Without patients, there is no medicine. We didn’t apply to medical school hoping to improve patients’ glucose levels. We don’t go to work just to normalize CRPs. Under the weight of daily clinical responsibilities, it is easy to lose track of this fact, but our goal is not to treat the pneumonia, but the person who has the pneumonia.
Patients are the essence of medicine. Connecting with our patients is essential. Good connections allow us to make the right diagnosis. Good connections ensure we don’t miss essential information. Good connections ensure we hear our patient’s values and priorities, fostering shared decisions making. And good connections add an element of joy to the job; a connection with the human spirit, rather than just the disease. For those reasons, a recent JAMA publication discussing practices to foster physician presence and connection with patients is a must read.
Zulman DM, Haverfield MC, Shaw JG, et al. Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter [published correction appears in JAMA. 2020 Mar 17;323(11):1098]. JAMA. 2020;323(1):70–81. doi:10.1001/jama.2019.19003 PMID: 31910284 [article]
This paper gathers evidence from a variety of sources. They started with a systematic review of the literature. Then, they supplemented that information through direct observations of clinical interactions in a variety of settings. They also interviewed patients and physicians about their interactions. Furthermore, they interviewed nonmedical professionals with jobs that involve intense interpersonal interactions about practices used to foster human connection. Finally, they synthesized this data through a modified delphi method.
They break their findings down into 5 major themes: prepare with intention, listen intently and completely, agree on what matters most, connect with the patient’s story, and explore emotional cues. Although everything sounds pretty basic, I think being mindful of these areas of care can have profound impacts.
Prepare with intention
This is an area where I struggle in emergency medicine. When there are 25 patients waiting, the temptation is to rush straight into the room; to get things started as soon as possible. I will admit that I am often frustrated when trainees start by sifting through a patient’s chart rather than just going to see the patient (we aren’t internal medicine, after all.) These authors would chide my impatience, highlighting the importance of preparation for good patient encounters.
The first part of this preparation is getting to know the patient. Unless a patient is critically ill, there is no need to rush into the room. In fact, patients are frequently frustrated at how often they have to repeat themselves in the hospital. A little preparation can help start the relationship on the right foot. There is certainly a balance. I don’t think this type of preparation can be done for every emergency patient, but I increasingly find this prep work invaluable.
Perhaps more important is their reminder to take a moment to pause and focus before entering the patient’s room. There are always a million things happening in the emergency department. Your body can walk into a new patient’s room, but your mind may still be back in the last resuscitation. Or you might be thinking about your upcoming vacation; or the argument you just had on twitter. The patient in front of you needs and deserves your complete attention. It isn’t easy, but we need to find ways to ensure that happens.
These authors suggest finding specific practices to remind yourself that you are entering a hallowed space and tying them to routine tasks, such as washing your hands. You might simply repeat the word “focus” while washing your hands. I have spoken previously about my mantra “stay curious”, as an attempt to ensure I move beyond the rote medical questions and engage with the individual in front of me. They extol the values of mindfulness as a technique for monitoring your attention and improving focus. Or you can keep it simple, and just take a couple deep breaths before walking into the patient’s room. The idea is to find some ritual to ensure that the patient in front of you gets your full and undivided attention.
Listen intently and completely
The title says it all. We can’t make the right diagnosis or align our treatment recommendations with our patient’s values if we haven’t heard what they have to say. However, for some reason, this is something we continuously fail at in medicine.
Nothing they recommend is going to come as a surprise, but it is worth repeating. Part 1 consists of using body language to communicate listening. Sit down whenever possible. Lean in towards the patient. Orient your body towards the patient (don’t sit facing a computer screen, with your back to the patient.) Common sense stuff, but important.
The second part of this theme is to avoid interruptions. We have heard this repeatedly in emergency medicine. The average physician interrupts their patient in 11 seconds, and I think we have shorter attention spans than most specialties. You can’t say much in 11 seconds. Just keeping your mouth shut might be the most important medical intervention you learn. When patients have more time to talk, they provide more medical information and report greater satisfaction. Silence also has the opportunity to prevent that dreaded “doorknob syndrome” – where the patient brings up another issue just as you are about to leave the room. (This is never the patient’s fault. It is the responsibility of the clinicians to determine the patient’s primary concerns.)
Agree on what matter most
This is another no-brainer that we often forget about in the heat of a shift. We need to learn what is most important to our patient and develop shared priorities for this visit. This is usually easy to accomplish. Ask patients about their major concerns, but don’t stop at the first answer. Often a parents major concern is “fever”, but what really matters is their answer to the question, “why are you concerned about the fever?” It is also a good habit to ask “is there something else you wanted to address today?” We can’t always solve every problem in the emergency department, but we have no hope at all if we don’t even know a problem exists.
Connect with the patient’s story
It is important to learn more about your patient than just their symptoms. Their personal circumstances have a huge impact on their health, and also heavily influence their values. In order to treat a person, you have to understand at least a little about that person. This can be as simple as understanding that a patient works as a chef, so we can give appropriate advice on return to work after gastroenteritis. It might involve a question about finances, to understand if the prescription you are writing will ever be filled. Or it might run deeper, with an exploration about spirituality and core values, as we explore treatment options at the end of life. We cannot treat a patient without understanding the person.
The authors also remind us to focus on the positive and acknowledge the patient’s effort. This advice may be more applicable in primary care, but I also try to apply it in the emergency department. When a patient says they recently quit smoking, I will say something like: “Congratulations! That is one of the hardest things anyone can do. I am really happy for you. Is there anything I can do to help?”
Explore emotional cues
They note evidence that when clinicians actively attend to patients’ emotional concerns, patients experience shorter and less severe illness. It is easy to overlook the emotional aspect of illness. A mild troponin bump without ST changes is pretty boring in emergency medicine. We have seen it many times before. We don’t experience much emotion, so it is easy to forget how emotional this encounter is for the other person in the room. It is their first heart attack. Their life is changing in front of their eyes. Their travel plans are cancelled. They are grappling with their own mortality. They wonder whether they will see their daughter get married. They are in the midst of an existential crisis, and we are ready to move on to the next patient.
There are two main components of this theme that the authors want us to focus on. The first is becoming more attuned to patients’ emotional cues, especially through changes in body language, tone of voice, and facial expressions, that we might otherwise overlook. Perhaps more importantly, they remind us that we can just ask. Be direct. As your patient “how are you doing” or “how are you feeling about this?” Reflect their feelings back to them for confirmation. “This must be very difficult for you.” “My comments seem to be making you angry. Can we talk about that?”
All of this information is both simplistic and profound. Most of it will come naturally if you can look past the patient and see the person.
Zulman DM, Haverfield MC, Shaw JG, et al. Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter [published correction appears in JAMA. 2020 Mar 17;323(11):1098]. JAMA. 2020;323(1):70–81. doi:10.1001/jama.2019.19003 PMID: 31910284
Morgenstern, J. Practices to Foster Physician Connection with Patients, First10EM, June 29, 2020. Available at: