If you believe that coping with some of the people we deal with in emergency medicine is difficult or impossible, you’re not alone. We all feel this way from time to time. We all work in stressful environments where it may feel as though we have too little time for effective patient communication, patient centered care and patient satisfaction. You and your patients may often have mismatched views of what’s important. You may have a specific medical agenda and they might have a very different agenda.
Then there’s the difficult patient – we all know who these people are – the hostile aggressive patient, the demanding patient, the know-it-all, the excessively anxious patient, and the incessant complainer, among others. If we don’t know how to handle these patients appropriately, they may receive suboptimal care, grind patient flow to a halt, and delay care of other patients. And of course, if the staff has to deal with a multitude of these patients on a given shift, there’s a sort of swarm-based escalation in frustration and sometimes, unfortunately, a total breakdown of effective care. These frustrations don’t only come out when we’re presented with multiple sequential difficult patients, but for some of us, the more we practice, the more we become desensitized to the needs of all of our patients and their families and, we run the risk of destroying the doctor-patient relationship, as well as making most of our patient interactions frustrating, unsatisfying, – even detrimental to our health and the outcomes of our patients.
How you communicate in the ED can improve patient outcomes and enhance job satisfaction, yet there is little education on patient centered care for EM practitioners. After listening to this episode, it is my hope that what you learn from the literature and from expert opinion,and then apply to the way you communicate with your patients, will effectively make you a happier health care professional.
Dr.Walter Himmel, Dr. Jean Pierre Champagne and RN Ann Shook guide us in this round table discussion on effective patient communication, patient centered care and patient satisfaction – this has evolved my practice into what I perceive as a higher level of personal satisfaction as well as patient care….I hope it will do the same for you.
Blogpost & Written Summary prepared by Dr. Keerat Grewal & Edited by Dr. Anton Helman August, 2014.
Patient Centered Care vs Patient Satisfaction
Patient Centered Care is an approach to care that can be defined as care based on respect for patient’s values, preferences, and expressed needs1. It involves building partnerships with the patient and family, and encouraging them to actively engage in their own care.
Patient Centered Care is not offering patients anything they want (i.e. antibiotics for a viral illness or narcotics). Wishes should be honored, but not mindlessly acted on.
Patient Satisfaction, on the other hand is defined by the patient’s experience; the perception the patient is left with after the health care encounter. This is a subjective concept, which is not necessarily associated with quality of care2. While studies on patient centered care have generally shown improved outcomes, studies on patient satisfaction have been inconsistent. Some studies have shown that better patient satisfaction is associated with higher mortality rates and poorer patient outcomes3-4.
One must integrate the patient’s values and expectations with evidence-based medicine in order to provide excellent care.
In one study, wait times were not associated with perception of quality of care but empathy was5.
Patient dissatisfaction with delays to care is less linked to the actual time than to
(1) lack of information about events and when they will occur,
(2) perceived lack of personal attention, and
(3) perceived lack of staff concern for the patients’ comfort. 6
Improving The Patient-Physician Relationship
The patient-physician relationship starts with a large power imbalance. Attempts should be made to normalize or reduce this power imbalance, so as to empower the patient to help make informed decisions for their care.
With regards to trust and believability, patients remember:
7% of the content (what was actually said), 38% of how you say it (verbal liking), 55% of how you look saying it (body language).7
1) How you look:
- Sit down at eye-level or lower (approximately 3-5 ft away, on a chair, or at the end of the stretcher)
- Show an open posture by keeping your arms at your sides, with palms facing up or facing each other
- Maintain good eye contact (3-5 sec), if culturally appropriate
- Smile appropriately
- Dress appropriately (slightly more formal that what is expected)
2) How you speak:
- Speak slowly
- Speak quietly
- Use a low tone in your voice
3) What you say:
- Introduce yourself, and consider asking to be referred by your first name (helps to minimize power imbalance)
- Use the patient’s last name (helps to minimize power imbalance)
- Acknowledge everyone in the room and ask what their relationship to the patient is (i.e. shake hands if culturally appropriate)
- Avoid medical jargon
- Establish what the patient’s agenda is, what their fears are
- Provide the patient with information regarding what will happen during their stay. This puts patients more at ease and improves satisfaction6.
