Episode 38: Making a Connection
Episode 38: Making a Connection
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An empathic connection and good communication between physician and patient can promote better outcomes.
In this episode of Pomegranate Health, U.S. physician A/Prof Danielle Ofri discusses where breakdowns in doctor-patient communication occur—often in the first 10 or 20 seconds of a consultation. Dr Ofri, author of What Patients Say, What Doctors Hear, suggests ways for physicians to listen better, to be understood and promote adherence.
Some media also report a ‘crisis of compassion’ in healthcare. Burnout of staff is a major contributor, and palliative care physician Dr Shamsul Shah describes how to mitigate it by convening groups to reflect on the emotional challenges of the job. She recently published an evaluation of Schwartz Center Rounds® (case-based reflections) run at Auckland City Hospital in the College’s Internal Medicine Journal.
Fellows of the RACP can claim CPD credits via MyCPD for listening and using resources related to this episode.
A/Professor Danielle Ofri MD PhD (Bellevue Hospital, New York; New York University School of Medicine)
Dr Shamsul Shah FRACP (Auckland City Hospital)
Other Podcasts and Videos
Conversations in End of Life Care [OntheWards]
Effective Patient Communication, Patient-Centered Care and Patient Satisfaction [Emergency Medicine Cases]
The End of Empathy [KeyLime]
The Science of Happiness [Antonio Fernando]
Voices of Caregivers [Schwartz Center for Compassionate Care]
References on Communication
What Patients Say, What Doctors Hear [Ofri]
Patients' memory for medical information [JRSM]
Communication Discrepancies Between Physicians and Hospitalized Patients [JAMA]
Hospitalized Patients' Understanding of Their Plan of Care [Mayo Clin Proc]
Miscommunication between patients and general practitioners: implications for clinical practice [Journal of Primary Health Care]
Speaking and Interruptions During Primary Care Office Visits [Family Medicine]
The Unexpected in Primary Care: A Multicenter Study on the Emergence of Unvoiced Patient Agenda [Annals of Family Medicine]
Prevalence of Intimate Partner Violence Across Medical and Surgical Health Care Settings [Violence Against Women]
Provider communication effects medication adherence in hypertensive African Americans [Patient Education and Counselling]
Response variability to analgesics: a role for non-specific activation of endogenous opioids [Pain]
In Praise of the Physical Examination [BMJ]
Patient-Clinician Communication [Australian Commission of Quality and Safety in Health Care]
What makes a good doctor? [IMJ]
References on Empathy and Schwartz Center Rounds®
Empathic distress fatigue rather than compassion fatigue? Integrating findings from empathy research in psychology and social neuroscience [Pathological Altruism, OUP]
Empathy in Clinical Practice: How Individual Dispositions, Gender, and Experience Moderate Empathic Concern, Burnout, and Emotional Distress in Physicians [PLOS One]
Empathic Distress Fatigue rather than Compassion Fatigue [Pathological Altruism, OUP]
Enhancing compassion in general practice: It’s not all about the doctor [BJGP]
Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer [JAMA]
The Inner Life of Physicians and Care of the Seriously Ill [JAMA]
Reigniting compassion in healthcare: Manaakitia Reflective Rounds [Shah, IMJ]
A realist informed mixed methods evaluation of Schwartz Center Rounds® in England [Health Management and Policy Alert]
Caring for One of Our Own [The Oncologist]
The Schwartz Center Rounds: Evaluation of an Interdisciplinary Approach to Enhancing Patient-Centered Communication, Teamwork, and Provider Support [Academic Medicine]
Caring to change: How compassionate leadership can stimulate innovation in health care [NHS]
Hard truths: The journey to putting patients first [GOV.UK]
Mid-Staffs hospital scandal: The essential guide [The Guardian]
The Francis Inquiry and consequences [health.org.uk]
Written and produced by Mic Cavazzini. Music courtesy of Blue Dot Sessions (‘Periodicals’), Sergey Cheremisinov (‘Old Ally’, ‘Tavern’), and Loch Lomond (‘A String- Instrumental’). Image property of RACP. Executive producer Anne Fredrickson.
Editorial feedback for this episode was provided by RACP members Philip Gaughwin, Michael Herd, Andrea Knox, Paul Jauncey, Rebecca Grainger, Joseph Lee, Rachel Williams, Mahesh Dhakal, and Katrina Gibson.
