The Doctor-Patient Relationship

The relationship you have with your primary care physician can mean the difference between life and death.

How’s that for an opening statement?

My parents had my eldest brother, Chris, in 1959, then 14 months later had my other brother, Andrew, and 18 months later had my sister, Mary. It was just the three of them in this tight cluster until 7 years later when I came along. Those two were full of energy, into everything, and had non-stop energy. She, on the other hand, was an introverted sensitive soul.

She also had a weight problem. For as long as I could remember she was extremely self-conscious about it. My brothers were skinny, especially Chris, and poor Mary got picked on. A lot.

It didn’t help that our primary care physician was a scary looking old man who spoke in a thick German accent and used to tease her about her weight every year at her annual school physical. She dreaded those visits and even as an adult hated going to the doctor for fear that they’d say something unkind.

Those early pediatrician visits made a big impression on her. She thought every doctor was an old man who said things like, “Vell younk lady, you ah putting on some veight, again, yah? You haff to shtop eating so many cookies.” And always in front of my brothers, giving them plenty of ammunition for teasing.

She never got over it. This was a woman who, in her late 30s, refused to go to a doctor when she clearly and unmistakably had gallstones. Incredibly painful gallstones which she insisted on treating with over the counter tylenol. They either resolved on their own or she just adjusted her pain tolerance, I’m not sure which. But it infuriated my mom who was a nurse and me who worked at a hospital. We begged her to go to a doctor but she absolutely refused. She told us didn’t want to go because she was sure they’d get on her case about her weight. Exasperated, Mom and I finally gave up.

Fast forward to the fall of 2012. Mary was suffering from some insanely horrible back pain. Nothing over the counter could touch it. She’d gone to a chiropractor, a massage therapist, and an acupuncturist, but got no relief at all. I remember her telling me that driving over railroad tracks made her see stars.

Finally, I said, “That’s it. I’m getting you an appointment to see a doctor. We have GOT to get this looked at.” A few days later, I was able to get her in to an internal medicine physician with the medical group I worked with. Although I turned my head when he asked her to take her shirt off, there was no way not to notice the giant lump she had on her breast. It was huge. Softball size huge. I couldn’t believe my eyes.

A few imaging tests later and it was confirmed. The pain in her back wasn’t a bulging disc or muscle spasms. It was stage 4 breast cancer with compression fractures in her spine. The cancer had spread from her breast, through her rib cage and into her back. There was nothing they could do. They gave her six months.

I was as supportive as I knew how to be but I had to ask why she didn’t go see a doctor as soon as she found the lump. It all came down to her fear of ridicule. She truly thought that her doctor would spend more time chastising her about her weight than addressing the lump in her breast.

Now I’m not going to blame my sister’s death on her childhood physician; at some point, we all have to grow up and do the right thing. But she was truly traumatized as little kid and those scars stayed with her well into adulthood.

Sometimes we say things and we don’t mean anything by it. We’re joking, we’re trying to inject humor in an uncomfortable situation, or we’re just not thinking about how the other person is hearing it. Whatever the reason – it matters. Doctors, believe me, we listen to what our physicians say to us. It may be a throwaway comment to you, but it’s gospel to us. Venn you vant to make a shatement about your patient’s veight, pause. Think about how that may impact their relationship to the medical field.

I loved my old PCP. There was nothing he could have advised me to do that I wouldn’t have done. And not because it was good advice; other doctors gave me the same advice, it was because I liked him. Liking him made me much more inclined to do what he asked. When he addressed issues about my weight, it was always with compassion and sensitivity

Doctors, you’re more than just the treating physician. Inspiring behavioral change doesn’t really happen without relationship. Get to know your patients. Be kind when you have to deliver some unpopular or sensitive news like needing to lose weight. The words you choose can make all the difference.

The Case for Leader Rounding

They call it sacred time. That hour between 9 and 10am where the leaders of the hospital go into their assigned rooms out on the floors and talk to patients and their families. It’s an hour when no meetings are to be scheduled. It’s protected time, dedicated solely to patient rounds.  

Sometimes it’s a social visit: how are things going, is there anything we can do to improve your stay, do you need anything, etc. Sometimes, it’s a focus on a particular issue: is it quiet at night, are you able to get enough rest, what kind of noise is keeping you awake, is it equipment, staff, other patients?

