Posts Tagged ‘empathy’

My Mother’s Recent Emergency Department Experience: Lessons for Learning

March 7, 2011

My mother, Julia, is part of a clinical trial, which involves monthly infusions.  The clinical trial protocol requires periodic blood work, scans, x-rays, etc.  Last week, the physician leading the clinical trial called me at my office and said that my mother has atrial fibrillation and they will not proceed with the monthly infusion. They also noticed that one of my mother’s legs was red and swollen; they were concerned about a possible blood clot. They suggested calling an ambulance and having my mother taken to the closest Emergency Department (ED). I agreed to this action. They then called the ED to inform them of the atrial fibrillation and possible clot.

I called the ED to mention that my mother is on her way and also told them that before leaving my office I will fax over my mother’s medical history information. I have a two-page summary of my mother’s pertinent medical information (e.g., medications, hospitalizations, allergies, etc.).  I told the ED that my brother and I would be there shortly.

Overall, everyone at the hospital was very friendly. However, there were several parts of the experience that could have been improved. This article is a summary of the issues with suggested changes.

Problems with hand off. When my brother and I arrived at the ED, we went to my mother’s room and the nurse told us that their tests did not find atrial fibrillation and that my mother was going to be discharged now.  I asked about the issue with mom’s leg.  They said, “What issue?” In spite of the fact that the clinical trial physician clearly stated the leg needs to be evaluated for a possible DVT, that information never made it to the ED records.  After discussing the leg issue, my mother was scheduled for an ultrasound.  (As an FYI, the ultrasound revealed no clots.) To avoid these botched communication episodes that could seriously harm patients, professionals should engage in “repeat back.” After the information is shared the receiver must “repeat back” the information to verify accuracy.

No partnership statements.  The relationship between the patient and professional is not about giving orders; it is about forming a partnership. Upon admission to the ED, all patients should be asked, “What would make this an excellent experience for you?” What does great care mean to you?” We need to immediately understand the patients’ needs. If we are to be truly patient centered, we need to understand the needs of the patient.  In order to work as a team, we need to understand the patients’ needs.  Working as partners leads to quality improvement and better clinical outcomes.  Of course, this partnership approach leads to higher patient satisfaction.

Use of medical jargon. The people at the ED did not know I was a healthcare professional. They often used medical jargon that I understood, but what if I was not in the field?  When they scheduled the ultrasound, we were told Mom was being evaluated for a DVT. The abbreviation, DVT, was never explained. This is a serious problem in healthcare — the constant use of medical jargon that patients often do not understand.  This is known as a problem with “health literacy.” (The term literacy could mean problems with reading, however it often refers to the ability to understand the language of medicine.)

No signposting. This is a communication strategy in which people are given an overview of what will take place during their stay.  Streets have posts with signs on them (street names) hence the term “signposting.”  These posts with signs give people direction; that is exactly what we want to do with patients, give them direction.  In other words, tell then what will be coming up in regard to their care. This could as simple as saying, “First we will assign you to a room, run some tests and have you seen by one of our highly-qualified doctors. Based on the results of the tests, we will let you know how long you will be here.”  Patients should also be told that we are here to help you and make your stay as pleasant as possible.  There was one significant fact not revealed to our family that could lead to serious damage with patient satisfaction scores.  After being in the ED for approximately 1 1/2 hours, I asked our nurse, “When do you think my mother will have the ultrasound?” She then smiled as though she was about to laugh!  She said the average time for an ultrasound is 4 1/2 hours, but it could be up to 8 hours! This fact should have immediately been told to us.  (As an FYI, we had the ultrasound done in about 3 hours.)

Lack of hourly rounding.  After my mother was in the ED an hour, I expected someone from the medical center to check in on Mom.  No one came to see how Mom was doing.  Hourly rounding is a critical tool for many reasons.  This process helps prevent potential falls by asking patients if they need anything, such as a trip to the bathroom.  Many patients are seriously injured each year because they have to use the restroom and no one is coming to check on them. They try to get up on their own and sometimes fall.  The rounding also has a psychological benefit in that you are reassuring patients that you are thinking of them and working on their care.

