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What Happens When Doctors “Just Listen” to Their Patients

Posted on Mon, Mar 20, 2017
What Happens When Doctors “Just Listen” to Their Patients

“Just listen to your patient; he is telling you the diagnosis.”

This medical maxim is attributed to Sir William Osler (1849–1919), widely considered to be one of the greatest physicians and diagnosticians of all time. Although Osler’s advice might seem impractical in today’s healthcare environment in which clinicians face increasing pressure to deliver care faster and more efficiently, a recent experiment by a New York City physician suggests that letting patients speak about their health problems without interruption can be both practical and beneficial for both parties.

Studies have shown that doctors interrupt or redirect patients within the first 30 seconds after they begin speaking, and two studies found the average time to interruption was 18 and 12 seconds, respectively. Danielle Ofri, MD, a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, confessed to having been guilty of such interruptions and redirections in her recent essay in STAT (adapted from her new book, “What Patients Say, What Doctors Hear”). Like many of her peers, she feared her patients would “ramble on ad infinitum” if she didn’t home in on their top priorities quickly. But after reading a study by a group of Swiss researchers who found that when doctors did not interrupt, the average duration of their patients’ monologues was a mere 92 seconds, Ofri decided to do some informal research in her own clinic the next day.

Throughout that day, she asked each patient how she could help her or him, then quietly clicked on a stopwatch to time their responses. She encouraged them to keep talking until they had finished telling her everything they wanted to discuss. Her first two patients, who were basically healthy individuals, spoke uninterrupted for just 37 seconds and 32 seconds, respectively. Her third patient, who had unresolved back pain plus glucose, cholesterol and weight that were creeping up, spoke for two minutes.

But Ofri was understandably worried about what would happen with her next patient, Ms. Garza (not her real name). Garza not only suffered from a wide range of chronic, insoluble pains compounded by anxiety, depression and irritable bowel syndrome, she also had to care for her demanding, elderly mother, who had insomnia and routinely was up and complaining at all hours during the night. “Exactly the type of patient who can drown you with a list of complaints,” Ofri noted. In addition, Garza, who had been a teacher in her native Argentina, had a penchant for offering observations about New York City’s “pretensions of culture” and its lack of sophistication compared to Buenos Aires.

Ofri feared that if she allowed Garza to say everything she wanted to without interruption, “the visit would unfurl like a Borges labyrinth. We’d tumble down a dizzying path of her symptoms that would encompass every organ system of her body, plus a list of her mother’s medical woes and a stinging critique of the Metropolitan Opera’s soulless production of ‘Turandot.’” Nonetheless, Ofri understood that if she excluded “difficult” patients from her experiment that day, her data—informal though it was—would be flawed. So, despite her qualms, she encouraged Garza to keep talking until she had “fully, truly, absolutely come to the end of all that she had to say” while Ofri jotted down the long list of issues. When Garza had finally talked her fill and Ofri clicked off the stopwatch without looking at it, she estimated that between eight and 10 minutes had passed. Later, when she checked the stopwatch, she discovered that even Garza’s lengthy monologue had actually taken just four minutes and seven seconds.

Garza had already had an extensive workup, and all the results were negative. Ofri explained to her that something was going on and that “Medicine is very poor at explaining pain syndromes, but that doesn’t mean we can’t go ahead and start treating your symptoms.” She and Garza spent the remainder of the time reviewing the list of issues. They went through each type of pain, which included shooting pains in Garza’s gums, a painfully sensitive scalp and neck pain that radiated down her spine, and identified treatments that might help, including ice packs, local heat and massage, physical therapy and pain medications. They discussed how antidepressants could be helpful, how seeing a therapist could decrease Garza’s stress, how she might get help in caring for her elderly mother and the critical role of exercise in treating chronic pain. Then they put together a written plan based on those discussions.

Even so, the visit didn’t run overtime by much. Before leaving, Garza said, “Just talking about all this has actually made me feel better.” To Ofri’s surprise, it had made her feel better, too. In fact, it was the first time she had ever felt good after a visit with a patient with chronic pain. “I was actually doing something to help, rather than just rearranging deck chairs,” she explained. “It’s a reminder that doctors sometimes need to zip it up and let the patient talk uninterrupted. Although it may feel like time is being wasted, it could actually make everything much more efficient.”

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Patient Satisfaction Must Start With Nursing Satisfaction

Posted on Wed, Nov 16, 2016
Patient Satisfaction Must Start With Nursing Satisfaction

By Alberto Hazan, MD

Ever since the U.S. government decided to link Medicare reimbursement dollars to patient satisfaction scores, hospital administrators have been obsessed with improving the quality of care for patients visiting their emergency departments. While the motivation may be partly financial, the goal of improving the patient experience during emergency department and hospital visits is an admirable one.

Unfortunately, many of the tactics used by administrators have done little to achieve that goal. Hiring national “experts” on customer service to give lectures to the hospital staff, or introducing catchy mnemonics to guide physicians in conducting more compassionate patient interviews, have been equally ineffective in markedly improving patient satisfaction.

If we aim to better the patient experience in the emergency department (and the rest of the hospital), we need to shift our focus from the patients to the nursing staff. After all, the people who spend the most time with patients are not the physicians but the nurses. If nurses are dissatisfied at work, patients will inevitably be dissatisfied with their experience.

Recent discoveries in the field of positive psychology have demonstrated that being successful in any endeavor (including improving patient satisfaction in emergency departments) requires happiness as a prerequisite. If we truly want to improve the safety, care, and experience of our patients, then we need happier people at work. In his book, The Happiness Advantage: The Seven Principles of Positive Psychology That Fuel Success and Performance at Work, Shawn Achor highlights the link between success and happiness: “Studies show that simply believing we can bring about positive change in our lives increases motivation and job performance; that success, in essence, becomes a self-fulfilling prophecy.”

Ensuring we have happier nurses won’t just improve patient satisfaction; it will, more importantly, improve the safety and well being of anyone being treated in the emergency department. Happier people are more aware of their surroundings, they take more pride in their work, and they’re less likely to make mistakes. In the ER, this is imperative. A happier, more engaged nursing staff will be able to recognize red flags (including physician error), identify septic patients, and stay on top of their workload.

Ultimately, success in the emergency department means many things: taking good care of patients, looking after their best interests, and ensuring they do not have a life- or limb-threatening illness. Being successful isn’t just about improving patient satisfaction scores. It also means taking care of patient anxiety, treating their pain, and making them comfortable. It means that nurses (and physicians) are in a state of flow, can handle stress, and are aware, in the moment, and conscious of what they’re doing. This will help them work better as a team. Being happy at work also provides nurses with self-confidence and self-esteem: “The more you believe in your own ability to succeed, the more likely it is that you will,” says Achor.

If our nursing staff is happy, they are likely to see working in the ER as a calling rather than a job. In other words, “people with a calling view work as an end in itself.” Achor makes a case that happy employees have different priorities beyond just earning a paycheck: “Their work is fulfilling not because of external rewards but because they feel it contributes to the greater good, draws on their personal strengths, and gives them meaning and purpose.”

When nurses view their work as a calling, they can see more clearly the benefits they provide to patients, such as alleviating pain and suffering, quelling anxiety, diagnosing illness, and providing compassionate care.

How to Engage Your Nursing Staff

I recently became the director of the emergency department at Desert Springs Hospital Medical Center in Las Vegas. As soon as I took over the position, my mind reeled with the changes I wanted to make to ensure that patients were adequately taken care of, treated with respect, seen in a timely manner, and that their pain, anxiety, and questions were addressed quickly and effectively. I soon realized the most effective way to bring about such changes is to make sure that the people spending the most time with those patients—the nursing staff—are adequately taken care of.

I’ve started asking nurses about their goals and frustrations. I don’t schedule meetings with a bunch of doctors to figure out how to best improve patient satisfaction, but rather I ask the nurses themselves, individually and in real time:
 

  1. What is your overall satisfaction working at our hospital?
  2. What is the most stressful thing about your workday?
  3. What can we do to improve your workday?
  4. Do you feel rested? Do you have enough breaks?
  5. Do you enjoy working with your colleagues? Is there anyone here who drives you down?

I’m not sure what changes will come out of this. Maybe we will mandate an 8-hour workday, or provide a better schedule. Maybe we will increase our staff, or make sure nurses don’t waste time on non-clinical chores like finding equipment. Maybe we will promote more social events, or have more discussions in real time, especially after traumatic experiences like the death of a pediatric patient or a major resuscitation, to ensure hospital staff deal with the grief inherent in treating dying patients.

Regardless, I’m starting the process where I should: focusing on the people at the heart of patient care.

Dr. Alberto Hazan is an emergency physician and the director of the Desert Springs Hospital Medical Center Emergency Department in Las Vegas. He is the author of the medical thriller Dr. Vigilante and the preteen urban fantasy series The League of Freaks.

This post originally appeared on KevinMD.com.

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