BECAUSE PATIENTS JUDGE YOUR SKILLS BY YOUR BEDSIDE MANNER
BECAUSE PATIENTS JUDGE YOUR SKILLS BY YOUR BEDSIDE MANNER
After a thorough examination the doctor tells his elderly patient, “I have good news and bad news. The bad news is that you have cancer.” The patient, distraught, asks, “What’s the good news?” “The good news is that you also have Alzheimer’s and pretty soon you’ll forget you have cancer.”
Compassion is the humane quality of understanding the suffering of others and wanting to do something about it. It isn’t only showing concern for a major loss like the death of a loved one, for example. You can also show compassion for the patient whose financial problems force them to choose a less than ideal treatment. Compassion is being able to put yourself in another person’s place. Feel what they feel.
It would be nice if compassion were a universal trait that needed no instruction, but not everyone seems innately capable of understanding the problems of others, especially when those problems represent an inconvenience or are not clearly expressed. Even if you run behind schedule and want the patient to decide upon a treatment plan, or you want them to stop asking the same questions over and over, you must remain compassionate. Some patients can’t express their feelings or needs and the practitioner must learn how to recognize, in a caring manner, what the patient requires.
Some practitioners have difficulty showing emotion, even when they feel it. There are others who start out empathetic then become burned out by constant exposure to sad events. It’s difficult for some practitioners to understand the possibility of losing compassion, the result of burnout, but it’s true. It is important to recognize the possibility, because stress and emotional detachment can cross over into relationships with family and friends. As a result, not only will your patients think you are detached, but so will your loved ones.
Whether or not you innately possess compassion, the day-to-day trials and tribulations of life can sometimes force you to become complacent and neglect the emotional needs of your patients. Fortunately, there are some simple rules that will allow you to fake it. After faking it long enough, it may actually become genuine—even if you have an inherent lack of compassion.
You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.
We need to start treating the patient as well as the disease.
Hunter “Patch” Adams
Loss is the driving force behind the need for compassion. In health care, there are four areas of loss that require you to express compassion: loss of money (financial concerns), failing procedures, loss of function, and loss of life. There are different ways to express compassion with each type of loss, but the common goal is to show you care.
LOSS OF MONEY
While fiscal matters shouldn’t be part of health-care delivery, they do affect every patient. As medical practitioners we don’t like to address fiscal issues, but their effect on the way doctors are perceived by patients cannot be ignored. It is difficult for a patient to respect the doctor they perceive as more concerned with money than their well-being. Fiscal policies impact how patients perceive your compassion when those policies determine the difference between obtaining proper care and being refused treatment.
A disgruntled patient: “I just couldn’t go back to Dr. Smith. When I told him I couldn’t afford the treatment he suggested, he told me to call him when I could find a way to make it happen. He never offered any alternatives and I felt abandoned.”
Many medical doctors participate in so many insurance plans that they and their patients have no interest in discussing fees. If all treatments are fully covered, then there is no need to discuss fees. However, don’t be surprised or disappointed when patients complain and refuse to pay your bill because they thought your services were covered, and they’re not.
If your service requires substantial uncovered fees or large co-payments, you should make sure the patients understand their responsibility. Some doctors find it difficult to discuss money. Many practice management gurus actually don’t want the doctors to discuss money with the patients. Remember, these are the same experts who show you how to make a lot of money by herding patients like cattle. They want you to limit your time to treatment planning and treatment, while they would have auxiliary staff present the financials.
You shouldn’t be expected to take the money, set up payment plans, and make the next appointment; however, discussing fees, rather than delegating this task to a staff member, helps you bond with your patient. It shows that you have compassion for financial concerns.
Patients receiving treatment not covered by insurance don’t like being herded into the financial arrangement office. It is very impersonal and will cause many to seek treatment from another practitioner. Those who are bullied into accepting treatment they can’t afford will often become non-compliant patients who never follow through, or they will end up in collection, resulting in you performing treatment for which you never get paid.
To avoid the discontent that results in patients leaving your practice and slandering you due to financial misunderstandings, you should discuss fees and make sure the patient is aware that they are responsible for any uncovered treatment. Fiscal responsibility shouldn’t be in the small print after ten pages of material your office staff asks them to read and sign. Be upfront about fees, insurance coverage, and expectations of getting paid for services rendered.