No empathy. Going to an ED is a very stressful experience. During my mother’s time in the ED not one person directly stated an empathic response.  I would have liked to hear at least one person say, “I know it is scary being here. However we are here to help you.”  This comment should often be followed by a partnership statement, such as, “We will work together with you to find out what is going on as soon as we could. We will periodically check on you, but if you ever need anything, please feel free to let us know. We are here for you.”

Directions — don’t just tell, show!  When I arrived at the ED, I asked the person at the front desk what room my Mom was in and they told me. I asked for directions. The directions were very complicated due to ongoing construction. The person at the desk said something to this effect, “Go down this hall, turn right at the first hallway, then make an immediately left, go down the corridor until you get to a desk, then make a slight right, etc. What? Huh?  I then asked, “Could you have someone take me there?”  They agreed. When people ask directions, don’t simply give directions; take them to their requested destination.  This is an excellent customer service tip all hospital staff should incorporate into their work with patients and their family members.

Teach back technique not utilized.  After the ultrasound was completed, we were given discharge instructions.  Being in healthcare, I understood all the directions, however what if I was not in the field? Saying to a patient, “Do you understand?” is not sufficient.  In order to determine if they indeed understand, you must use the communication technique called, “teach back.” Ask the patient to summarize the information you provided. This could be as simple as asking, “Tell me what you will do when you get home.”

In summary, all of the hospital staff members were quite pleasant.  However, there were some very significant problems that could have negatively impacted my mother’s health. Based on a poor hand off, the ED was unaware of the leg issue.  Fortunately, my mother did not have a DVT. But what if she did?  This medical center needs to have staff development training covering communications skills, rounding techniques, educational strategies and customer service. These techniques are more than “bedside manner” tips; rather they are skills to avoid potentially serious medical errors.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!  http://www.CommunicatingWithPatients.com or 1-800-677-3256

Edward Leigh’s new book, Engaging Your Patients, is due out in June 2011!

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The Cleveland Clinic Improves the Patient Experience … by Improving the Hospital Gown!

October 12, 2010

The hospital gown. They have become a standard joke among comics who talk about being in hospitals.  If patients do not fasten them just right, their derrieres (or other body parts) may be on display for all to see!

The Cleveland Clinic wants to change the hospital gown and they have enlisted the help of a glamorous fashion designer! Fashion icon Diane von Furstenberg created a unisex patient-friendly, comfortable, wraparound apparel that looks good on everyone.

Jeanne Ryan, committee chair, stated, “The original goal had been to improve patients’ hospital experiences. We wanted to provide people with some dignity. They come to the hospital, it’s very stressful and then we ask them to take off their clothes. People said they feel exposed.” The gowns are expected to become available to all patients in the Cleveland Clinic’s Ohio facilities sometime in 2011.

Everything a hospital does creates either a negative or positive “patient experience.”  This initiative certainly enhances the patient experience.  From my work at enhancing the patient experience, I know that these little changes have a big impact. Bravo to the Cleveland Clinic!

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

MD Anderson Cancer Center Offers Innovative Patient-Professional Communications Program

October 8, 2010

The Interpersonal Communication And Relationship Enhancement (I*CARE) programs are excellent educational tools developed to enhance the communication skills of oncology professionals. The program is part of MD Anderson’s Department of Faculty Development. The program developers strongly believe that “skillful communication is a competency that can be taught and learned.”

The I*CARE program mission: “Most cancer clinicians have not had the opportunity to develop their skills in managing difficult patient encounters such as those where there are strong emotions, stressed families or uncomfortable conversations when transitioning a patient to palliative care or discussing end of life. Oncology providers want to extend their role beyond treating disease to establishing a therapeutic and supportive alliance with the patient and family. Our goal is to assist you in sharpening the skills necessary to manage these challenging encounters.”

I*CARE PROGRAM INITIATIVES

I*CARE Website

The website, http://www.mdanderson.org/icare, contains the MD Anderson Cancer Center’s Video Library of Clinical Communication Skills and is an educational resource for communication skills development. The video library helps with understanding the basic principles of communication and advanced skills such as discussing end-of-life issues and error disclosure by providing specific protocols that can be used and illustrating them with video re-enactments.  Free Continuing Medical Education (CME Ethics credit is available) and Risk Management credits are available to physicians enrolled in The University of Texas Professional Liability Insurance Plan. People may download materials for teaching purposes.