SHAMSUL SHAH: I guess as doctors we’re trained to fix things, fix problems, and often in my patients I can’t fix what they’re going through. And one of the questions I love asking people sometimes is, “If there was one thing I could do for you today, what would that be?” Because sometimes it might be, “Actually, I really want a decent coffee.” And so that’s what I’ll do, I’ll go down and buy them a decent coffee. So it’s not always about the medicines—sometimes it can be so simple.
MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast for physicians of the RACP.
You just heard Dr Shamsul Shah, a palliative care physician at Auckland City Hospital. In this episode, she’ll talk about empathic reflection in healthcare professionals, in a climate some media report of a ‘crisis in compassion’.
But first we’ll start with communication skills, which are of course critical to building a trusting relationship with patients. To learn more about becoming a better listener and communicator, I called U.S. physician, Associate Professor Danielle Ofri, author of a book titled What Patients Say, What Doctors Hear.
DANIELLE OFRI: Sure. My name is Danielle Ofri and I’m an attending physician at Bellevue Hospital in New York City, which is the oldest public hospital in the United States of America. I’m also a faculty member at the New York University School of Medicine.
MIC CAVAZZINI: Wonderful. So let’s go into—you describe of the experience of hospital for patients can be byzantine and surreal, and studies variously show that 40 to 80 per cent of the information that’s thrown at patients is typically retained But tell us about that particularly alarming survey of patients discharged from the Connecticut hospital that showed this really starkly.
DANIELLE OFRI: Well, it’s interesting, and it reflects exactly what I have seen: that less than 60 per cent of patients on discharge could name their diagnosis—that is, what made them ill. And only 18 per cent knew their primary doctor’s name. Which it seems amazing to me, because we’re there every day, but in fact, most of them know their nurse’s name.
MIC CAVAZZINI: And what does that tell you about what’s lacking in the patient-doctor interaction?
DANIELLE OFRI: Well, it lets us know that the ability to remember is not just information that’s given to you, but how it comes through. So typically doctors stand at a distance from the patient’s bed, usually arms crossed, talking maybe with a whole group in white coats. Whereas nurses tend to be close by, they’re usually touching the patient, taking their blood pressure and cleaning them and changing them and helping change the bed. The doctors are delivering the medical care, the nurses are taking care of them. And that is proceeding so differently.
When I introduce myself now, I try to be very slow and clear with my name, and I describe who I am. “My name is Dr Ofri, I’m the attending physician here.” And then at the end of the visit I say it again, I hand them my card; “Here’s how to reach me.” So an extra emphasis on that. And the other thing we do with information is asking the patients to repeat it back. And you have to be careful not to sound condescending, like this is a test. But something like, “Well, we’ve gone over a lot—can you tell me what you understand so far about your illness?”
MIC CAVAZZINI: You refer to a study that some of our New Zealand fellows will probably have already heard about; a 2013 paper by Sonya Morgan of the University of Otago, where GP consultations were videotaped, and both the doctor and the patient were interviewed afterwards. And even when they both came out saying they were satisfied with the interaction, there were problems.
DANIELLE OFRI: This is a very emblematic case study, in which there is a physical finding of alarm, in this case it was a mole that looked of concern, it was bleeding a bit. And for the doctor, seeing an unusual skin lesion that either bleeds or has some of the red flag signs, the alarm bell goes off right away. Now, for the patient, they ended up not going to the appointment, because the sense of alarm wasn’t automatic for them. They just heard, “OK, you have this thing, you should probably go get it biopsied.” “Yeah no, maybe I’ll do it.” And we doctors, what is so automatic and instinctive for us, we don’t recognise that this is not the same for a patient. We haven’t seen it from the patient’s perspective. And so, it wasn’t conveyed that this is at the red alarm level, and needs to be taken action immediately.
MIC CAVAZZINI: So is there something in the emotiveness of the language that as doctors you sort of filter that down? There’s almost a risk of being too cool and clinical, and it’s losing the emotional affect that will really lodge in people’s minds.
DANIELLE OFRI: Oh, I think it’s absolutely true. I think we doctors, we tend to use clinical jargon, and it’s very automatic. We’ll say a patient has an MI, which stands for myocardial infarction, or a heart attack. And that wouldn’t trigger the same response in a patient as it would for a fellow clinician. In this case with the mole, a patient may have many moles, and people have birthmarks all their life.
