To heal more, clinicians can learn to listen more
When encounters go sour, find ways to mend
Frederic W. Platt, MD, tells clinicians that only 50% of medicine is about disease. "The other half is the people wrapped around the organs you’re working with," he says. Platt is regional consultant for the Bayer Institute for Health Care Communication and clinical professor of medicine at the University of Colorado, in addition to his practice as a primary care physician in Denver.
Most clinicians know how to fix, prevent, or slow down disease, as long as the patient cooperates. But healing is more elusive, which happens when the owner of the disease becomes a partner in the clinical fix, rather than a rebellious subordinate. Platt teaches seasoned clinicians as well as medical residents how to use the portals to a healing partnership, and he shares them with QI/TQM:
• Slow down to go faster. If you listen more and talk less early in the encounter, you can accomplish much more later. For openers, shake hands and greet the patient by name. And, most importantly, Platt stresses, "sit down and look the patient in the eye." Say to the patient, "Before we get into the medical stuff, I would like you to tell me something about yourself." Then give him or her about 60 seconds to talk without interruption. "Usually after a minute, they begin to wind down," he says. "Meanwhile, you’ve learned about their lifestyle, their job, and what matters to them." In seminars, Platt observes, doctors assure him that they consistently listen to their patients without interruption, but at least two studies show otherwise.1,2
• Learn open-ended inquiry. Instead of questions that can be answered with yes or no responses, cast a wider net: "Tell me about your back pain." "What makes it worse?" "How often do you have to miss work?" "What were you hoping to accomplish during this visit?"
• Ask, "Anything else?" to prevent "Oh, by the way," as you exit. Sometimes, a patient will raise the most important point of the visit just as you stand up to leave. To prevent this from happening, or at least reduce the frequency, ask "Is there anything else?" as you note the patient’s list of topics for the visit. In a study2 of urban, semi-rural, and rural practices, 75% of physicians solicited such input. However, only 28% of the patients got to complete their opening statements. Others were redirected by the physician after an average of 23 seconds. Last-minute concerns were more common when physicians did not solicit them up-front, nearly 35% vs. 15%.
• Open portals in the clinician-patient relationship. Platt describes portals as doors, rooms, or spaces in the clinician-patient relationship where something other than medical fixing happens. Opening the portal to negotiation enables you and the patient to set the agenda for the visit. Ask, "What are all the things on your list to discuss today? I don’t think we’ll get to all three. So which is No. 1?" Then, says Platt, negotiate a follow-up plan, whether it’s a future appointment or a referral to another provider.
The words, "sounds like" unlock the portal to the empathic space. Those words are nearly magical when it comes to assuring a patient that you understand and respect his or her feelings. For example, "Sounds like your life has been lonely since your wife died," or "Sounds like you have felt real sad since your dog died."
In his book, Field Guide to the Difficult Patient Interview, co-authored with Geoffrey H. Gordon, MD (Lippincott Williams & Wilkins, Baltimore), Platt acknowledges that empathy takes time. However, he writes, "If you use understanding responses, you will be amazed at how much faster the interview progresses once the emotional outburst is named and understood."
• Redefine "difficult patient" to "difficult clinician-patient relationship." Labeling the patient as difficult focuses your attention on something you probably cannot change — the personality. If you focus on the relationship as the trouble, however, you have some options. "It could be a difficult disease or difficulties in the system of health care, or in the ways you are interacting with the patient that are causing the friction," Platt observes.
To avoid blaming the patient, or to re-focus blame that the patient is dumping on you, stop and consider what’s wrong with the interaction. "Ask him or her for help," he advises.
How can you do this? Invite mutual problem solving with a statement such as "I think we are having some difficulty here. Sounds like you see that the way out of your pain is to keep taking the pain meds. The way I see is for you to finish the rehab appointments. Is there any way we can work together on this?"
If the patient is angry about something you did, even if you could not help it, consider an apology. For example, if you agreed to talk with Betty Smith and her daughter at 4:30 but were involved in an emergency with another patient at the time, express your regret. Offer to make amends and ask Betty Smith how she would like you to handle it.
While the techniques described above facilitate the best use of time allotted to each visit, "you can’t do 20 minutes worth of work in 10 minutes," Platt contends. If outpatient appointments consistently run overtime, before prodding the clinicians to go faster, administrators should ask their input on the amount of time it takes to do the job. Platt also suggests asking patients how much time they think they will need when they call for appointments.
After all, he observes, "You don’t say to the surgeon, You have X minutes to complete a gall bladder operation.’ It takes how long it takes. That could be less than average’ for an uncomplicated operation and twice the average’ for a complicated one."
1. Beckman H, Frankel R. The effect of physician behavior on the collection of data. Ann Intern Med 1984; 101:692-696.
2. Marvel MK, Epstein RM, Flowers K, et al. Soliciting the patient’s agenda: Have we improved? JAMA 1999; 281:283-287.
Need More Information?
For information on communicating with patients in ambulatory and inpatient settings, contact:
- Frederic Platt, MD, 1901 E. 20th Ave., Denver, CO 80205. Telephone: (303) 377-2759. Fax: (303) 333-9262. E-mail: Frederic.Platt@ UCHSC.edu.
For information on continuing medical education workshops on patient interaction skills, contact:
- Bayer Institute for Health Care Communica-tion, 400 Morgan Lane, West Haven, CT 06516. Telephone: (800) 800-5907. Fax: (203) 812-5951. E-mail: firstname.lastname@example.org. Web site: www.bayerinstitute.org.
For information on effective wording of printed communications, contact:
- Peter Salovey, PhD, Department of Psychol-ogy, Yale University, New Haven, CT. E-mail: email@example.com.