Programs

There are many program options, including fellow & faculty forums, interactive workshops, train-the trainer sessions, conferences and the quarterly Achieving Communication Excellence (ACE) lecture series.  One program, “On Being An Oncologist,” features actors William Hurt and Megan Cole who assume the personas of various doctors. Using dialogue gathered by physician focus groups, they share their feelings about the stress of caring for patients with life-threatening illness; the time pressures; the challenge of breaking bad news; the need to keep hope alive; the balancing of sympathy and empathy and keeping personal boundaries, as well as dealing with both the patient’s and their own emotional reactions.  A workbook with reflective exercises can be downloaded for both teaching and learning purposes.  In the Spring of 2011, there will be a new program launched for patients and families to learn how to communicate their needs to their medical team, and specific information on the cultural aspects of communicating with patients. 
One-on-one Coaching

Trainers observe healthcare professionals with patients and feedback is provided.

Research Opportunities

There are many ongoing research projects such as assessing aspects of the patient / oncologist relationship through audio taping clinical encounters and the impact of empathic statements on a patient’s emotional state.
These outstanding initiatives are making a big impact in helping oncology professionals successfully connect with patients on an interpersonal level.

Walter F. Baile, M.D., is the I*CARE Program Director and Cathy Kirkwood,
M.P.H., is the I*CARE Project Director. For more information about I*CARE, visit: http://www.mdanderson.org/icare

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

Medical Students Learn what it is like to be a Resident in a Long-term Care Facility … by becoming a Resident! The Learning by Living© Project

September 29, 2010

Empathy in healthcare is all about understanding what it is like to be “in the shoes of “ a patient / resident.  Medical students at the University of New England College of Osteopathic Medicine learn what it is like to be a resident in a long-term care facility by becoming a resident!

The Learning by Living© Project is the brainchild of Dr. Marilyn R. Gugliucci, Director of Geriatric Education and Research at the College of Osteopathic Medicine.  In this innovative program, medical students are “admitted” into a long-term care facilities to “live the life” of a resident for two weeks.  Each student comes with a diagnosis and appropriate treatments. For example, if the student is admitted in a wheelchair, the student must stay in the wheelchair for every activity, including changing clothes and bathing.

Prior to the development of this project, students learned about long-term care via traditional methods (e.g., lectures and brief visits).  

In 2005, the first medical student was “admitted” into a Maine long-term care facility to live the life of a resident. Each summer since then, Dr Gugliucci has admitted students into long-term care facilities.  The students do not return home at the end of the day; the students live in the facility on a 24/7 basis.

Dr. Gugliucci maintains constant contact with students portraying an adult daughter of the student acting as a resident.  The students carefully document their experiences. The long-term care facilities provide a bed and meals at no cost.

The program has a 100% success rate!  Follow-up data reveal that students practice medicine differently because of their experience of living in a long-term care facility.  According to Dr. Gugliucci, students gain the following by having this experience:

  • Importance of physical touch, voice inflection, and word cadence when working with patients.
  • Enhancement of communication by being at eye level with the patient, whether they are in a bed, a wheelchair, or on a treatment table.
  • Communication with authenticity and sincerity, emphasizing the importance of being comfortable sharing with patients.
  • Connection with and treating the person rather than the diseases or frailties of the patient.

Currently, the University of New England College of Osteopathic Medicine is the only medical school in the country admitting students into long-term care facilities for extended periods to live the life of a resident. The plan is make this a nationwide project. The project is also applicable to nurses and other health profession students.

The Learning by Living© Project is being filmed for a documentary, due out in June 2011.

For more information about the Learning by Living© Project, please contact Dr. Marilyn R. Gugliucci at mgugliucci@une.edu

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

 

Patient Advocates Help Healthcare Professionals

August 31, 2010

 

In 2004, Trisha Torrey discovered a golf-ball sized lump on her torso.  There was no  pain associated with the lump.  Trisha contacted her doctor and ultimately several tests were performed.  The tests revealed a devastating diagnosis, a rare form of lymphoma that is nearly always fatal.  She was told to begin chemotherapy immediately.

Trisha felt something was not right.  She did all her Internet research and discovered that she had no other significant symptoms associated with this type of lymphoma.  It just did not add up.

Through a friend, she found a new doctor for a second opinion.  Then came the shocking (but happy!) news.  Trisha did not have cancer!  She would have gone through chemotherapy for nothing!  (Chemotherapeutic agents are toxic. It would have been devastating to go through this treatment and not actually need it!)

For Trisha, this was a life altering time for many reasons.  From that moment, she became a patient advocate to help others through the healthcare maze. Today, Trisha is the About.com expert on the topic of patient empowerment.  She recently posed a question to her readers, “What Should Medical Students Learn?”  These are some the responses that you will find helpful:

  •  Do not “give/write orders.” Medicine is not a military command. The patient makes the final decisions. You are there to offer expertise on diagnosis and treatment options. Take the time to make certain that patients understand clearly what options are available to them and the pros/cons/costs of all the options.
  • If you want patients who have money / insurance, you will have to accommodate some aspects of customer service in the medical care regimen. Treat patients, not disease.
  • Treat every patient with dignity and respect, imagining that each patient was your own loved one: parent, grandparent, child, brother, sister, or spouse.
  • For some patients, gender matters, especially with intimate procedures and exams. Some women would prefer female caregivers, some men would prefer male caregivers. Medical staff should not assume just because a patient doesn’t discuss their preferences, that everything is just fine.
  • Never forget that your world, the world of the hospital, is not the real world. It’s not where most of us live. Explain things. Talk. Communicate. Don’t assume too much about what patients already know, want to know, or value personally. Ask.

 Trisha’s first book, You Bet Your Life! The Ten Mistakes Every Patient Makes, was published in 2010. You can contact Trisha through her personal website:  www.EveryPatientsAdvocate.com

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  The Center focuses on increasing patient satisfaction and decreasing the risk of medical errors. We offer high-impact training, consulting and one-on-one coaching. Contact us today!
http://www.CommunicatingWithPatients.com or 1-800-677-3256

My Mother’s Recent Hospitalization Experiences: The Good, the Bad and the Ugly!

November 18, 2009

About a month ago, my mother was crossing the street with her friend. Just as she stepped on the sidewalk she started feeling faint and began to feel sick.  An ambulance was immediately contacted and my mother was taken to the ER.  My mother’s friend accompanied her to the hospital — she called us from the hospital and told us to come right over.

My brother and I entered the hospital’s ER to find my Mom awake and alert. An ER nurse told us that my mother’s EKG was abnormal and that she had a condition known as Atrial Fibrillation and would need to take the medication, Coumadin.

A few hours later, my mother was admitted to the hospital.  The physician on the unit determined the underlying medical issue, dehydration.  We thought my mother was drinking enough fluids — obviously not.  My mother was in the hospital for four days.  Upon proper hydration, she was feeling fine and looking forward to returning home.

These are my observations regarding my mother’s recent hospitalization.  I base the observations on my PIE Model of Patient Communication.
P  Psychosocial (providing emotional support)
I  Interviewing (getting information)
E  Educating (giving information)

Psychosocial Dimension

Everyone was very friendly and kind.  I found the healthcare professionals to be very caring and treated my mother quite well.  However, what I did not find was any direct empathic responses.  I was waiting for someone to make a statement such as, “I know this must be difficult for you.”  Every medical center and practice always mention that empathy is an important component of their work.  In reality, empathy is rarely displayed.  This is due to the fact that healthcare professionals are not educated on how to convey empathy.

Interviewing Dimension

The questioning techniques employed were sufficient to gather information from my mother and I.  There was the usual issue of asking too many closed questions in succession and not allowing the patient sufficient time to discuss their medical issues.

The biggest issue was closing the interview with this question, “Do you have any questions?”  That is a closed question.  To encourage patients to ask questions, we should rephrase the question as an open question, “What questions do you have?”

Educational Dimension

Brace yourself and fasten your seat belt!  This was by far the weakest area.  Upon discharge, the unit nurse reviewed the discharge instructions, which were disjointed at best.  There were so many issues, I almost did not know where to begin my evaluation.  These are the problem areas and suggestions for improvement:

Excessive use of medical jargon:  The discharge instructions used the terms presyncope and mixed hyperlipidemia.  I am in the healthcare field and know what the terms mean, but what if I wasn’t in the field and didn’t know what the words meant?  Use patient-friendly language.

