power in word placement

Posted on June 12, 2012 by Helane Fronek

Have you ever noticed that two people can hear the same words and have very different interpretations of what was said? We respond to our world on the basis of our experience and our expectations, so it’s not uncommon that our patients “hear” very different things than we actually said. One common way in which we all affect the interpretation of what we say is by varying the intonation of a word – for example, consider the difference in meaning between saying “right” as a way of agreeing vs. adding a sarcastic intonation and saying the same word.

Yet another important way in which our brains interpret words is based on their placement in a sentence. We are wise to make use of this powerful fact and design statements that deliver information so it will be interpreted in more helpful ways by our patients. One simple technique for using this is to place the most important items first and last when giving patients a long list of information. We all remember the first and last (especially the last) thing that we are told better than what comes in between. A second tool is to use “turning words,” such as “but” and “however.” These words essentially negate whatever information came before them in a sentence. For instance, when telling patients about symptoms that might arise after a procedure, it’s best to state the possibility of symptoms first, add a turning word, followed by the appropriate reassurance. For example:

Some patients experience discomfort for a few hours and others have developed a fever, rash, or swelling for a day or two, BUT most patients do just fine.

As Thomson and Khan discuss in Magic in Practice, doctors “often report an increase in unnecessary calls or visits by worried patients” when the order is reversed.

So, in explaining the risks and benefits of a procedure or a new medication, or simply educating our patients about their condition, we can use word placement to our advantage – to emphasize what’s important and helpful, while putting the other information in proper perspective. In this way, we can reduce the chance that our patients will experience unnecessary anxiety or distress and improve the likelihood that they will hear what we feel is most important.

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Revel in, and don’t ignore, the richness of diversity

Posted on June 3, 2012 by Helane Fronek

Summer is here!
For many of us, it’s a time of year when we travel and experience places and cultures that are different and exciting. As we see other parts of the country and the world, we are reminded that many people have a very different experience of life than we do. They see the world in a different way; they have cultures and religions that have given them different values, approaches, and customs; and they speak in ways that are not understandable to us. As travelers, we find these differences novel and interesting.

For people from other countries who now live in the United States, our culture and norms may seem bewildering and sometimes even frightening. This is especially true when they become ill and have to negotiate the medical establishment so they can obtain the care they need. Can you imagine the frustration and anxiety of not being able to communicate what’s wrong with you when you’re already worried about what might be causing your symptoms? Fortunately, there are several concepts and practices that serve us well when dealing with people of different cultures and/or who speak a different language.
–Spending some time getting to know our patients’ culture and showing interest in their country and customs will help to establish rapport and build relationship.
–Speaking slowly, as well as paraphrasing and checking for understanding frequently during the visit is essential to ensure accurate transmission of information.
–Beware of gestures, as they often do not translate well into other cultures. For instance, our “thumbs up” gesture is considered lewd in many cultures, and patting someone on the head, as we often do with children, can be threatening for some people.

An even more profound realization is what our patients believe about their illness. This was illustrated in Anne Fadiman’s fascinating book, The Spirit Catches You and You Fall Down, the story of the disastrous confrontation between the beliefs of the Hmong family of a child with epilepsy and her American doctors. Patients can have strong ideas about the significance of their illness, its cause, and its potential cure that will affect their acceptance of treatment recommendations and response to treatment. For this reason, medical anthropologist Arthur Kleinman developed eight questions to help uncover a person’s ideas about how their illness functions and relates to their life:
1. What do you call the problem?
2. What do you think has caused the problem?
3. Why do you think it started when it did?
4. What do you think the sickness does? How does it work?
5. How severe is the illness? Will it have a short or long course?
6. What kind of treatment do you think the patient should receive? What are the most important results you hope to receive from this treatment?
7. What are the chief problems the sickness has caused?
8. What do you fear most about the sickness?

All population estimates reflect the increasing diversity of the American population. As physicians, we are entrusted with the health of all those who come to us for help – those who share our backgrounds and those who don’t. Limiting ourselves to only what we know about the medical aspects of a patient’s condition does just that – it limits us. But with these insights and practices, we can better help each of our patients, no matter what their background and culture is. The gift to us of broadening our perspective is that we can truly enjoy the richness and diversity of human experience that we are privileged to encounter as physicians.

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The sounds – and shame – of silence

Posted on May 4, 2012 by Helane Fronek

“Much unhappiness has come into the world because of bewilderment and things left unsaid.”
– Fyodor Dostoyevsky

We all worry about things we say – have we hurt someone’s feelings? Spoken too harshly? Been too sarcastic? I would argue that we do just as much damage by the things we leave unsaid. Think about it – when we are angry, hurt, or just confused and elect not to say anything, we usually make the situation worse. We respond coldly to the other person, attempt to “get even” or make assumptions that alter all future interactions with that person. If we’re honest with ourselves, we know that when we don’t speak up, we act out.

I’m happy to report that there is something positive we can do when we find ourselves in these situations.

We can speak up.

I can almost hear the panic in your voice – but how do I do that? Or the anger and frustration – it will never work!

It is true that our initial impulse might be to attack those who do things we don’t like. As Patterson, et al describe in Crucial Confrontations, the usual path that our reaction takes looks like this:
We see/hear something…Create a story about what’s going on…Feel an emotion…Act
Unfortunately, our stories are usually flawed, our emotion deprives us of sound reasoning ability and our actions reflect it. So first, be clear about the story you’re telling yourself and, as Patterson and colleagues suggest, stop and ask yourself, “Why would a reasonable, rational, decent person do this?” What other explanations are possible?
If there was ever an antidote to judgment, it is curiosity.

At the outset of the discussion, a sense of both mutual respect and mutual purpose must be established. Their absence can sabotage even the best of intentions and skills. Mutual respect is frequently conveyed (or disproved) with our tone of voice, facial expressions, or simply by asking the person if this might be a good time to talk. When mutual respect is missing, try using the communication skill of contrasting – say what you don’t mean, followed by what you do mean (see post 10/8/11). And if the other person feels that your intentions are at odds with theirs, it becomes important to state why and how this discussion will help them as well as you.

Armed and empowered with an open mind and supported by a foundation of mutual respect and purpose, approach the person who has disappointed you and describe the difference between what you expected and what happened. Stick with the facts and avoid descriptive words or an emotional tone of voice. “I expected you to do your job well and you didn’t” is not helpful. A more useful description of the gap between expectations and occurrences might be, “I expect that you will have the charts/X-rays/reports ready when we see each patient and yesterday, many of them weren’t available when I needed them.”

After describing this gap, tell the story that you created about what happened. “I noticed that you were making personal phone calls while patients were waiting, so it seems that your personal life is getting in the way of your doing your job. This is negatively affecting our ability to see patients on time, to have the information we need for them, and makes us seem disorganized and incompetent.” End with a simple question such as, “how do you see this situation?”

By opening your mind to other explanations, establishing safety with mutual respect and mutual purpose, then clearly stating the gap between expected and observed behavior and following with a genuine, curious question, you will be able to fill those dangerous voids of silence with powerful, effective, relationship-building communication.
Try it – it’s a lot easier than you think.

Posted in building relationship with patients, effective communication in healthcare, honesty in medical care, physician coaching, physician communication, Uncategorized | Tagged | 2 Comments

Get credit for what you do

Posted on April 26, 2012 by Helane Fronek

In the Broadway musical Fiddler on the Roof Tevye asks his wife, Golde, that very important question:
“Do you love me?”
Golde replies: “Do I love you?
For twenty-five years I’ve washed your clothes
Cooked your meals, cleaned your house
Given you children, milked the cow
After twenty-five years, why talk about love right now?”

We all assume that our actions speak louder than our words – that certain things we do express our sentiments and intentions. But is this true?

I would argue that it is not.

Just as Tevye, after 25 years, needed to hear the words to confirm that Golde’s actions reflected her love, our patients derive tremendous benefit from our words, as does our relationship with them.

When seeing a patient in the ED, we pull the curtain because we want to insure our patient’s privacy. Our patient may completely miss this intention and would certainly benefit from the knowledge that her physician is caring and thoughtful enough to be concerned about that.

