Stephen Walston

Practicing medicine in the 21st century is hard. Demands on doctors are nothing new, but inevitably the expectations of every player in healthcare continues to evolve.

	My clinic expects me to meet my productivity threshold, earn high patient satisfaction scores, be available for coverage on weekends and evenings, and put forth a collegial and positive presence in the office.

	Insurance companies expect me to document thoroughly and bill accurately for each clinical encounter using the most current version of the ICD, justify the medical decisions I make and represent the disease burden of my patient panel with HCC coding and RAF scoring and meet current quality measures for complex diseases like high blood pressure and diabetes.

	But today’s specific topic (not unlike a good physician) focuses on patients. What do 

	An appointment at their preferred time with minimal waiting. Free parking. They expect to be able to talk about each of their concerns in the allotted time, and expect to leave with adequate diagnostic and prognostic information. They expect to be guided on a path to feeling and living better. And the only way I can adequately rise to that challenge is by creating a real connection within the doctor-patient relationship.

	As a primary care doctor, connecting with patients is my most important job. And that connection is where the joy of medicine is really found. It’s a feeling of genuine trust and mutual respect. It requires patience, active listening, clear and useful information, and providing real emotional support.

	Take a second and imagine the satisfaction a quarterback must feel when he completes a perfect throw to a wide-open receiver in the end zone. It’s a great feeling when things come together that way-that’s why he chose to play football.

	In this healthcare environment, the act of making that type of successful connection sometimes feels less like an easy perfect spiral and more like a wild hail Mary-while running sideways full-speed, away from a swarm of 300-pound linebackers. 

	Don’t understand football? I know how you feel: sometimes I don’t understand the healthcare system. 

	In any case, I don’t want to make it seem like connecting with patients is a lost cause. In fact, here are two strategies that have helped me get better at this.

	I’ve found the habit of “agenda-setting” right at the start of the visit is an effective tool to optimize the use of time. Before I even get into the details of a single problem, I want to know everything that’s on my patient’s list of issues to discuss. I’ll often encourage them to write that list down before the visit. Some items may be very simple and addressed with a very quick answer to their satisfaction.

	To my occasional mild shock, I’ve been able to address issues numbering into the double-digits in one visit using this technique, and patients undoubtedly appreciate it.

	Sometimes one of these issues could be potentially serious and buried at the bottom of a long list of fairly benign and non-urgent items. Agenda-setting right from the start helps me quickly identify what needs to be addressed today, not tomorrow.

	When we arrive at the end of the agenda I read the entire thing back to my patient, line by line. Sometimes I actually notice a subtle change in their demeanor as I do this, almost as if they’re thinking to themselves, “Gosh, that actually sounds like more stuff to discuss than I realized.” And when the list proves to be too long for a 15-minute visit, it’s time to work together so the final agenda can be set.

	“OK great, Mr. Thompson, I see we have nine issues on our list, and unfortunately we won’t be able to do adequate justice to each of these things during our time today. I feel it’s really important to discuss your chest pain, as this could be the most serious. Let’s choose an additional two issues that are most important to you…”

	This gives patients a more active role in planning the visit, and they leave knowing their other concerns were at least briefly heard. And if we need to schedule more time in the near future to address issues four through nine, we can plan for that as well.

	The other crucial time for making connections often comes at the end of the visit when communicating my assessment and plan. This is important for both patients and the family members involved in their care. While health systems often act as if every patient fits neatly into a 15-minute box, some most certainly do not. In order to give the best counseling possible, I need to know what my patient knows. So I ask them:

	“Based on the injury you described to me and my findings on your shoulder exam, your pain strongly suggests a rotator cuff injury, Ms. Greene. Before we go further, however, tell me this: What do you know about rotator cuff injuries?”

	The response may be, “My sister had a rotator cuff injury and she had to have surgery, and I definitely don’t want to have surgery.” Or they may know more about rotator cuff injuries than I do. But now that I have a better idea of where my patient is coming from on this specific problem, I can start from their place of knowledge, address their specific concerns and ultimately recommend a treatment plan that is safe, effective and consistent with their values.

	Making these connections is hard work, but it’s critical to being an effective physician and reaching a therapeutic goal. When I use the two techniques described above, one at the beginning of a visit and another at the end, by the time a patient leaves my clinic, we’re much more likely to be working together as a team. 

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It’s more difficult than ever to connect with patients. One physician explains why its worth the effort.

Author | Stephen Walston

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