MIC CAVAZZINI: And what about the approach to interviewing, getting the patient history? You write about how doctors aren’t always that able to let the patient tell their story.
DANIELLE OFRI: Typically we start an interview with, “What can I help you with today? What brings you here today?” And the patient will say “Well, I have this pain over here.” And then we doctors, we jump in right away, on average maybe 10 seconds,and we jump in with legitimate questions: “When did the pain start? When did it stop? What makes it better? What makes it worse?” because we want to find the origin of this pain. But of course, the patient may have had a second thing to say like, “I think I may have had a stroke last week,” but we’ll never get to that, because we dive right in. And it’s really this dogged detective instinct that in essence backfires, because we interrupt the patient, and they may never get back to the most important thing. So, you can see the genesis of medical error right there in those first 10 seconds, and we doctors divert the dialogue in the area that we want to go.
MIC CAVAZZINI: I found quite amusing in the book your insistence on testing this out on yourself with a stopwatch.
DANIELLE OFRI: You know, I wondered, “How long would patients actually talk if I let them speak?” And so I found one study that actually looked at that. A Swiss study where they let the patients talk until they naturally stopped, and checked the stopwatch. And on average, it was 92 seconds. Not the tsunami that we all were fearing. But you know the Swiss—reserved, precise, diplomatic. They don’t necessarily have the gab for loquaciousness that maybe Americans have. So, I tried it out myself. And what’s interesting, the first patient talked maybe 30-some odd seconds, it wasn’t too bad, but he was pretty healthy, and the second patient also less than a minute.
But then came my patient Josephina Garza, which is not of course her real name. A patient with a host of aches and pains, anxiety, depression, irritable bowel, she has an elderly mother to take care of and an unsupportive boss. And I thought “Boy, we’ll be here forever.” But I made a promise to let every patient talk. So I said to her, “How can I help you?” and turned on the stopwatch. And she said, “Every single thing hurts, from my nose to my toes,” and she reeled off every symptom, her tongue was burning, and she had pains up and down her elbows, and she just went on and on, and every time I said “Anything else?” there always was. Finally, she came to the end. I checked the stopwatch, it was about four minutes and 10 seconds, right—not four hours.
And what I noticed about her is when she finished, I had a list of things she was concerned about. And then once we had a list, we could tackle it. And I found that our visits thereafter went much more quickly. So, when I talk to my students and interns about how to be efficient—and we’re a very, very busy clinic—I talk to them about the counterintuitive strategy of letting the patients talk uninterrupted. It’s a real investment in good communication, and of course decreasing medical error.
MIC CAVAZZINI: So that sort of fear of letting the patient go on and on, it’s also framed in the phrase sometimes applied to patients as being poor historians, there’s this real burden on the patient to be as concise and articulate as possible. Is that really fair?
DANIELLE OFRI: That phrase always cracks me up. My interns will come and say, “The history’s not so good, the patient was a poor historian. And I always say “Oh, would they make a better architect, or social worker?” And the idea is that the burden is on them to tell the best story, as opposed to the burden being on us, or shared by us, as being good listeners.
There’s really interesting research on how the quality of the listener directly affects the quality of the storytelling. There’s a wonderful study out of Canada in which they paired college students. One would tell a story—a real life, near-miss, ‘almost killed by the train’ kind of story, and the other person would listen. But while their friend was telling a story, they had to press a button every time their friend used a word starting with the letter ‘t.’ And they of course nodded and said “Uh huh” in the right spots, but they equally missed the punchline of the story. And what was intriguing, was the effect on the storyteller, because as the person’s telling a story, and they sort of catch that their listener isn’t with them, well then they circle back and they tell the plot again, and eventually the story falls apart and peters out.
The t-word counters were confusing, because they looked like they were paying attention, but they weren’t actually hearing what was being said. And I believe that’s us, the doctors. We kind of look like we’re paying attention, but we’re busy typing into a computer, and so that alone already detracts from the ability to look at the patient, see how their face is responding to the questions, catch the body language. And so we’re not actually hearing what the patient says.
MIC CAVAZZINI: As you’ve said, the key complaint might be the second or the third thing that the patient gets to if you let them talk uninterrupted. And there’s a study you mention in the book of over 2,000 primary care visits across Europe where in one out of six consultations some psychosocial aspect to the illness emerged; domestic violence is one that is behind the story in many GP and emergency consultations. What about in the specialist visit?