When we ask our patient to return for a follow-up visit after a procedure or an illness, it is usually because we want to diagnose a potential complication as soon as possible or make sure that our patient is responding to our treatment and improving. Our patient might consider this extra visit a nuisance, a ploy on our part to generate more income, or not important enough to follow up on. Telling him why we want to see him helps him understand what we are concerned about, that he is important to us and that his welfare is uppermost in our minds.

So pay attention to the many things you do while caring for your patients and ask yourself why you do them. Share those motivations with your patients as you go about your day, and ask your office staff to demonstrate this behavior as well.

While injecting a local anesthetic, inform your patient that you are doing this so the procedure won’t hurt as much. Let her be aware of your kindness.

When your receptionist schedules a patient’s follow up appointment, she might say, “Dr. Smith wants to see you in a week to make sure that you are healing well.” A minor adjustment to the usual scheduling statement that conveys a message of caring and conscientiousness.

Letting your patients know the things you do on their behalf may pave the way for better communication, as it gives them confidence in you and helps them trust you. They see you as someone who not only understands their needs but takes them seriously enough to go out of your way to accommodate them.

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Want change? Lighten up.

Posted on April 14, 2012 by Helane Fronek

As physicians, we frequently want our patients to change. We tell them to exercise more, eat differently, take their medications regularly, stop smoking. We explain why they should change, draw pictures, tell stories, cite literature. Our patients agree they will change – and then, nothing happens. So, how can we motivate them to make the changes that we know will be better for their health?

While we are clear that these changes are good, the fact is that our patients remain ambivalent. They know that smoking or excessive drinking is bad for their health. But they also know that when they are anxious, smoking calms their nerves. And when everyone goes out for a drink, they like to be a part of the group. It’s an important source of friendship for them. Most of us have felt this ambivalence. We are sure that we want to eat less and lose some weight, but when handed a piece of delicious chocolate cake, we are somehow unable to turn it down.

One effective way of helping our patients move through their ambivalence is found in the field of Motivational Interviewing. Skilled practitioners have usually spent years studying and perfecting their approach. But we can employ a simple version of this highly useful technique whenever we sense ambivalence.

The first step is to really listen to what our patient is ambivalent about and to name the two sides. “It sounds like you would really like to stop smoking, but you also feel as if smoking plays a big part in your social life and in helping you relax.” Dr. Igor Koutzenok at UC-San Diego suggests that we follow with these questions:
Why would you like to stop smoking?
How might you go about stopping?
What are the 3 best reasons for stopping?
On a scale of 1 to 10, how important is it for you to stop smoking?
Why are you at (the number they gave) instead of at number (two numbers below that)?
Then end with: What do you think you will do next?

Throughout this questioning, the best thing we can do is to listen. People change best when they hear themselves state the reasons and a plan for change. In Motivational Interviewing, this is called “change talk.” When a person is ambivalent, if we speak in favor of change, he will counter with an argument against it in order to maintain the ambivalence. But if we allow him to speak in favor of change, he will more likely move in that direction. As Miller and Rollnick suggest in their book, Motivational Interviewing, we can enhance the effect of change talk by simply making a positive comment such as, “that sounds like a good idea.”

With more time, we can explore our patient’s readiness to change as well as her confidence that she can do it. Tying the change into an important value is also helpful. Mentioning that our family-oriented patient wants to be alive and active in the lives of children or grandchildren can be very motivating in making changes such as smoking cessation.

Change is difficult and usually doesn’t happen instantly. By allowing our patient to explore her ambivalence and verbalize her own reasons and plan for change, we can often be more effective in a shorter amount of time than the countless lectures we have all delivered trying to talk our patients into healthy behaviors.

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Watch your language – literally. Physician coaching helps doctors communicate with more than words

Posted on April 9, 2012 by Helane Fronek

Doctors feature prominently in many movies, but perhaps nowhere as pointedly as in the 1991 movie, The Doctor. In this film, William Hurt plays Dr. McKee, a busy cardiothoracic surgeon who prides himself solely on his surgical skills and emotion-free decision making ability. That is, until he becomes a patient himself. As he is diagnosed with and treated for laryngeal cancer, he sees another side to patient care – the human side. As movie watchers, we are gifted with the ability to see ourselves in action – in one scene, Dr. McKee’s own doctor uses the same words that he previously used with one of his patients. On the receiving end, the words sound strikingly different. However, even more disturbing than the words is the body language as they are delivered.