If you discuss fees compassionately, patients will see you are sensitive to their financial concerns as well as their medical problems.
After I quote a fee, I always mention that, “Root canal therapy is expensive, but it’s best to try to save your tooth if you can afford it.” This lets the patient know I understand potential financial concerns. It helps them discuss the issue without embarrassment.
If I quote a fee, and before I have a chance to mention how expensive it is, the patient makes a face that looks like they were just told they have a week to live, I modify my line slightly: “I know that’s an awful lot of money, and while it’s best to try to keep your tooth if you can afford it, there are other, less expensive alternatives.”
Showing concern for the high cost of services is an expression of compassion not usually thought about by health-care providers who often don’t understand that many patients cannot afford optimal care.
Even if you treat wealthy patients, never assume that a fee isn’t a potential burden unless you have known the patient for many years and can take that liberty. Fees should always be quoted, in a compassionate manner, even for patients who you expect to have full insurance coverage for a particular treatment. This shows patients you understand the expense involved and it puts a value on what they receive. If it turns out that they didn’t have the coverage you and they expected, they will not be totally shocked at their financial responsibility.
When a procedure fails, your patient will still hold you in high regard if you have great bedside manner. You will be better protected from legal redress if you have a proper informed consent and you have communicated the possibility of failure before the treatment. Even with these protections, you still want to express your concern and show compassion. In my specialty, that conversation could go like this:
“I’m so sorry the root canal treatment hasn’t worked out for you. We tried everything possible and, unfortunately, your case was one of the ten percent that just doesn’t heal.”
It is best to stop at this point and wait for the patient’s reaction. If they accept your statement, you should proceed with one of the following solutions:
“I’m going to make arrangements for you to have the tooth removed.”
“I’m going to contact your dentist and let him know that he will have to make arrangements to replace this tooth.”
“I want you to contact your dentist so he can make arrangements for you to have this tooth removed and replaced.”
If the patient exhibits any feeling of discontent you proceed:
“I’m sure you remember we discussed the chance of success when we chose to give it a try.”
Notice, blame is not assigned, and you remind the patient that this was what you discussed before treatment was chosen.
Sometimes the belligerent patient will deny ever having such a discussion, at which point it is time to pull out the diagram you drew explaining the treatment, or mention that it was noted in the consent they read before deciding upon treatment.
It is difficult to express compassion for a belligerent patient, but you must continue to be apologetic and explain the situation again, if necessary.
Every practitioner knows what types of failures occur in their particular field and you must have explanations for the most common questions you can expect to hear.
“Why didn’t the scar fade? It looks worse than before!”
“As I explained before we decided to try this procedure, we can’t predict how anyone is going to heal. Some people heal over invisibly and others develop heavy scarring. In your case, we have more of the scarring.”
“How come I have more pain after the back operation than before?”
“I’m sure you remember our conversation about how we usually get a great response to this type of surgery, while other times it just doesn’t work out. When there’s scarring around the nerve root, it can put pressure on the nerves in the same manner that the herniated disk did before the operation.”
For every procedure you perform, you must have a complete understanding of any and all complications, so that your explanations are confident, clear, legitimate, and offer comfort. Patients don’t like to hear, “I’ve never seen anything like this before.” That is not an acceptable response to their concerns. It makes them think you are incompetent. It shows no compassion. It is poor bedside manner.
Even if you have never seen anything like that before, try to have a good answer to help the patient deal with their concerns. This is often the case with an emotionally disturbed, petulant, or chronic pain patient.
“But doctor, ever since you removed my bunion, I noticed that my urine is green and my hair is thinning.”
Although I’m not a podiatrist, I’m fairly certain those symptoms have nothing to do with the operation. Rather than getting defensive and saying, “I never heard of anything like that before,” take a deep breath and try, “I’m very concerned about those symptoms you just described, especially because they have nothing to do with removing your bunion. I want you to get in touch with your medical doctor concerning this matter. I’d be happy to discuss your case in detail, if he/she wants to speak with me.”
If you’re the patient’s medical doctor, or if you’re the specialist their medical doctor sent them to, you may say you want to get a second opinion. Remember: Every patient wants a solution. Don’t be afraid to refer them to one of your colleagues.