DANIELLE OFRI: Well, I don’t have the data to necessarily back that up, but it is the same patients who go from the GP to the specialist. So, their domestic violence doesn’t go away when they get to the gastroenterologist, it just may not come up, because now they feel they’re focusing on one small issue. And certainly for patients whose symptoms are unexplainable by standard medical workup—if we ask, we will find out about them. And in the same way in our clinic we started a big push towards asking about depression. Not that these psychosocial issues caused the problems, the problems are clearly real, but they certainly exacerbate them. So if someone’s having a peptic ulcer, we may give them the right treatment, but if they’re being abused at home, that ulcer is unlikely to get better until we address that and their safety.
MIC CAVAZZINI: In the psychology literature, a distinction is made between empathy and compassion. Empathy is the ability to take someone else’s perspective, to feel their pain. Compassion requires the additional step of seeking to alleviate suffering.
Auckland psychologist Dr Tony Fernando gives the example of a doctor rushing to an important meeting who sees a pregnant woman crying in the waiting room. Whether or not they stop to offer support depends on a number of personal and situational factors—for example, the doctor’s own wellbeing, the pressures of the workplace, and the relationships with other staff and the institution. In the British Journal of General Practice he writes that viewing compassion ‘via the lens of compassion fatigue has tended to imply a finite reservoir of caring “resource”—there is, however, no proof that compassion “runs out.”’
Another barrier to compassionate care is a failure to reflect on one’s own state of mind, and how this affects the course of consultation. Psychoanalyst Michael Balint explored this in the late 1950s and started the practice of group therapy sessions that would allow physicians to talk about emotionally challenging episodes. He would facilitate the discussion with comments such as, “How does this patient make us feel?” or “If I were the patient I would probably be feeling abandoned.”
Today, there are various less formal incarnations of these so-called Balint groups. One example are the Schwartz Rounds, established in memory of US healthcare lawyer Kenneth Schwartz, who was diagnosed with lung cancer at the age of 40. Over his 11-month decline in 1995, he wrote about the elements of care that made the biggest difference—in his words, how “the smallest acts of kindness made the unbearable, bearable.”
There are hundreds of healthcare facilities in the North America and the U.K. that organise Schwartz Center Rounds, usually on a monthly basis. Shamsul Shah has been helped bring this practice to New Zealand and last year had an evaluation of the 12-month project published in the Internal Medicine Journal.
Dr Shah describes the episode that drew her attention to this area:
SHAMSUL SHAH: How I got interested in this, it was just before I was due to come out to New Zealand on a sabbatical, and my mum was diagnosed with ovarian cancer. And it was just really interesting, being on the other side—being a daughter and a carer. And by the end of the 6 months it was like the blinders had come off, in a way—that somehow the system that I was trained in, I was really familiar with, wasn’t always conducive to a patient’s wellbeing or a carer’s wellbeing. And yeah, I think we forget how alienating it is, how isolated you feel, and you kind of lose a lot of your liberties in a way. And I guess this was on the backdrop, certainly in the U.K., where there was a big media onslaught about the lack of compassionate care, the lack of dignity in hospitals and care homes and so on.
MIC CAVAZZINI: Yeah there have been high profile, scandalous cases, such as the—was it the Staffordshire Hospital in the U.K.?
SHAMSUL SHAH: That’s right, Mid Staffordshire—
MIC CAVAZZINI: —where patients were neglected without pain relief. Or in Australia there’s been scrutiny of aged care after it was found that incontinence pads aren’t changed unless they are 75 per cent wet. So those are moving, dramatic, particular cases. Is there evidence for a system-wide lack of compassion and therefore lack of trust?
SHAMSUL SHAH: I mean, when we talk about compassion, I think there are several layers to it. I remember a really good quote which is that, “A difficult person is nearly always a person in difficulty.” And I also equate it to the oxygen mask in flights—they always say that you have to put your oxygen mask on before you put it on for your loved one.
And it’s the same in healthcare. You know, we don’t do a normal job. In a way it’s not normal to witness pain and suffering every single day, it kind of seeps under your skin in a way. Perhaps it might be our helplessness, our sense of unfairness of what’s happening, and we withdraw. And that’s I’d say a normal human response when we witness pain and suffering.