Research tells us that only 7% of what we communicate comes from our words. 38% is our intonation. And the majority, 55%, is conveyed through our body language. The famous actress, Mae West, knew this when she commented, “I speak two languages, Body and English.”

As Dr. McKee’s surgeon enters the recovery room with the news that “the tumor is malignant,” she smirks while apologizing for an unintentional enema her patient has just received, remains standing, crosses her arms across her chest, and looks down at her fingernails after delivering the bad news. Her tone is arrogant and dismissive. We can easily see that none of her body language or vocal tone conveys any sense of caring, compassion or an interest in partnership.

Can we be more skillful in our communication?

The answer is a resounding yes – and it doesn’t have to take much time or effort at all.

The most important thing we can do is the easiest, by far. We can make and maintain eye contact. Although we now struggle with how to look at both a computer screen and our patients at the same time, we can intentionally make eye contact at the beginning of each patient interaction, and then consciously come back to it whenever we want our words to make an impact or when our patients are telling us something important or emotional. There is nothing that gets across our concern quite as well as eye contact. Conversely, we can deliver the most compassionate message, but without eye contact it will not be received the way we intend.

By keeping our upper body open, we convey approachability and sincerity. When we cross our arms or hold a chart over our chest, we appear defensive and closed off to others’ opinions and concerns. While sitting, keep each arm at a different level, and lean forward a bit to indicate your interest in what your patient is saying. Especially when delivering bad news or discussing something emotional or difficult, sitting down communicates your sense of its importance.

Maintain openness between your mouth and your patient – covering your mouth is often interpreted as being deceptive, mistrustful, unsure or withholding information. If you are in the habit of putting your hand on your face, try cupping your chin in your hand, which implies that you are actively listening.

Beware of head nodding – most women interpret this as being caring, while men generally believe it indicates agreement. Too much of it can also be interpreted as impatience. On the other hand, occasional head nodding along with facial expressions (smile, frown, look of concern or surprise) are important factors in helping our patients feel our concern and attention.

An additional 38% of communication is carried in our tone of voice, so it’s useful to use that tool as well. In general, ending a statement on an up-note (common is some cultures and among women in the west) implies a sense of uncertainty. To convey confidence and some authority, end your statements either on a level or down note.

While much research has been done on body language, I’d like to invite you to do some of your own. Next time you are in a hospital or clinic, pay attention to the body language of your colleagues, staff and patients. You may be surprised at how much unspoken communication goes on. I encourage you to try some of the above suggestions – be the master of your own communication and see what a profound difference it makes.

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Just one thing

Posted on March 23, 2012 by Helane Fronek

In the hilarious Billy Crystal movie, City Slickers, the old cowboy Curly tells Billy that each person has one thing that really gives their life meaning. Sometimes, it only takes one thing to make the difference between feeling lost and rootless and feeling important and fulfilled. Similarly, sometimes it might take just one thing to make our interactions meaningful and our communication more effective.

After giving a presentation on communication at the American College of Physicians’ regional meeting last fall, I was approached by a physician who had found the one thing that had made a difference in her practice. As part of her MOC program, she elected to institute a change in her communication to raise her patient satisfaction scores. She decided to include one final question at the end of each patient encounter to see if it made a difference. So for a period of time, before leaving the exam room she asked, “is there anything else I can do for you today?”

All of her patient satisfaction scores rose to “10.”

Yes, we are rushed. But how long does it take to ask one final question?
Ah, but then we might have to deal with the answer!

In fact, when we fail to listen or hear our patients’ concerns, they generally repeat them until we do. We usually end up dealing with the concern anyway – at a later time when our patient is frustrated and has lost confidence in us and perhaps the medical situation has worsened. How much easier and quicker would it be for us to include this single question from the start?
Imagine the information you might obtain that could improve the accuracy of your diagnosis or your clinical outcomes.
Imagine the time you and your staff would save, avoiding those doorknob conversations or phone calls after the visit.
Imagine the satisfaction you will feel, knowing that your patients realize you care and that they trust you.

So consider what final connection you would like to make with each patient – a question such as, “Is there anything else I can do for you today?” demonstrates your concern, allows the reticent patient to share what is really on his mind, and lets you know that you’re not missing anything.