In this manner you offer a solution without making light of their concerns or appearing defensive, which many patients interpret as incompetence or lack of compassion. Best of all, you get them into the care of someone who may be able to offer help.
Complicated cases require a cadre of specialists whom you can rely upon.
A pain specialist is a must-have for every practitioner, since we all see chronic pain patients or challenging pain management cases. Attempting to treat these patients without the proper expertise will be a disservice to the patient, your staff, and yourself.
It is also important to have a psychologist/psychiatrist for referral, but making psychiatric referrals are difficult. Patients don’t like to think their problem is in their mind. The slightest mention of a psychological cause of symptoms can make the patient defensive and harbor feelings that you are not compassionate to their needs. Quite often they will doubt your expertise and seek care from other practitioners until they find one who will offer them one treatment or another, though often useless.
When you do suspect a psychological etiology, you may attempt to ease your patient into accepting a psychiatric referral: “After trying all of the methods and techniques I have at my disposal, it may be best to consider seeing a pain specialist or neurologist.”
These doctors will rule out an organic etiology and make the psychiatric referral if necessary. When the patient sees, yet, another doctor who can’t help them, they may finally accept the possibility that they have a psychological problem.
Since neurologists and pain specialists treat many chronic pain patients and many undiagnosed ailments, they often utilize the same antidepressants used by psychiatrists and achieve a high level of success. And when required, they have much more experience making the psychiatric referral.
The Referral Process
All too many practitioners think making referrals makes them look inadequate. That is a dangerous attitude as the patient may not receive appropriate care, and the doctor places himself in jeopardy of legal redress for performing services that didn’t meet the standard of care.
Making referrals shows your concern and is perceived as being compassionate as long as you do it in the appropriate manner.
It’s Not Only What you Say, but How You Say It
Referrals can be perceived in two different ways:
The distinction between caring and callous does not only lie in what you say, but how you say it.
"Mrs. Smith, I've never seen anything like this before. I'm almost to the point that I don't think it's your tooth that's causing the problem. I'm just not sure what it is. Doing anymore here will be a waste of time. I want to send you to a specialist."
“Mrs. Smith, I am so sorry to see that your pain hasn’t responded to any of the treatment I’ve done. While I can’t determine why it hasn’t gotten better, you most certainly have a problem, and we have to find an answer to your problem. I want you to see a doctor who specializes in hidden sources of pain. He’s very good at finding why some symptoms don’t respond to the usual treatments.”
“Mrs. Smith, everything we have tried is just not working. I want you to get better, and I want you to see someone who specializes in more complicated cases like yours. I’m going to send you to a doctor who has a great deal of success in cases that don’t respond to conventional treatment.”
This manner of referral sets up a pathway for success with the potential for placebo effect by mentioning how the new doctor has a “great deal of success.” The key is to communicate compassion while maintaining your credibility. You must always be cognizant of how you are perceived by your patients.
Sometimes doctors who show great compassion and empathy become a magnet for chronic pain patients and lonely old folks. This type of patient has finally found someone who will listen to them, and they have no intention of getting better as it would end the relationship. When you refer these types of patients (after a reasonable attempt to help them), you avoid this dependency situation. If you fail to recognize this pattern, you will enable this dysfunctional behavior and you will not have time to see many patients each day.
LOSS OF FUNCTION
Some health-care providers treat patients who have lost function as a regular part of their practice. One might expect that the more dramatic the loss, i.e. blindness, deafness, paralysis, the more compassion needed. However, any loss of function may be considered devastating to the individual who places great value on something others may not consider. The practitioner with great bedside manner is never complacent about exhibiting the utmost compassion for any and all losses experienced by their patients.
Upon first meeting with the patient experiencing a loss of function you should acknowledge the disability with an expression of life affirming spirit.
“I could never understand what you are going through, but I can assure you I know many people dealing with your same problem, because that’s my job. I am here to help them all day, everyday. I’m here to help you.”
If the patient is receptive, your treatment and their recovery will go well, however if the patient is in the self-pity stage of healing, other tactics may be employed.
“There are two ways you can deal with your loss, the negative way or the positive way. If you choose the negative way, you will let this loss defeat you and you will never recover. The positive way to deal with your loss is to accept it and let it make you stronger, so strong, in fact, that you will be able to deal with everything that comes your way better than most people.”