Ultimate diagnosis not mentioned. My mother initially fainted, but was ultimately diagnosed with dehydration by the attending physician.  Dehydration was never mentioned in the discharge report. This is a perfect of example of how poor handoffs lead to medical errors. At the time of discharge, I asked about the dehydration and how much fluid my mother should consume.  The nurse said, “About 3-4 glasses a day, I guess.” (Having a solid healthcare background, I researched the topic and developed a daily fluid intake plan for my mother.)
Vague comments. The discharge form states, “Will order Influenza vaccine.” Was it ever administered to my mother?  I called the hospital and was first sent to the Medical Records Department — they had no idea.  The Medical Records Department sent me to the unit, who also had no idea.  The unit nurse did say this, “Your Mom most likely did get the flu shot.  We usually give it to people 50 or over.”  Why didn’t the report state, “Patient was given a flu shot?”

No educational materials / resources.  In spite of the fact my mother was diagnosed with dehydration, no information was provided.  A brochure, website or organization to contact would have been helpful.

Overall, the healthcare professionals who took care of my mother were kind and skilled at their jobs.  There were some issues with the interviewing questions and empathic responding, however the biggest concern was the poor patient education component.  If patients do not comprehend their medical situation, they are at risk.

I signed the form for my mother (I have Power of Attorney).  By signing the form, I indicated I understand the discharge papers.  I actually did understand them — I have been in healthcare over 20 years.  My biggest concern is that most people will sign the form stating they understand, but they really do not.

Hospitals need to do a better job at educating patients.

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  To book one of his high-content credit-hour-approved keynote speeches or training programs, visit or call: http://www.CommunicatingWithPatients.com / 1-800-677-3256

When Patients Want Antibiotics They Don’t Need: Offer Explanations, not Prescriptions

August 31, 2009

AntibioticsNotForColds

A patient with an upper respiratory infection comes to see you.  After performing a history and physical, you determine the patient has a viral infection.  You are concerned the patient will insist on a prescription for antibiotics.  Below are the steps to handle this patient concern.
 
Show Empathy
 
Think about how sick you felt with a respiratory illness.  They can be a miserable experience.  Here is an example of a statement you can say to a patient, “I understand you are not feeling well.  I want to assure you that I want to help you.”
 
Explain Difference between Viruses and Bacteria
 
For patients, viruses and bacteria are all “bugs.”  They do not perceive a great deal of difference between these organisms.  We need to explain to them the difference and then discuss how antibiotics are effective for bacteria, but not viruses, such as the virus causing the common cold.
 
You can mention to patients, “Most adults, on average, get two to three colds a year; and children can have eight to twelve colds a year. Most colds last about one week. But it’s not unusual for symptoms to continue for as long as two to three weeks.”
 
Describe Dangers of Antibiotics
 
Side Effects. Mention how antibiotics can be have unpleasant side effects. Say, “I do not want to give you a drug that will not help and possibly make you feel even sicker.” Describe potential antibiotic side effects including: upset stomach, diarrhea, rashes, and (rarely) serious allergic reactions (even with antibiotics that they may have used safely in the past).
 
Resistance. In addition, explain how overuse use of antibiotics can result in resistance to them.  For example, you can say, “Using unnecessary antibiotics can cause some bacteria to become resistant to the antibiotic. This increases your chances of having bacterial infections later that can’t be treated by antibiotics. This is called ‘antibiotic resistance.’”
 
Potential Patient Issues
 
Concern over Green or Yellow Mucus. A patient may state they are having green or yellow mucus and fearful that means their illness is serious.  We need to combine empathy with our explanation. You can state, “I could understand your fear.  We used to think that green or yellow mucus indicated a bacterial infection. However, today, we know this is not true. A viral infection can cause green or yellow mucus.”
 
Previous (Unnecessary) Antibiotic Prescription. Explain to patients that if they were given antibiotics in the past for colds that antibiotics often get credit that your body’s own immune system really deserves. Review issues of antibiotic side effects and resistance.  Also, mention newer knowledge of antibiotics.
 
Emphasize the use of self-care measures (such as fluids) and nonprescription medications.
 
It is important to remember, patient satisfaction is generally linked to communicating effectively not writing prescriptions.
 