And it really came home recently where I was looking after a patient with really complex chronic pain. And I saw her on the Friday, and I made some changes to her medications, thinking, ‘we’ll get on top of this.’ And I got back on the Monday, and I found out she had a terrible, terrible weekend. And it was only after I reflected on it, I was obviously feeling quite guilty, I felt responsible, I was also feeling a little bit hopeless in a way because everything had pretty much been tried. I realised that I was carrying that into the room that Monday morning. And sure enough, she was feeling hopeless, she was feeling frustrated. And I guess we don’t really talk about transference and counter-transference, I think we talk a lot about it in mental health, but you know it happens to us all.
MIC CAVAZZINI: So in the middle of all of this, how did the structure of these Schwartz Rounds fit in?
SHAMSUL SHAH: Yeah, how the format of these rounds are—usually centred around a case that has been challenging for a team. And two of three members of that team agree to be panellists. And each person spends five minutes sharing their thoughts and feelings around that particular case. Then it’s opened out to the audience, where people start sharing their stories, their experiences. And they can be incredibly powerful.
MARIANNE SUTTON: And I received a page that there was a woman, 35 or 36 weeks pregnant, who had had some bleeding at home, and that there was concern this woman had had a serious abruption.
MIC CAVAZZINI: This is an example of a Schwartz Centre Round® recorded at Emerson Hospital in Massachusetts, U.S.A. The first speaker is paediatrician Marianne Sutton. Twenty seconds in you’ll hear registered nurse Kim Peterson, and then some other members of the audience.
MARIANNE SUTTON: They brought the mum to the operating room, they did a stat C-section, got the baby out as fast as possible, and out emerged a limp blue babe with Apgars of 0, who did not respond to pain, made no respiratory efforts. This baby has not had any oxygen for about an hour and a half.
KIM PETERSON: We really thought there was no hope here, that the baby—this was going to be, we’re going to call the code at 15, and we did our best. And at 14 minutes I felt for the heart rate, and there it was. And all of a sudden it’s a whole different story, and you get really frightened. Well, you’re excited because the heart rate’s there and you’ve got a baby, but then you’re worried about how much damage has been done and what’s happened, and was this the right choice to have done what we did?
MARIANNE SUTTON: The role that we played is something that I think none of us feel comfortable with, that 30 seconds ago we were going to call this baby dead, and now we’re calling him alive, and he has a name, and he’s going to—because we gave him one more does of epinephrine.
And I just remember feeling that I knew how to do the mechanics of what I do, but I didn’t understand what I was doing.
AUDIENCE MEMBER: I had the identical case and the baby didn’t die. It’s been 10 years, the baby does really nothing but drool, he’s totally incapacitated. But the family thinks that the doctors in the hospitals were wonderful, because we listened to them, did what they wanted us to do, and they do have a baby. And I guess I had to feel good that I fulfilled their wishes, but I don’t feel good that I gave them such a devastating situation.
KIM PETERSON: As the day progressed and the baby got worse, it kind of gave me a feeling of—we saved this baby for Mum to hold a live, warm, heart beating, to say goodbye. So I knew what was going to happen, and I knew what was down the future, but I also knew that it was a better thing than having to say to a Mum, being a nurse, “Your baby is dead, would you like to hold it?” and then trying so hard to make this cold, blue baby look presentable and feel good.
SHAMSUL SHAH: So certainly, we evaluate every round that we do. Our last evaluation where we did over 12 months showed that over 90 per cent of attendees rated that it improved their knowledge in terms of how to care for patients and felt that they were able to work better with their colleagues as well. It’s not that we don’t have meetings, we have lots of meetings in hospitals, but most of them are based around problem solving. But there is no meeting that allows you to share your emotions about a situation.
I can certainly speak from my own experience, I find it an incredibly humbling experience. I remember an oncology colleague with whom I’d had some sort of challenging interactions, and I remember him talking about a patient who was diagnosed with breast cancer, which was treatable, but chose not to have treatment, chose not to have chemotherapy, and how he struggled with that. And it made me—yeah, influenced my respect for him and understanding. It’s recognising that we all struggle in some way. None of us are immune to having those feelings.
MIC CAVAZZINI: So the facilitators, do they come from a particular school, do they have a particular training in this format especially?
