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Would it be easier if I went home and skyped you?

When I am sick or worried I need you to look at me. I know you need to maintain my records doctor but while you are doing that it isn’t helping me to tell my story. Wasn’t that the point of me being here? Would it be easier if we both looked in the same place through a screen?

The non-verbal behaviour of doctors themselves is easily overlooked in communication research. Many instruments for measuring qualities such as patient centredness are designed to be applied to audio rather than video tapes, and questionnaires for patients may not be sufficiently detailed to seek their views on this area. However, an increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman and Kinnersley

Picture by Robin Hastings

What happens next is up to you

Healthcare more than any other service warrants taking the long view. Supposing a toddler becomes feverish overnight. Mum and dad (assuming they are living together) are likely to fret about that child all night. No one will sleep well. The following day the parents will continue to worry that their baby is ill. Friends or family will be consulted. It is possible but not certain that a grandparent may be able to offer some relief with childcare.

Researchers in the United States have found that a third of children under the age of six receive up to 10 hours of care a week and that 47% of all grandparents with grandchildren (under 13 years) living nearby provide some childcare . Although more grandmothers (54%) provided child care it was found that grandfathers (38%) also made a significant contribution. In the United Kingdom it has been estimated that up to half of working parents rely on grandparent care for their children. It was also found that although grandparents were prepared to provide some child care, and at times even reduced their working hours to provide it, they did not want to give up their jobs. Australian Institute of family studies

The partner who has to go to work the next day will be distracted and anxious. The childcare arrangements, if that’s the norm will be on hold as one parent may take time off to be at home. The parents will visit a pharmacy (drug store) and acquire whatever is recommended in the hope that the child will recover quickly. That is unlikely as even a viral illness can make a child unwell for several days. Eventually they will seek medical advice. Phone calls will be made and appointments requested. Parent or parents and toddler will travel and wait in line to see a doctor. They will eventually wheel the toddler into a health practitioners room. If that person is you what happens next is up to you.  Most likely the child will have a viral illness, be teething or have some other minor illness. But to this family this will have been a stressful and worrying couple of days. How you respond will form their impression of your service and make a bad situation an opportunity to learn about caring for a sick child or add to the  drama.

Picture by Andrew Seaman

Do you take the shortest route to add value?

Every thriving business adds value. If it didn’t it would not exist. Healthcare shares many points of difference with any other service but none is more remarkable than the  ability to forge connections via the physical examination. It meets our fundamental need when we are ill.

Treatment that uses direct touch can have a depth and potency that can have a great therapeutic impact, which provides some explanation for why so many people are seeking out their own “professional touchers” or are filling the waiting rooms of physicians, waiting for the doctor to find the cause of the pain and make them better. In the process, they are touched. When the patient is assured that the work of the professional toucher is free from infringement, that sexual contact is clearly out of bounds, and that the patient can say “no” to any intervention the body-work practitioner proposes, then the patient can have the experience of trust and physical touch in the context of a controlled respectful relationship. Sharon K Farber

If you are a healthcare professional in what proportion of cases don’t  you perform a physical exam? Why?

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Do your words strike a discordant chord?

Most upper respiratory tract infections are caused by viruses. However saying that to a parent with a sick child doesn’t always help:

Parent 2: They think they make you feel better saying it’s a virus…but they make you feel worse

Parent 7: When they say it’s a virus, I mean what kind of virus? Just where does it come from? Parent 1: You’re none the wiser how they got it, what you can do, how long it will go on…

Parent 5: You feel you’re no further forward…you just have to accept it if they don’t explain further, I would like to know…

Parent 2: It’s an unknown thing to a doctor, they can’t pinpoint it, they don’t know really…

Parent 1: I feel a bit annoyed really because you think they’ve studied for years to learn that and I haven’t studied at all, you feel dissatisfied as if you wanted to hear something more…you just wish that everything was clean cut

Parent 4: At least if you really knew what it was then it’s easier to cope with (Group 3) Joe Kai BMJ 1996

What do you say in these circumstances?

Picture by Massimo Variolo

Do you use stories?