After rounding, there’s a huddle to review any big issues that need escalation and recognize any staff that patients said provided outstanding care and service. It becomes very apparent at those huddles who is doing those rounds and who is phoning it in. When day after day, a person says, “My patients were sleeping,” or “My patients said everything was fine,” we know there’s not a whole lot of rounding going on.

It was a source of frustration for me, trying to make those leaders understand the importance of connecting with patients. After all, this was our opportunity to see the hospital through their eyes and find out what’s working well, what’s not, and what’s important to them so we could make things better. Why wouldn’t they make time for that?

Pleading and begging and even data about how leader rounds improves patient experience scores didn’t appear to be having much of an impact. Turns out, nothing is as compelling as a real-life story.

Doug was in charge of facilities, a no nonsense kind of guy who made sure all the engineering, heating and cooling, and equipment was humming. I never would have guessed he’d be so passionate about patient care.

He was in a room one morning trying to have a conversation with the patient and his family members and needed an interpreter. We had interpreter services with an outside company and, while reaching those individuals was sometimes a chore, it was necessary. After connecting with them, it was clear the family was in the dark about what was happening when the physicians and nurses came in.

Doug hung in there. He stayed with them, wanting to know if they knew what the patient’s condition was, if they understood what the medications were for, if they’d had a chance to ask questions, and on and on. He reassured them, told them he’d get them the answers they needed and left to find the manager of the unit.

She, too, did some digging and identified each of the nurses who had been caring for this family. Of the six or seven, only one had documented in the chart the she had used the language assistance program.

From that moment on, everything changed with this family. No one went into that patient’s room without the interpreter service and no one left without checking with the family that all of their questions were answered.

We likely never would have known any of this without the leader rounding program and for Doug’s persistence. He could have reported that the patient wasn’t English speaking and the interpreter services weren’t working. He could have reported that the family said everything was fine. He could have skipped the room altogether and just said the patient was sleeping, But he didn’t. He went in, took the time, and helped this family get answers.

I can only imagine what they must have been feeling up until Doug stepped in.

Some hospitals don’t do leader rounding because they think it’s too much work or they don’t want the nurses to think they’re checking up on them. We do it because we feel that leaders are part of the care team. We bring a different perspective in with us and we’re another set of eyes making sure patients and their families are receiving the best possible care and service.

Doug’s story was just what we needed to light a fire under some of the leaders and help them see just how important it is. I hope it does the same for you.

Surprise and Delight

I recently came across a book called The Power of Moments: Why Certain Experiences Have Extraordinary Impact by Chip and Dan Heath. If you haven’t read it, I strongly suggest you do. Once I picked it up, I couldn’t put it down and it completely changed the way I approach my work in patient experience and employee engagement.

In healthcare, we talk a lot about Evidence-Based Best Practices, things that have been tested and shown to be effective. We work tirelessly to implement and measure best practices and then we wonder why our patient experience scores are so low. It’s frustrating.

I took a look at our comments on our surveys and the responses we get on our discharge follow-up phone calls. They largely consist of, “Everything was fine.” Ugh. Fine. I hate fine. Fine is the kiss of death.

Turns out, these best practices, things like introducing yourself to patients, explaining what the next steps are in the plan of care, or describing the possible side effects of their medications are things patients have come to expect from us. We’re not going to get outstanding surveys if we only give them what’s expected. It’s like buying a car with air conditioning. We’re not going to wow people with the awesome air conditioning package; they expect it. They didn’t always. I can still remember cars without air conditioning but it’s unthinkable now. Same with these best practices. Patients notice when we don’t do them.

So how do we create a hospital stay memorable enough for patients to even bother filling out a survey and then to describe their stay as exceptional?

This is where Dan and Chip’s book changed my whole perspective. They dive into the science behind what makes things memorable and offer real-life, practical examples of what staff can do to create those peak moments that patients will remember more than anything else. They don’t have to be expensive or labor-intensive or time consuming. They can be quiet moments of connection or surprising moments of responsiveness. And they not only delight the patients, they can touch the other staff, re-engage them, reconnect them to their passion and have a ripple effect across departments.

Best practices are important, they’re the minimum level of service we should be providing every time, and they’re not going to get you anything but middle-of-the-pack results. If you want to deliver a truly exceptional experience, surprise and delight.