- Provide expected wait times. Some experts suggest overestimating the time for results and consultant services (Disney Technique).
- Explain reasons for delays and apologize for it9
- Map out the next steps in the process in the ED after your history and physical (ie establish expectations)
- Fold your arms over your chest as this displays an aggressive posture
- Ask why the patient did not come in earlier
- Repeatedly ask ‘why’
- Use the words ‘never’ or ‘always’
Showing Empathy to Improve Patient Centered Care
Empathy is the ability to understand and share another person’s experiences and emotions.
Try to understand the patient’s agenda: ‘Help me understand what brought you in today’, ‘help me understand what I can do for you’, ‘tell me more’. Try to normalize the patient’s situation.
Four steps to improve empathy/reflective listening:
- Echo: repeat what the patient says; this gives the message that you heard the patient.
- Paraphrase: paraphrase what the patient says; this gives the message that you understand the patient.
- Identify the feeling: for instance ‘you seem frustrated’, ‘worried’, ‘upset’; this produces trust.
- Validation: validate the patient’s feelings, ‘I can see why you feel that way’.
RELATE mnemonic for Empathetic Listening
Reassure – share your qualifications and experience
Explain – describe in clear concise language what the patient can expect
Listen – rather than hear; encourage the patient to ask questions
Answer – summarize what they have said and then answer & confirm their understanding
Take Action – let them know what is happening each step of the way
Express Appreciation – thank the patient for allowing you to care for them
For a great lecture on by Casey Parker The History of Empathy from The SMACC Gold Conference go here
Recommended Books to Improve Communication Skills & Influence
Emotional Intelligence: Why it can matter more than IQ. Daniel Goleman. 2005.
Covey, Stephen. The Speed of Trust. Free Press. New York. 2006
Ury, William. Getting Past No. New York: Bantam Books, 1993
Fisher Roger, Ury Willaim, Patton, Bruce. Getting To Yes. New York. Penguin Books.
Goleman,Daniel. Social Intelligence. New York: Bantam Dell, 2006.
Stone, Douglas, Bruce Patton, Sheila Heen. Difficult Conversations. New York: Penguin Group, 1999.
Brinkman, Rick, Rick Kirschner. Dealing With People You Can’t Stand. New York: McGraw-Hill, Inc. 1994.
Decker, Bert. You’ve Got To Be Believed To Be Heard. New York: St. Martin’s Press, 1991.
Dr. Helman, Dr. Himmel, Dr. Champagne and RN Shook have no conflicts of interest to declare.
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- Epstein, R.M & Street, R.L. The values and value of patient centered care. 2011. Ann Fam Med, 9(2): 100-103. Full text
- Chang, J.T. et al. Patients’ global ratings of their health care are not associated with the technical quality of their care. 2006. Ann Intern Med, 144(9): 665-72. Abstract
- Detsky, J. & Shaul, R.Z. Incentives to increase patient satisfaction: Are we doing more harm than good? 2013. CMAJ,185(14): 1199-1200. Full text
- Fenton, J.J. et al. The cost of satisfaction: A national study of patient satisfaction, health care utilization, expenditures, and mortality. 2012. JAMA Intern Med, 172(5). Full text
- Beattie, M. et al. Compassion or speed? Which is a more accurate indicator of health care quality in the emergency department from the patient’s perspective? 2012. International j of person centered med, 2(4): 647-655. Full Text
- Lloyd, J. 2009. “Waiting Isn’t ER Patients’ Top Issue.” USA Today. June 22, 2009. Full Text
- Mehrabian, Albert (2009). “”Silent Messages” – A Wealth of Information About Nonverbal Communication (Body Language)”. Personality & Emotion Tests & Software: Psychological Books & Articles of Popular Interest. Los Angeles, CA: self-published.
- Taylor, C. & Benger, J.R. Patient satisfaction in emergency medicine. 2004. Emerg Med J, 21: 528-32. Full Text
9. Mowen, J.C. et al. Waiting in the emergency room: How to improve patient satisfaction. 1993. J Health Care Mark, 13(2): 26-33. Abstract