SHAMSUL SHAH: The Schwartz Centre themselves do provide facilitators which is really important to keep it safe. Because it’s not about providing solutions, and I think one of the things that people in the rounds, one of the things that people have said is that they found it really valuable knowing that there was no right or wrong. And there’s this huge grey in a lot of what we do. You know we are really hard on ourselves, and we have high levels of perfectionism often. And I think that’s something the Schwartz Round helps, is giving a space where we can be honest about how we felt, whether we felt we failed, or whether we felt angry or frustrated or helpless or whatever it might be.
And anyone can come, from a cleaner, administrative staff, doctors, nurses and so on, clinical staff, anyone can come. We’ve had domestic staff as part of our panel alongside a senior leadership member as well. I think the round we had that time was titled ‘Why I Come to Work.’ We have also done a round on Patient Experience Week, where we had patients coming in and sharing their stories. That’s the beauty, that you can have a real mix of people in that room. You know, Kenneth Schwartz, he talked about in his experience how when a person, a carer, shared something about themselves that made that personal connection with him, how that made him feel less lonely. And he talked about how it was those little things actually, were more healing than the chemotherapy and radiotherapy that he was having.
One of the practices I do, which I stole from Tony Fernando, is before I go into the room, we have to gel our hands. So as I’m gelling my hands, I say a little sort of mantra in my head, which is, “May I be of benefit to this person, may I be of service to this person.” And also recognising that I’m walking into a space, I guess a sacred space, and that’s the person’s space. And it’s not mine, and it’s not the hospital’s. That just gives you a sense of humility, and grounded-ness.
MIC CAVAZZINI: There are a few qualitative surveys of Schwartz Center Rounds conducted around the world which echo the findings described by Dr Shah. An longitudinal study in the U.K. has been quantifying improvements in psychological wellbeing using the GHQ-12 questionnaire and preliminary data were published recently in Health Services and Delivery Journal. These showed that incidence of psychiatric cases decreased by half in staff who attended the rounds regularly over 8 months, while there was virtually no change in the group that did not attend.
Now, we’ve talked a few times on Pomegranate Health about the challenge of adherence. Very generally we know that about half of patients stop following therapies, and many explanations for this have been put forward: cost of medications, health literacy, and difficulties in following multiple regimens. But physician empathy and communication are reported as critical drivers of critical drivers of adherence—and even clinical outcomes in both the common cold as well as diabetes.
A 2012 study in the journal Academic Medicine followed nearly 21,000 Italian patients with diabetes and noted their rates of acute metabolic complications. The treating physicians were profiled using a validated assessment tool for empathy, and they were stratified into three groups based on their scores. It turned out that patients of doctors classified as high in empathy had a 41 per cent lower odds of disease complications than patients of lower-empathy doctors, even after controlling for some variables relating to clinical competence.
Danielle Ofri explains just how communication style can affect the patient’s engagement with the therapeutic strategy:
DANIELLE OFRI: We know that more than half the patients don’t end up taking their medications as prescribed, and so we doctors just tend to berate our patients over and over, “If you don’t take that medication you’ll end up amputated, blind, in a wheelchair, on dialysis.” And that’s very ineffective. Most patients already know that part. I loved a study done at Georgetown where they videotaped doctors and patients over the topic of diabetes, and then interviewed the patients and doctors separately afterward. The doctors never asked the patients, “Why is it hard to take this medication?” Because the answers could be, “You know, it makes me nauseous,” “I lose my sex drive,” I’m embarrassed to use a needle at work, it looks like drug paraphernalia,” “My family makes fun of me when I eat my brown rice instead of white rice like everyone else.” All these various reasons that are completely different from what we expect. When they miss an appointment we say, “Oh, the patient didn’t show up,” or “The patient refused treatment,” but there are reasons behind that. And so if we actually ask and listen to the answers, that’s what patients respond to. I think it’s the genuineness that really matters.
MIC CAVAZZINI: And we hear a lot about how it’s best for healthcare to be collaborative. But some patients do turn up who want to feel completely in your hands, they want to feel completely looked after by an expert, to not have to make very difficult decisions with complicated data. How do you strike the right balance?
DANIELLE OFRI: So for every patient, you want to get a sense of how much agency they want, and where they want you to be in that spectrum. But you have to elicit that. I had one patient I wrote about in another book who the issue is whether or not he should get a pacemaker—a defibrillator and a pacemaker. And he really said, “You know, you tell me what to do.” And I’m really feeling uncomfortable about that. But the burden of making the decision was too hard for him. So I talked with him and tried to elicit his values, and then I did my best based on what I thought would be best for him. But it would have been unfair for me to say, “You know what, I will say nothing, it’s all your decision,” because then I’m abandoning him.