Outcomes in healthcare can be assessed using measures, meters and monitors. The art of healthcare is to ‘sell’ health because most of what promotes health are the choices of autonomous individuals. Healthcare can choose to present facts and figures:

Your BMI is 27, your blood pressure is 150/95mmHg, your lipids are in the higher range, your K score ( measure of depression) is 26

So if this is you you’ll be advised to lose weight, exercise more, eat less and relax. Even as you hear these numbers you will glaze over. In other industries they use stories to avoid ‘push-back’. The typical story has a setting, a hero, a complication a turning point and a resolution. Story teller’s say:

He must enter the hearts of his listeners, where their emotions live, even as the information he seeks to convey rents space in their brains. Our minds are relatively open, but we guard our hearts with zeal, knowing their power to move us. So although the mind may be part of your target, the heart is the bull’s-eye. To reach it, the visionary manager crafting his story must first display his own open heart. Peter Guber

The story might be:

You know you remind me of another 45 year old chap I knew. He was a very successful and worked long hours. While he loved his job he also wanted to retire early so he didn’t pay much attention to his lifestyle. Then one night he went to the Emergency department because he had terrible chest pain. He was due to go to an important meeting in the morning but that evening he was sweating, vomiting and clutching his chest. He was lucky because it turned out he didn’t have any serious illness but he needed to change his habits. Two years later people didn’t recognize him, he put all of his skills to reinvent himself, lost weight, started exercising and having regular breaks. So although he, or should I say I, won’t retire soon I plan to live long enough to enjoy it when it does happen.

Bernadette Jiwa’s new book the Right Story might help.

Picture by MorkiRo

How do you prepare for disagreement?

Sometimes you might be asked for something that seems entirely pointless. In healthcare almost every speciality has examples of such challenging situations. In intensive care and oncology such issues are most poignant as patients may end up suffering before death:

In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 ± 32 years (mean ± 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (χ2 5 degrees of freedom = 26.7, p < 0.001).

Seth et al

This scenario may be avoided if it is anticipated as a ‘set play‘. List all the ways you may be adding to the person’s problems and consider how you might avoid contributing to a bad situation.

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How do you know your solution is the best?

Healthcare professionals offer solutions to problems. Doctors at community healthcare offer a solution to another problem every 10-15 minutes. Meanwhile the people seen there are making choices that seem entirely unrelated.

I’ll eat this, I’ll drink that, I’ll spend my money on this. I’ll work here. I’ll interact with these people. I’ll frame my problem like this…..

Some seemingly unrelated choices impact on the solutions offered by their health practitioner. It may be that people carry on making choices that undo all the benefits offered in prescribed, neatly packaged and costly labelled boxes.

If you are in healthcare how do you know the solutions you are offering are effective or even the best available? Could you do better?

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Do you use aids to help you explain?

If your job involves explaining complicated ideas- and let’s face it nothing is simple in medicine- do you use models or aids of any kind?

if not, why not? If you do what do you use and how do you know they work? How do you explain sciatica, heart disease, asthma, cancer?

Physicians cannot control all the reasons for patients pursuing legal atonement but they are able to determine the quality of their connection with them, by improving their communication skills and techniques. Law-suits for medical negligence can be lowered or prevented by taking steps to keep patients content, thus making them more compliant to the treatment, adhering to the medical policies and procedures. Tevanov et al 

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Are you sure you will focus on the right problem?

In any business where you are paid to solve problems you need to be clear that you are indeed solving the right problem. Doctors can frame the problem in many ways- if their patient has been brought in after a car accident then ‘the problem’ is  clearly the broken leg or the bleeding wound. What’s much less obvious is the problem that needs to be solved in all other circumstances.

In the moment you are sitting in front of the doctor the problem isn’t the runny nose, the headache, the sore throat or the anxiety. Being told it’s just a virus won’t help. You need that  doctor to give you their undivided attention and to see the context in which you are experiencing that discomfort. To acknowledge your distress. There is ‘no cure’ for a viral upper respiratory tract infection and you knew that before you walked into that office. Right?

Pcture by Luis Sarabia

How do you end your meetings?

We know how to start a meeting- we stand up, shake hands, say hello, smile. But what’s the best way to end a meeting? It matters for one reason:

The peak–end rule is a psychological heuristic in which people judge an experience largely based on how they felt at its peak (i.e., its most intense point) and at its end, rather than based on the total sum or average of every moment of the experience. The effect occurs regardless of whether the experience is pleasant or unpleasant. Wikipedia

If you are a doctor this is all the more important because people generally don’t seek a meeting with you because all is well. They may be experiencing all sorts of unpleasant feelings. So how do you end that meeting? How do you know it’s working?

Picture by Peter Lee