The CDC has an excellent brochure for patients, “Cold or Flu. Antibiotics Don’t Work for You.”  Here is the link:
http://www.cdc.gov/GetSmart/campaign-materials/print-materials/Brochure-general-color.pdf

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Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  To book one of his high-content credit-hour-approved keynote speeches or training programs, visit or call: http://www.CommunicatingWithPatients.com or call 1-800-677-3256

Great Communication Skills = Lower Risk of Malpractice

April 1, 2009

medicalmalpractice

A friend who worked as an oncology social worker for many years told me of
a pediatric oncologist who was working with young cancer patient.  The
oncologist
accidentally gave her a very large (and potentially fatal) dose of
chemotherapy.  The young girl survived this medical error.  My
first thought — that girl’s parents will immediately go to an attorney.
However, that was not the case.

The oncologist spoke to the girl’s parents and explained what happened.
She said she felt terrible and said, “I’m sorry.”  She also said, “Based on
what happened I think it would be best if your daughter worked with
another oncologist.”  The
parents said, “We don’t want another oncologist.  You have been so
wonderful to our daughter.  You were there holding her hand when she was
ill from the various treatments.  We want you to continue treating our
daughter — we won’t have it any other way!”  By the way, they also told
the oncologist they had no plans to take legal action.

Why did the parents have no intention of pursuing litigation?  One simple
reason
— they liked the oncologist.  In general, people don’t sue people they
like.  We get people to like us through great communication skills.

The June 4, 1997 issue of the Journal of the American Medical
Association (JAMA)
included an enlightening article called,
“Physician-patient communication. The relationship with malpractice claims
among primary care physicians and surgeons.”  The primary objective was to
identify specific communication behaviors associated with malpractice
history in primary care physicians and surgeons. The research compared
the communication behaviors of “claims” vs. “no-claims” physicians
using audiotapes of 10 routine office visits per physician. The study
consisted of 59 primary care physicians (general internists and family
practitioners) and 65 general and orthopedic surgeons and their patients.
The physicians were classified into no-claims or claims. There was
significant differences in communication behaviors of no-claims and claims
physicians in the primary care physicians group (no differences in
surgeon group). The helpful behaviors exhibited by the no-claims primary
care physicians included:

Length of primary care office visit
The study demonstrates a strong
correlation between extra time spent with patients and lower frequency of
malpractice claims. Since patients dislike feeling rushed or ignored,
physicians who are “too busy” to sit down, listen attentively, and respond
to a patient’s questions may set the stage for problems down the road.

Engaging in a dialogue
Physicians should encourage two-way communication that includes:

using orientation statements, which educates patients about what to expect and the flow of a visit.  This includes statements such as, “First, we’ll talk about your stomach pain, then I will examine you, and then we will
talk about ways to treat the problem.”

applying facilitation techniques to obtain patients’ opinions, check for understanding and encourage patients to talk.   These include questions such as, “What do you think is causing the pain?”

using applications of humor, laughter and encouraging statements, such as “I’m happy to hear you are feeling better.” Use of humor and laughter express warmth, friendliness and empathy and builds a bond between physician and patient.

inquiring into psychosocial and lifestyle issues, such as, “You said you went on an anniversary cruise last month, how was it?”

providing information and advice, such as by making a statement like this, “The medication may make you feel sleepy.”   This also includes providing educational literature and suggesting organizations to contact. Imparting information
and advice in a manner that demonstrates the
physician’s genuine caring tends to diffuse patient anger and resentment.

Physicians who have been sued for malpractice often cite “unrealistic
expectations”
on the part of their patients. Encouraging two-way communication helps the
patient develop appropriate expectations about a medical visit, and
prompts the sharing of critical information.

Breakdowns in communication between physician and patient fuel distrust
and pent-up anger. No one wants to feel that their concerns are ignored,
nor that their problems have been minimized or disregarded. Factor in a bad
outcome to the scenario and we are setting the stage for a lawsuit. On the
other hand, effective communication skills tends to enhance patient
satisfaction.

The study identifies specific and teachable communication behaviors
associated with fewer malpractice claims for primary care physicians.
Physicians can use these findings to improve communication
and decrease malpractice risk.

Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  He is the author of the book, Communicating with Patients (due out in the summer of 2009). For more information about his high-impact communication skills programs, visit or call: http://www.CommunicatingWithPatients.com or call 1-800-677-3256

The Cleveland Clinic Foundation Offers Novel Approach to Dramatically Improving the Patient Experience

March 2, 2009
M. Bridget Duffy, MD, Chief Experience Officer, from the Office of Patient Experience, speaks with staff members

M. Bridget Duffy, MD, Chief Experience Officer, from the Office of Patient Experience, speaks with staff members

The Cleveland Clinic Foundation is always on the cutting edge of
breakthrough medical treatments.  However, the organization is also at the
forefront of meeting the human needs of patients.

The Cleveland Clinic Foundation created the Office of Patient Experience
(OPE), whose mission is to “create an environment that delivers superior
clinical care while valuing human-to-human interactions as a critical
component of healing.”

Through OPE, the Cleveland Clinic Foundation main campus and several
system hospitals developed councils, which focus on empowering
patients and families to take an active role in their healthcare
experience. The councils also serve as an advisory resource for employees,
staff and administration.

The Cleveland Clinic Foundation has 26 institutes that group multiple
specialties together to provide collaborative, patient-centered care.
Each institute designates a doctor and nurse to be part of the OPE
Council.  It is important that every segment of the system be represented.

Throughout the system, the councils work to impact four dimensions of the
patient experience (organizational culture dimension, clinical dimension,
emotional dimension and physical environment dimension).

There are many projects in each dimension.  Here are some examples:

Cultural/Staff and Employee Engagement Dimension
In order to deliver excellent clinical care and create meaningful patient
experiences, employees need to feel they are having a significant impact.
The councils help define, implement and communicate activities that
specifically enhance the employee experience, which in turn, positively
effects the patient
experience.  This includes work-life balance activities, such as
complimentary memberships to gyms and weight loss programs.

Clinical Dimension
Patients often feel confused and overwhelmed within the healthcare system.
The OPE is currently piloting a Health Navigator program that will assist
patients in understanding an often complex healthcare system.  The
dictionary defines “Navigation” as the process of plotting or directing
the course of a vessel.  In this case, we talking about helping patients
find direction through the healthcare system.

Emotional Dimension
Excluding wellness checks, when patients enter the healthcare system,
there is something wrong.  The condition they are experiencing can lead to
feelings of anxiety and / or depression. A program called Healing
Solutions focuses on improving the patient experience by promoting
positive activities.  An example of this program is offering massotherapy
to reduce stress.

The dimension also helps employees.  For example, if a healthcare
professional is devastated by the loss of a patient they had grown very
fond of, a “Code Lavender” can be pulled.  In this way, the employee can
be comforted by one or more people from Healing Solutions.  They also have
the option of wearing a lavender bracelet so other people would know they
are gong through a difficult time and offer their support.

Physical Environment Dimension
This area focuses on the physical environment to provide comfort and
support for patients.  This includes artwork throughout the system.
Music and dance performances also play a role in creating a therapeutic
environment.

I recently watched a TV medical drama and one doctor on the show said, “We
have a breast cancer in room 110, a heart murmur in room 118.”  Patients
are not simply “disease states.”  This type of conversation would never be
heard
at the Cleveland Clinic Foundation who value the entire patient and this
is exemplified through the Office of Patient Experience.

For more information about the Cleveland Clinic Foundation’s Office of
Patient Experience, please contact: 216.445.5230 or
patientexperience@ccf.org

**********************

Edward Leigh, MA, is the Founder and Director of the Center for Healthcare Communication.  For more information about his high-impact communication skills programs, visit or call: http://www.CommunicatingWithPatients.com or call 1-800-677-3256

Giving Bad News: An Effective Three-Step Approach

January 28, 2009

BXP39638

“Breaking bad news is not as much a delivery as it is a dialogue between
two people.”
— Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients who
suffer. West J Med 1999;171:260-3.

One of the most difficult tasks for a healthcare professional is to
deliver bad news.  It is never an easy activity even for the most seasoned
of professionals.  However, there are steps we can take to be sure the
news is delivered in the most effective and caring manner.

The Definition of “Bad News”

We tend to think of bad news as telling a patient they have a terminal
disease.  However, that is a type of bad news.  There are multiple types
of bad news.  For example, telling a construction worker he can’t lift
heavy objects for six months is bad news if that is his livelihood.  Also,
telling a person they have a chronic disease, such as diabetes, is also a type of
bad news.

