Barb Grinwis, PA-C and director of Oasis of Hope Center walked into the room of a long-time patient at Oasis and was greeted with this bittersweet line, "Oh good, it's you", which was spoken with a sense of relief. Now, as I said before, Barb is the director of this health center - the one who recruits all of the other practitioners at Oasis. So this line from the patient is equivalent to a husband telling his wife, "I am so glad you look beautiful today." It is a compliment... but not really.
As the encounter continued, Barb inquired about the patient's sense of relief. To her delight, the patient responded, "Well there is nothing w
rong with the other providers, it's just... Well, you pray with me." Then, with a smile on her face, Barb exited the exam room, told us the story, and said, "So many times we get caught up in the medical technicalities and the science and forget that, to the patients,it's the little things that have the greatest impact."
Now this little heart-warming story could end here, but there is much more to be said about the kind of connection that took place between patient and provider. I am not even finished with school yet, but I have already spent a ridiculous amount of time studying science/medicine. So I am beginning to understand more and more how easy it is to see patients as complex puzzles as opposed to people with emotions and a story.
In the clinic and around the hospital I have seen countless doctors, PAs, and nurses fist-pump in victory after making a tough diagnosis or catching an important clue that led to the solving of a "medical riddle." Don't be too quick, however, to give yourself a high-five or a pat on the back after correctly differentiating a viral infection from a bacterial one, or after correctly rattling off every detail of the ketogenic diet, because there is still one factor remaining to make sure this patient benefits from your medical advice: adherence.
In the clinic and around the hospital I have seen countless doctors, PAs, and nurses fist-pump in victory after making a tough diagnosis or catching an important clue that led to the solving of a "medical riddle." Don't be too quick, however, to give yourself a high-five or a pat on the back after correctly differentiating a viral infection from a bacterial one, or after correctly rattling off every detail of the ketogenic diet, because there is still one factor remaining to make sure this patient benefits from your medical advice: adherence.
According Dr. Manoj Pawar, MD MMM in his article for the American Academy of Family Physicians...
- "When patients trust their physician, they are more likely to adhere to treatment plans and follow advice."
Not only that, but keeping your job as a healthcare provider may depend on making those connections via Health Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction surveys which are being used as a part of a providers efficacy evaluation. So how can providers establish a trustworthy relationship and thereby increase patient compliance?
Daniel Goleman and his colleagues are referenced in the 2005 article, "Five Tips for Generating Patient Satisfaction and Compliance" as they explain that establishing a sense of trust begins by avoiding stimulation of the amygdala (the portion of the brain that stimulates your sympathetic nervous system "fight or flight"). For when a patient feels threatened, manipulated, uncomfortable, or unsafe in any way, the amygdala is stimulated, releasing hormones in your brain that alters the path of incoming information before it reaches the prefrontal cortex (the part of your brain that determines what is good and bad). When this happens, the patient will associate your advice/presence/the situation with the negative emotions and will be much less likely to adhere to your recommendations. In order to refrain from stimulating this portion of the brain and inhibiting compliance, providers should learn to do the following, recommends Dr. Pawar:
Daniel Goleman and his colleagues are referenced in the 2005 article, "Five Tips for Generating Patient Satisfaction and Compliance" as they explain that establishing a sense of trust begins by avoiding stimulation of the amygdala (the portion of the brain that stimulates your sympathetic nervous system "fight or flight"). For when a patient feels threatened, manipulated, uncomfortable, or unsafe in any way, the amygdala is stimulated, releasing hormones in your brain that alters the path of incoming information before it reaches the prefrontal cortex (the part of your brain that determines what is good and bad). When this happens, the patient will associate your advice/presence/the situation with the negative emotions and will be much less likely to adhere to your recommendations. In order to refrain from stimulating this portion of the brain and inhibiting compliance, providers should learn to do the following, recommends Dr. Pawar:
- Uncover Patients' Actual Needs - By asking questions with sincere curiosity and intentionally seeking after patient goals and desires, you learn about the big picture of the patient. There may be more you can do to assist the patient in reaching their goal if you understand that unexpected shortness of breath is not only bothersome, but has forced him to opt out of men's league basketball with his friends this season. Not only will this give you a better idea of how to help the patient, this effective questioning also generally leads to a stronger, long-term relationship with the patient. The patient needs you may discover with this improved relationship, as Barb discovered, could also be spiritual in nature.
- Think Dialogue, Not Monologue - The days represented by the 1847 American Medical Association Code of Ethics are long gone; no longer are patients clinging to every word of their physician's paternalistic advice. So understand this and figure out how much the patient knows. Then embrace and compliment the internal knowledge of their own bodies. This way 1- they don't feel as if you are telling them what to do (trust!) 2 - you're making them an active part of their health care team (increased adherence!!) and 3- the patient should feel an increased sense of responsibility to improve their own health with healthy lifestyle changes. After all, it doesn't take years of medical training to understand how to live a healthy life - - make sure your patients know this!
- Don't Force 'The Close" - "The close" comes from sales, and although medical professionals are not salesman, you are still trying to get the patient to "sign on the dotted line." Whether they are signing to exercise more, quit smoking, see a counselor, or begin a new medication, if you cannot get the patient to sign, you are not a successful salesman of the medical advice. Dr. P
"O awar says, however, "if you push it too soon, you'll instill a sense of mistrust and even anger", and continues with a technique to prevent this:ne technique is called a “test close.” For example, if a patient with uncontrolled diabetes says he's too busy to exercise, try saying: “It sounds like time has been your biggest concern when it comes to exercising. If we could find an exercise plan that doesn't take a lot of time, would you be willing to move forward?”
Once again, you're still giving the patient a sense of control of their own bodies, and when that happens, they are much less likely to feel threatened by their provider and more likely to adhere to medical advice. - Always follow up - Whether you encourage the patient to call back in a week with an update, or make a personal phone call yourself, following up shows the patient that you sincerely care about their progress. Phone calls are especially effective for patients who are skeptical about healthcare as a financial business (because phone calls don't require a co-pay!). E-mails work too, but tend to be a little less personal. Outside of the medical follow-up, birthday and holiday cards are another easy, inexpensive, and effective way to improve the provider-patient relationship.
So whether you pray with your patient, ask them about their basketball game, or send them a thoughtful card, understand that it's the little things that have the greatest impact in making sure that you have happy and healthy patients who trust YOU, their healthcare provider.
Goleman D, McKee A, Boyatzis RE. Primal Leadership: Realizing the Power of Emotional Intelligence. Boston: Harvard Business School Press; 2002
Pawar, M. (2005). 5 tips for generating patient satisfaction and compliance. American Academy of Family Physicians. 44.6
Pawar, M. (2005). 5 tips for generating patient satisfaction and compliance. American Academy of Family Physicians. 44.6