Thursday, November 10, 2011

Why Every Patient Contact Counts - The Micro Relationship

If you listen carefully to trauma survivors, like I do as a psychotherapist, some of the things you hear will surprise you. Although they have horrendous experiences to report, often minor encounters with caregivers (professionals of all sorts and especially physician extenders) are the most upsetting and memorable.

The Frequency of Brief Encounters

Let's do the numbers, first for the doctor's office, then for the hospital.

There are likely a minimum of four (4) people with whom the patient interacts during a typical office visit - receptionist, medical assistant who takes the patient back to the examining room (and perhaps does vitals and takes blood), physician (or PA), and billing clerk on the way out. Physician's offices see from 30 to 50 people per day. So, for a five (5) day week there is a minimum of 600 staff-to-patient contacts (4 staff X 30 patients X 5 days = 600). In one month that amounts to 2400 interpersonal contacts. If the patient is sent for tests and we count the telephone contacts calling the office and the hospital and the person who calls with the laboratory results, you can add a minimum of three more to the staff and for a week the total number of contacts increases to 1050 or 4200 for the month. If we do the math for an office that sees 50 people in a day, the weekly total for a staff of 4 is 1000, 4000 for the month and for an extended staff of 7 the totals are 1750 for the week, 7000 for the month. In all these situations the number of interpersonal interactions from an ordinary doctor's office visit is enormous.

Staff-patient contacts can be brief - most are from a few seconds to a few minutes, even with the doctor. Each has the potential to have significant impact, positive or negative. Any one can be life changing: all affect care (more about this later). The negative contacts seem to create the strongest memories, are the most emotionally charged, and patients are most motivated to share these. Perhaps it is because sharing is cathartic, gets sympathy and attention and is a good story begging to be told. For whatever reason, these incidents take on an importance which recommends we raise our awareness of them and understand the risk of them going viral in our digital world. (Long standing marketing research has established that negative customer service experiences are much more likely to be reported than positive ones. As someone once said: Praise whispers; criticism shouts".)

In the inpatient situation of the hospital, the primary care giver is the registered nurse.

However, many others report to the nurse and he or she is responsible for their work. These "nurse extenders" increase the number of staff-patient contacts by a great deal. There are others in the hospital who also have contact with the patient (not counting the physicians and surgeons) from housekeeping to dietary to respiratory therapist to pharmacy and others. The nature of the inpatient contacts is likely more impactful and sometimes of a longer duration. The needs and vulnerability of the patient are responsible for this greater effect. But the patient contact as an event with a beginning and an end is still a useful unit of measurement. Let's consider the numbers for an inpatient situation.

To develop an estimate of the number of inpatient contacts over an eight hour period, let's imagine four workers -nurse, nurse's aide, housekeeping and dietary- and the number of contacts each might have with five patients. For the nurse, four contacts in eight hours for five patients equal 20 contacts. The nurse's aide may have six contacts for each of five patients in an eight hour shift, totaling 30. Housekeeping may have three contacts for an eight hour total of fifteen and dietary may have six for a total of thirty. The overall total number of patient contacts is ninety-five for this shift. The total for the week (seven days) is 665 and for the month is 2660. From any perspective, this is a high number of contacts. Without any consideration of the technical impact of the interventions, which is a crucial part of these contacts, the interpersonal effects have to be substantial. If we say the interpersonal is trivial, then we are saying that it is inconsequential that a person is delivering the service to another person. Whatever the intervention is technically, it is always interpersonal,l because it is delivered by a person and received by a person.

Consider the above example a daytime situation and an estimate of a typical, that is, not an extraordinarily needy, patient. From my observation in a hospital as a patient and as a visitor, these seem like minimal estimates. They were obtained from interviews with nurses and other hospital personnel. There are, of course, inpatient situations where the number of patient contacts is a significant multiple of these. There are also twelve hour shifts and twenty-four hour days for inpatient care, so an eight hour shift is certainly not complete or an exaggeration.

In both the outpatient and inpatient situation, these contacts are interpersonal relationship experiences. Often they are singular and brief, what we call "Micro Relationship™" experiences: a sense of emotional connection is felt by the parties and a persistent memory is established by the patient. Thoughts and feelings are both activated; moods can be affected; a perception can be created that generalizes to the situation; and an involuntary conditioned reaction can be established, positive or negative, to the setting and the personnel, hereafter activated when in a similar environment. The patient most likely will take away an intention to share the experience with others. And when the experience is negative, the motive to share is stronger.

How Does a Brief Contact Have Power?

Good patient care always requires attention to detail. The information and attention load is heavy. Technological advances march on relentlessly and require increasing skills. Additionally, there is enormous pressure to be efficient in the face of significant demands to provide care. Within this environment, the incidental-events experience of the patient drifts down to a low priority. Even when valuing the experiential, brief interpersonal encounters are easily overlooked details. "After all, we have pain, discomfort and fear to deal with. What difference does it make how I connect interpersonally with the patient while I do all the important and dangerous things I do?" the staff might think. This would be an unfortunate and costly conclusion.

The experiences of interpersonal encounters are potentiating and affect the processes of biology, biochemistry and physiology. That's why they should be important to caregivers who want the physical effects of their interventions to be maximally effective. Attitude, mood and perception affect bodily functions and can aid or interfere with healing. The interpersonal affects these psychological functions and is the most powerful medium for them.

A single Micro Relationship experience in the doctor's office or in the hospital can create a mood or attitude that will enhance or diminish compliance. Patients have the most difficulty following complex regimens, but are most likely to do so to please their caregivers. Think of that: not because it benefits them, but because it pleases their provider. That'd the power of the interpersonal.

Every patient faces every medical encounter - from the simplest and most benign to the most important and life threatening - with vulnerability and apprehension. Often for them it is encountering the unknown. And, the patient's role is one of dependency in which they are expected to comply with what they do not understand or like. If they are in pain or ill, all the more their defenses are down and their sensitivity is up. Whatever they experience, it will be enhanced by the state they are in. It will have impact and be remembered. If it is negative, there will be a drive to share it with others. And if they have a history of emotionally and physically painful encounters, they come to a new experience primed to have a strong reaction.

All of this is just the way humans are and cannot be changed. Providing relief and curing life-threatening conditions does not negate this reality. Seldom does the patient say, "I did not have good experiences with the staff, but they helped me and that's what was important." More often they will report that the care was effective, but the interpersonal experiences were unpleasant. A worse conclusion is that sometimes the patient concludes the technical competence was faulty (when it was not) because the interpersonal was unpleasant (which is what research shows often happens).

The most important stimulus on the planet is another person. Encounters are never trivial and always leave a residual." Brief" does not translate "trivial". As someone once said "No matter what business you are in, you are in the people business." Accelerating technical advances, increasing pressure to keep costs down and to achieve desired revenue, excessive demand for care from an aging population do not justify ignoring this reality.

What is the Skill Set for Effective Micro Relationships?

1. Raise your awareness to the importance of every patient encounter.

For you it is the 50th patient you've seen that day: for the patient it is the one and only, most important event of the day. Hit the refresh button. This encounter is as important as the first of the day.

2. Individualize. Avoid "robotitis" - the mechanical, repetitious interaction with patients.

When we do something over and over again it becomes routine and automatic. We don't even have to think about it when we ask a patient to fill out forms, follow me, disrobe, etc. When we do it like a machine, the experience of the patient is "I am one of many and not important. This is not a person talking to me." A coldness is inadvertently transmitted.

3. Review your social skills. Are they as important as your technical skills?

The patient is unlikely to say "He didn't take my blood pressure correctly." He doesn't know. But he may say "When he took my BP, he touched me coldly. I didn't feel respect or caring. Perhaps he's having a bad day." Touch is an important communicator. It is powerful and when used well can aid healing through the connection that is felt.

A simple social skill, often neglected, is introducing oneself. If the worker is not a person with a name and role description, patients will not feel their "personness" is recognized. Addressing the patient by name is an important interpersonal event. It is not always the friendliest or most interpersonal to address everyone by their first name. It feels and is disrespectful for an elderly person to be called by a young worker in this familiar form. Mr. or Mrs. John or Mary X.Y, or Z is formal, respectful, and confidential and avoids mispronouncing the last name. Ask the patient their preference; it is as important as privacy needs.

4. Hone your empathy. Nothing connects like empathy.

To be empathic means to take a moment to realize the emotional state of the patient. A benefit of seeing so many patients over an extended period of time is that there are ample opportunities to observe, learn and practice a skill like empathy. And what the patient is feeling, even if it is irrational anxiety or misplaced anger is important for care. Obtaining the feeling data should guide your interaction: you will respond differently to an anxious patient than to an angry one. In either case you will know what you are dealing with.

To be empathic does not take more time and does not add to stress. Patient gratitude and cooperation will reduce resistance and add that positive tone that makes life easier.

5. Change the "culture of waiting" in medicine.

While patients may take it for granted that they will have to wait at the doctor's office or the hospital, they do not like it. Knowing why they are waiting, perhaps receiving an apology along with the explanation can go a long way to reducing the anger and frustration that exists.

6. Create an authentic, positive social environment where the patient is listened to and the stress for the staff is reduced. Patients know what is going on in their medical environment. It is inaccurate to believe that patients are fooled when it comes to their understanding the dynamics and tensions that exist in the world they anxiously enter. It is adaptive for humans, when afraid, to have sharper attention to detail and to perceive surroundings and people on many levels. If the phlebotomist is unsure of his competence in facing the patient, if the nurse is resentful and over worked, if the stress in the office because of "politics" is rampant, etc., the patient will know at some level what is going on - and, it will affect her response to care.

To be competent in one's technical specialty is necessary, but not sufficient. A surgeon at a recent conference reported that 95% of kidney transplants today are successful. Of the 5% that are not successful, patient noncompliance was the reason. This is an interpersonal relationship issue. Remember we are in the business of people. And like all the other attention to detail that medical personnel do so well, attending to interpersonal details -the Micro Relationship - is critical as well.

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