Bad news can be any type of news that will negatively impact a patient in
any way.

Is it Always Necessary to tell a Patient the Bad News?

Fifty years ago, it would not be unusual to withhold a terminal cancer
diagnosis from a patient.  However, recent studies have shown that
patients do want to know this information.  It is important that patients
are given all the details of their health situation; they have a right to
know.  They may want to make decisions regarding wills and other legal
matters.

Based on a case-by-case basis, there may be situations where withholding
information may be a good option, such as in the case where a patient may
have a mental breakout or harm themselves.  In some cases, the patient
themselves may ask not be told.  This should be looked at as a type of
informed consent.

Steps in Giving the Bad News

I. Before Giving the News

Think about the agenda before you meet the patient, so that you have the
significant information available. There are several items to consider
when planning what to say:  specific diagnosis, treatment plans,
prognosis, and support strategies. For a patient who has been shown to
have hypertension, this would be an appropriate manner of discussing:
specific diagnosis (describe diagnosis of high blood pressure, avoid
medical jargon like the term hypertension), treatment plans (discuss
different options to treat high blood pressure), prognosis (discuss
successful options for treating, however be careful of not guaranteeing
100% success), and support strategies (provide resources to help cope).

Prepare for the conversation with the patient.  Think about what you want
to say.  Mentally rehearse your words so you feel more comfortable sharing
the news.

Have a box of tissues in the room in case the patient begins to cry.

II. Giving the News

Physical setting: Find a quiet private place to share the news.  Be sure
you are seated at eye level with the patient.  Avoid any physical
barriers, such as a desk.  Ask the patient who else should be present; let
the patient decide who, if anyone, should be present in the meeting.
Silence all beepers and request no interruptions unless it is an absolute
emergency.

Communication strategies:
* Give the patient a warning that difficult news is forthcoming, such as by
stating, “I’m afraid the results reveal the situation is more serious than
we would have hoped for …”)
* The patient is your first priority, however if the patient has other
people present (e.g., spouse), be sure to attend to those people as well.
* Speak slowly, clearly and concisely.
* Provide the information in small chucks; do not give a long lecture which
can be overwhelming to an already anxious patient.
* After discussing each segment, pause to allow the patient to take in what
you have stated.  This is known as “chunk and check.”
* Be honest about the prognosis; do not give false hope.  Be sensitive, yet
direct.
* Use empathy in the discussion (e.g., “I know this is difficult news.”)

Assess current level of knowledge.  Determine how much the patient already
knows, such as by asking, “What have you already been told about your
illness?” Pay close attention to what the patient says to evaluate their
level
of sophistication regarding the illness and their current emotional state.

Ask the patient how much they would like to know.  Inquire as to whether
they want all the details or just the “big picture.”  Emphasize the
fluidity of the dialogue, so they know they could always ask more
questions at a later time.

III. After Giving the News

Be very attentive to the patient’s feelings.  After you have shared all the
news, listen very carefully to the patient’s reaction while observing body
language.  Use empathy (e.g., “I know this has been very stressful to hear.”)

Emphasize your role as a partner.  Let the patient know you are working with
him or her on this medical issue (“We will be working together to help
you.”).  Confirm your role as an advocate for the patient.

Follow up plan.  This is a time for reviewing, summarizing and making next
steps.  Develop a step-by-step plan, review the plan with the patient and
then agree on follow up plans.  Provide resources, which could be a
referral to a counselor (if needed), brochures, phone numbers and
websites.

Closing Thoughts

Healthcare professionals are taught technical skills to attend to the
patients’ physical needs.  However, when giving bad news, the greatest
skill is effective communication.  Unfortunately, during a healthcare
professionals’ formal education, communication skills are often not given
the vital importance they deserve.  A growing body of evidence illustrates
how the communication skills of the healthcare professional will greatly
influence how well a patient will cope with the bad news.

Edward Leigh, MA, is the Founder and Director of the Center for Healthcare
Communication.  To book one of his high-content energetic keynote
speeches or training programs, visit or call:
http://www.CommunicatingWithPatients.com or call 1-800-677-3256