MIC CAVAZZINI: We’ve heard how empathetic consultations can avoid miscommunication and improve adherence, but it can also directly improve clinical outcomes via the placebo effect. Tell us about that Italian study with the IV drips published in the journal Pain.
DANIELLE OFRI: Sure. And why I find this so fascinating is that we think about placebo usually in terms of research trials, where you always want your new medication tested against a placebo, and that’s absolutely rigorous and you wouldn’t have a clinical trial without that. But in clinical practice we find the use of placebo a bit shady and a little unethical. And this trial was with patients who had chest tubes—very painful condition, it’s a tube in your chest and requires strong morphine-like medications. And they had two groups of patients who got the same amount of morphine. One group got the morphine in a drip every four hours, and the other group, every four hours the doctor came in and pulled up the syringe full of morphine, injected it. And those latter patients had twice the amount of pain relief compared to the other ones, with the same amount of morphine. Twice as much.
And it points out that the ritual around the care, everything around it, so the doctor comes in, talks to you: “How are you?” Maybe examines you, you see them pulling up the medication in the syringe, the injection—all of that adds to the analgesic effect, and that’s of value. I had one patient tell me, “I don’t care if it’s a dill pickle, if it makes my pain better I want it!”
MIC CAVAZZINI: There was quite a moving editorial by Dr Abraham Verghese which you’ve probably come across in the BMJ in 2009, called ‘In Praise of the Physical Examination.’ And he says, “We propose that if the ritual is short-changed, if it’s done in a cursory fashion, if its sacredness seems to be violated, then the formation of the doctor-patient bond does not take place. We believe the failure of that bond could account for a great deal of the dissatisfaction patients express, and doctors feel about their encounter”.
DANIELLE OFRI: I wholeheartedly agree with that. And I look at placebo and communication as tools in our bag. We have many tools in our bag, and thankfully more tools than we had a hundred years ago, and I wouldn’t ever want to be without my tools of MRIs and antibiotics and chemotherapy and heart transplants, those are wonderful and lifesaving. But if I can double the pain relief with how I present the medication, why not give them both? There’s no downside.
But I also look at the physical exam as a refuge. You’re now communicating only with words and touch, with no technology between you. And that is increasingly rare in medicine, and society at large. And once you’re talking with nothing between you, a conversation of a different type is possible. And countless times it’s only when I’m, for example, listening to a patient’s lungs, they remember, “Oh, the cough I was having.” Or they feel comfortable enough to reveal the depression issues or sexual symptoms or domestic violence, things they didn’t feel comfortable at the desk with the computer. Because talking and touching is very intimate. It’s not a romantic intimacy, but it’s intimate nevertheless, and it changes the dynamics of the conversation.
MIC CAVAZZINI: That was Danielle Ofri, sharing insights form her book What Patients Say, What Doctors Hear. Thanks also to Shamsul Shah for joining in this episode of Pomegranate Health. Just to recap the main points they make:
- When introducing yourself to a patient, it’s worth clarifying your role from all the different staff they see.
- When taking a history, try and let the patient speak uninterrupted, as they may reveal important details which are otherwise overlooked in a more hasty interrogation. And the more engaged you appear as a listener, the more coherent the history is likely to be.
- Use commonplace descriptors of disease and therapy as these are retained better than unemotive technical jargon. To make sure you and the patient are on the same page, you can ask them to repeat back what they’ve understood.
- When it comes to adherence to therapy, there may be hidden personal or social reasons that get in the way. It’s worth trying to understand the unique barriers each patient has.
- Some scenarios are emotionally challenging and it can be helpful reflect on your own reaction to a patient or their outcomes. Share your feelings with colleagues, and the burden of so-called ‘compassion fatigue.’
If you’re thinking about establishing Schwartz Rounds in your hospital or clinic, follow the link from our website. Thanks to the Schwartz Center for Compassionate Care for allowing use of the audio clip you heard earlier. Our web address is racp.edu.au/podcast, and you’ll find a transcript of this episode embedded with all the academic references mentioned. There are also links to some other interesting podcasts about communication and empathy. Click on MyCPD to log credits for using these resources and subscribe to every episode of Pomegranate Health via the mailing list or any podcasting app.
I’m Mic Cavazzini. I hope to hear from you.