The other piece is knowing that, as leaders, we are very good at solving problems. We know how to smooth out the potholes but we probably don’t know how to create peak moments for patients. You know who does? Your front line staff, that’s who. Let them drive this. Don’t roll out some ‘moment making’ program in which administration tells the staff exactly what they are to do to delight patients. Empower them to come up with those ideas and deliver them.

And while they’re out there pouring their hearts into this, you’d better be doing everything you can as a leader to surprise and delight them. Fill their cups, do a few unexpected things to show your support and appreciation of them. Don’t expect them to create any moments for patients that you wouldn’t also create for them. Watch how fast your culture changes, how happy your staff members are, and how infrequently you hear the words, “Everything was fine,” in your discharge follow up phone calls.

…But I Don’t Deal With Patients

Early on when I first started doing Patient Experience training, I spent a lot of time talking about all the ways we can better connect with patients, starting with simple courtesy and friendliness and moving to more personalized interactions with them, like the Platinum Rule.  

The nurses, medical assistants, reception and scheduling staff were always very complimentary on their evaluation forms after completing one of my sessions. But I seemed to miss the mark when it came to the nonclinical staff who didn’t interact with patients. Over and over again, I saw the same comment, “Good presenter, but I don’t deal with patients. This training had nothing to do with my job.”

The Information Technology staff saw themselves as I.T. experts who were there to ensure that users were able to log in and everything computer-related was working. Working in an office building or a hospital didn’t seem to matter. Their approach to their work was identical.

Same thing with the finance team. They were brilliant when it came to budgets and forecasts and managing accounts receivable and accounts payable. But they hadn’t connected the dots as to how their role impacts patient experience.

My talking about connecting to purpose and focusing on the tactical ways we connect with patients and their families didn’t resonate at all with them.

So I started focusing on company culture.

My trainings began to emphasize everyone’s role in creating exceptional service for everyone: patients, their families, and other employees. It wasn’t just fixing a computer system, it was ensuring that the electronic medical record didn’t go down right in the middle of an exam, creating a whole bunch of headaches for staff and patients alike. The ‘why’ behind the ‘what’ began to drive the content of each session.

Soon, my evaluation forms were reflecting the change and, more importantly, the patient satisfaction and employee engagement scores were improving. People in all departments started feeling like they were a part of something bigger, more important and meaningful.  

When putting together new employee orientation and on-boarding, it’s imperative to help every individual understand how his or her role contributes to delivering exceptional experiences at every turn. Once employees see themselves as part of the process, you won’t hear “This training has nothing to do with my job,” again.

Is the Glass Half Full, part 2

Last week, I wrote about the glass being half empty or half full and how that’s supposed to be a statement about optimism or pessimism. I think what’s more important is taking that glass and offering to someone who may be thirsty.

This time, I’d like to talk about that half full (or half empty) glass and how heavy it might be.  

A typical glass of water is 8 ounces, so, logically, half full is a meager 4 ounces. Very light, right?

Imagine, however, that instead of water in that glass, you have a pet peeve, an annoyance or a grudge you’re holding against someone and I asked you to hold the glass up above your head. You could probably hold it up for a few minutes without any problem but after some time it would start to hurt. Hold it up for too long and you could do some serious damage to your arm.

I used to be a person who allowed myself to get easily annoyed by other people. The sound of someone crunching their food, slurping their drink, cracking their knuckles, tapping their pen, coughing, and then unwrapping a cough drop from a crinkly wrapper… oh my goodness. Drove me up a tree.

And then, I let it go. I decided that whatever annoying habit they had was too stupid to rob me of my happiness.

What does any of this have to do with patient experience?

Happy patients are, for the most part, a result of happy employees. If we are so busy fighting with each other, rolling our eyes at one another, back-stabbing or holding grudges, we are in no position to share a little kindness with our patients.

If what your co-worker is doing is truly affecting your work, you owe it to yourself and your patients to address it head on. It’s uncomfortable but no one should have to be bullied at work. If your manager sides with the bully, then clearly this isn’t the place for you.

But if it’s nothing more serious than a pet peeve or hurt feelings from a misunderstanding, my advice to you is to put the glass down. It’s only hurting your arm, not theirs. Make a decision to put down the glass before it really starts to hurt you. Choose to not let little things get under your skin. It’ll take practice but it can be done.