Just one simple question…with a huge impact.

Posted in building relationship with patients, effective communication in healthcare, first impressions, physician communication, scanning, Uncategorized | Comments Off on Just one thing

The opposite is also true – physician coaching allows the greater truth to emerge

Posted on March 7, 2012 by Helane Fronek

Someone recently told me about a bumper sticker that read, THE OPPOSITE IS ALSO TRUE. I love how that simple concept can open up whole new perspectives in our thinking. We are frequently so confident that our ideas are right – and the only way of thinking about something. But what IF the opposite were also true?

In dealing with patients, the results might offer us a window into their thinking, and therefore an opportunity to communicate more effectively. For example, we KNOW that our patients should take their medications, wear their compression stockings, exercise regularly. But if THE OPPOSITE IS ALSO TRUE, why shouldn’t they do those things?

Maybe the medications have unpleasant side effects, cost too much, are a nuisance to take or make our patient feel unhealthy because they associate taking medications with sick people. If any of these are true, our patient should NOT take their medications, from their point of view. But when patients don’t conform to our treatment plan we frequently become frustrated and angry, labeling them “non-compliant.” Sometimes, we give up on them because we decide that they must not care about their health.

In her excellent book, The Spirit Catches You and You Fall Down, Anne Fadiman tells the story of a Hmong family whose infant daughter had a seizure disorder. Because they believed that the etiology of her condition was spiritual, the parents did not give their daughter her medication and her seizures raged out of control. The physicians considered the parents neglectful and treated them poorly. After the child suffered brain damage and her seizures stopped, the family continued to care for her in their same loving way but now the physicians saw the parents as saintly. Clearly, each side had a different view of the situation. Could these physicians have provided more effective care if they had just seen that, while they believed the child would benefit from anti-convulsant medications, the parents believed that the opposite was true?

When dealing with friends, relatives, or colleagues who hold a different opinion, encouraging ourselves to consider how THE OPPOSITE IS ALSO TRUE can help us see a different perspective, allowing us to expand our vision of the world. Holding on to our judgment that the other person is wrong deprives us of meaningful discussion and learning and prevents us from a having a true relationship with that individual.

And in considering our own ideas, asking ourselves how the opposite stance might also be true gives us an opportunity to get closer to the truth of any matter, rather than remaining walled off in our own, usually self-serving, thoughts.

So, try it for a while. Whenever you have a thought that you are absolutely sure is correct, ask yourself in what ways the opposite is also true. You just might be surprised at what insights you gain, how different the world and other people in it begin to seem, and how much less stressed you feel.

Posted in building relationship with patients, effective communication in healthcare, honesty in medical care, physician communication, physician fulfillment, Uncategorized | Comments Off on The opposite is also true – physician coaching allows the greater truth to emerge

What am I missing?

Posted on February 8, 2012 by Helane Fronek

As part of a second year medical school course that I’m involved in, I recently attended a panel discussion on LGBT health issues. I consider myself fairly sensitive to cross-cultural issues that impact medical practice, and since I know several people in the LGBT community, I anticipated that I would understand and feel some kinship with the LGBT individuals who comprised the panel.

As I sat and listened to them relate some of the experiences they had with medical and allied health professionals that left them feeling completely misunderstood and dehumanized, I found myself wondering, how many times have I spoken thoughtlessly, assuming that every one of my patients shared my world view? How many interactions have left my patients feeling unseen, and therefore less confident that they could trust me with their care? If I am to be their guide, their partner in caring for their health, how can I truly see each person as a unique individual, with their gender identity, religious beliefs, occupational stresses, family supports and demands, and all the facets of their lives that contribute to their health and disease?
How can I make sure I’m not missing something important?

The answer came out during the panel, and it’s surprisingly simple.

I can ask.

I can ask how people would like to be addressed. How their family/work/living situation/etc. is affecting their medical condition and their life. What their hopes are. What their expectations are. How they would like to be treated. I can admit that I’m not familiar with their culture or religion or background. That I’m interested in knowing what they feel is significant for me to know.

I certainly don’t want to miss anything important.
Our relationship, their health, and my own satisfaction as a doctor depends on it.

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