You were called to a career in healthcare to relieve suffering. Start with your own.

The Platinum Rule

I, like many of you, was brought up with the Golden Rule: Do unto others as you would have them do unto you or treat others as you would like to be treated.

There’s certainly a lot of good in that rule but I now try to do even better. I try to live by The Platinum Rule: Do unto others as they would like to have done unto them.

I’m not sure who coined the expression, but I first heard it when I was working in Physician Relations at a very large suburban Chicago hospital. None of us in the department was a physician, but we all worked very closely with them and had to continuously find ways to keep them happy, engaged, and admitting their patients to our hospital instead of our competitor down the street.

We all approached the task from our own perspective; what would I want, what would make me happy. A few times we got it right, but if we were going to truly be effective, we had to start seeing things from the physicians’ point of view. What would they want?

I didn’t realize it at the time, but it became a very valuable life lesson for me. I started approaching a lot of things with the Platinum Rule and it’s one of my key points when I’m delivering Patient Experience training.

One of my favorite examples is what to call people. My name, as it appears on my medical chart, is Katherine. But I’ve found that most people, for some reason, love to use nicknames when they see a long name like Katherine. They call me Kathy. It drives me crazy.

Don’t get me wrong, Kathy is a perfectly fine name, it’s just not my name and I hate when people assume it’s okay to call me that.

Funny thing is, there are Jennifers out there who don’t mind being called Jen or Jenny, and Margarets who take it in stride if someone calls them Maggie. These people can’t understand why I get so bent out of shape when someone calls me Kathy.

They don’t have to understand why. They just have to understand that it does.

So how are you supposed to know? Simple. Ask.

The key to connecting with patients isn’t in giving them everything that would make you happy and comfortable if you were in their shoes.  We need to ask them what they want.

How many of us actually have a question like that on our admission forms? Or our white boards in patient rooms? We have a perfect opportunity to find out exactly what we can do to make patients’ stays with us a little better (and improve our H-CAHPS scores, by the way) and we consistently miss it.

Individualized, personalized care matters. We can’t keep going with what we think is important. We have to ask our patients what matters to them and then do it.

It’s better than gold; it’s platinum.

Final Impressions

You’ve got a pet peeve, right? That thing that really irritates you. Nothing huge, just something that gets under your skin.

When it comes to doctor appointments, I think my latest pet peeve is not knowing what to do when you think the visit is over.

It used to be (and maybe sometimes still is) that, once you saw the physician and he or she told you what the problem was, a nurse came in, answered any additional questions you might have, and told you to check out at the desk before you left the office.

These days, you see the physician, a nurse comes in afterwards to answer any additional questions and tells you to have a nice day. I always find myself stopping at the desk on my way out to be sure there isn’t something else I need to do before I go. Usually, the person at the desk is very sweet about it and says something like, “You’re all set. Take care!”

Sometimes, though, that person looks really annoyed and says, “Well, did the doctor say you needed something else?” in that condescending tone that screams “I hate my job”. “No,” I reply. “I just wanted to be sure we were good to go,” which is often met with a fake, dismissive smile.

And THAT will be my final – and lasting – impression about my visit.

As a Patient Experience trainer, I spend a lot of time talking about the greeting: that first impression that’s so important to people when they walk in the door. But lately, I’ve started spending just as much time on that final acknowledgment, the last thing patients see and hear before they walk out the door. You can undo a lot of good in those final moments, negate the things that had gone well up to that point. Or you can reaffirm your commitment to patient experience and continue to be helpful and kind, even after the visit is over.

The end is just as important as the beginning. Develop a good exit greeting and make a wonderful final – and lasting – impression.

Tactics vs. Culture

I had a conversation with a senior leader not long ago; we were talking about what kind of an organization we wanted to be, what kind of talent we wanted to draw, what we wanted patients to think of us. I mentioned that I’d worked for a hospital with many clearly defined expectations and standards that at first seemed uncomfortable but eventually became habits.

Certain things were so ingrained at that hospital that they became a natural part of me even in other places. For example, if we saw any kind of trash on the floor – paper, wrappers, anything – we were expected to pick it up instead of walk past it and hope that someone from environmental services came around soon. I haven’t worked for them for several years but I still can’t imagine walking past a piece of trash on the floor. I still pick it up when I see it.

The vice president I was speaking to said, “But does that really matter? If it doesn’t impact patient experience, I don’t want to waste any time training staff to do it.”

And that’s when I knew it was going to be an uphill struggle.

When we think of patient experience as a series of tactics designed to raise scores, we’ve not only missed the point, we’ve put the cart in front of the horse. We were trying to shape our organization’s future, define want we want to become. That can’t be expressed merely in a series of things you can measure, it’s more than that.

It starts by having employees take pride in where they work. Part of that means acting like an owner and taking action when you see something wrong, like trash on the floor. It may seem like a small thing but it’s those small things that add up to create your organization’s culture.

When you step outside of your expressed job responsibilities and take action when something is wrong, you’re more engaged, you’re part of something larger than yourself. That’s a big part in creating a positive, patient-centered culture with employees who feel connected to purpose.

The employees still walk past trash on the floor. Patient experience scores haven’t improved. Think there’s a connection?

Manage Up

One of my pet peeves (and it appears I have a lot of them) is being led to an exam room by a receptionist who puts me in exam room 4 saying, “Someone will be with you shortly.”

Someone? Someone who? Who will be with me shortly? I sit and I wait. For someone.

It would be so much nicer if the receptionist said, “Okay you’re going to be right here in exam room 4. Tom will be your medical assistant today and he’ll be in to take care of you in just a few minutes. Tom is great. He’s one of the best we have here and patients love him. You’re in good hands.”

Three great things come from those simple words.

  1. A nervous patient starts to relax. She has heard that this other care provider is good at his job and is good with patients. She feels better already.
  2. Employees actually do a better job after a set of expectations has been set. I step up my game when I know someone has heard that I’m good at my job. If someone says I’m warm and friendly, I am turning up the warm and friendly for sure.
  3. Co-workers get along better when they get into the habit of speaking well of one another. Less gossip and more praise mean higher morale. And by the way, patients pick up on that, too.

But what are you supposed to do if you’re handing a patient off to Tom and you don’t like Tom? Do you lie and make something up so the patient feels better? Of course not. Find out a little something about Tom, like how long he’s worked here or how many years of experience he has.

Maybe patients like Tom just fine, even if you don’t. Try this, “Okay, here we are in room 4. Tom is going to be your medical assistant today. He’s been with us for about three years now and patients love him. I’m sure you’re going to love him. He will be here in just a few minutes.”

That wasn’t so hard, was it?

And you know, there’s a very good chance that after hearing you say nice things about him every day, Tom might actually become easier to work with. You might start to genuinely like him. You’ll like coming to work, patients will pick up on the energy and collegiality around the office, and nervous patients aren’t so nervous anymore.

All because you managed up.

What’s stopping you?

Just Show Up

I saw a video a couple of weeks ago from one my very favorite authors, Brene Brown.  She was talking about sympathy and empathy and something she said really stuck with me:

“When someone shares something really painful, maybe the best response is, ‘I don’t even know what to say right now, I’m just so glad you told me.’ Because the truth is, rarely can a response make something better. What makes something better is connection.”

I’ve been in many painful situations and some of my worst memories aren’t of the situation, itself, but of the thoughtless things well-meaning people say when they think they’re being helpful.

  • Don’t worry, there’s light at the end of the tunnel
  • You won’t be given more than you can handle
  • You’re strong, you can get through this
  • You think this is bad, I know someone who has it way worse than you

People can say some incredibly idiotic things when they’re trying to help but I tend to cut them some slack because I know they don’t know any better.

For many of us, the more difficult situation is the one in which we are with someone who is suffering and we don’t know what to say. We struggle for just the right words that will make that person feel better. We can’t bear the uncomfortable silence so we say something, anything, hoping it’ll be better than nothing.

The truth is, just simply being with another person can make all the difference.

When a person is suffering, he or she feels alone. It’s not the kind of alone like ‘no one understands what I’m going through or how I’m feeling.’ The truth is, no two painful events are the same and no one can truly know how you feel, whether they’ve been through it or not. It’s the kind of alone like ‘no one wants to walk with me while I go through this.’

Simply having someone next to you, to hold your hand, sit with you, just be there… that’s one of the most meaningful gifts you can give a person.

Don’t worry about what to say. Silence and Presence may be all you need. Just show up.