You can work on your own life affirming speech, or perhaps tell the patient about some interesting or famous person who overcame the same problem and went on to conquer the world. Patients need encouragement and the knowledge that you and your team are there for them.
When you specialize in treating severely handicapped individuals, you might forget that aside from special physical needs they have special emotional needs. Treatment without compassion is not humane. I remember an internship at the head and neck cancer center where the chief of the service had us gather around severely disfigured patients while he described them as objects of interest and treated them without dignity. To show us anatomical points of interest he made each patient experience pain and gag to the point that several interns had to leave the room. He seemed to be devoid of any emotional understanding of their plight. To him these patients mattered little in the scheme of things. This doctor had no bedside manner.
LOSS OF COMFORT
Patients are often fearful and anxious when they go to their healthcare providers. Their fears can be psychological as in neuroses or obsessions, or they may be grounded in real life issues from the fear of a painful procedure to actual death concerns regarding a terminal diagnosis.
The doctor with great bedside manner must deal with the fears and anxieties of their patients with extra time to allow them to voice their concerns and address them, both real and perceived. Offering comfort and confidence helps to allay the patient’s fears.
If the patient needs your services and you convey to the patient that you are going to do your best and that you are the best, it offers comfort. The patient feels they are now doing everything they can to deal with their problems.
With a terminal diagnosis, it is imperative to offer hope even when there may be none based on your medical experience. There is always the possibility of miracles and you must keep that hope alive for the patient. Statements like, “Even though the survival is low at ten percent, there is no reason you can’t be in that group and I will do everything in my power to help you be in that group.”
While you should never give false hope, there is no reason to show any negativity. Humanity dictates that you always show compassion.
For the patient who is fearful of the procedure you perform, you must explain things clearly and realistically. You should inform them, “I will do everything in my power to make this as pain free as possible.” Naturally you should utilize the latest, greatest techniques to minimize pain.
You don't want to lose the patient's trust by telling them things that aren't true. If there is some pain associated with a procedure, prepare them and offer encouragement, much like the hand-holding required for an apprehensive child. You may have to offer a psychological hand-holding for the fearful adult. Use distraction techniques and have your auxiliary staff talk the patient through a difficult procedure.
When a patient is in pain, you may have to address the pain before moving forward. With acute pain, as might be encountered in the emergency room, it may take more than compassion and talking to the patient. In those situations you may need to resort to medication, sedation and even anesthesia to get the patient out of acute pain. Naturally, there are times you can't achieve that goal when you need to get medical information for the safety of the patient.
Situations that involve acute pain can frustrate the practitioner and that must be suppressed. That is the time compassion is needed the most.
LOSS OF LIFE
The loss of life is so difficult for most people to accept that it requires special scripting and study to become adept at delivering the bad news in a compassionate manner, and even then, it is never easy.
For tragic situations in medicine, you will need to have prepared responses and avoid anything that sounds detached. Never say to a patient’s family, “There is nothing more that I can do.” While you may know this to be the case, you simply must have a better way to say the same thing.
Quite often religion is the best excuse to offer comfort when preparing a family for the end. You don’t have to be religious and you can even be an outright atheist. It is not necessary to divulge your personal beliefs to comfort people at time of need. While they may curse you along with God, at least you’re in good company.
“We’ve done everything possible to help your mother and now it’s in God’s hands.”
“What does that mean?”
“It means that everything medically has been tried. Now we’ll see what God wants for her.”
“But I don’t believe in God.”
“I’m truly sorry, and I hope you find comfort in your family and friends.”
“I am so sorry to bring bad news, but while we tried everything available, your father didn’t make it through the operation. Though I could never feel your pain, I, too, lost someone very dear to me and my pain was overwhelming.”
While some may perceive mentioning your loss as self involved, others will appreciate that you, too, shared a loss and have some understanding of their pain.
If expressions of compassion don’t come naturally to you, memorize these lines and practice saying them in the mirror. Make up your own expressions of comfort, use others’, and learn each time you encounter responses from grieving families that make you feel awkward. Gradually, you will develop many offerings to help comfort those in need.
Physical manifestations of compassion like the embrace, hug, and pat on the shoulder are extremely effective nonverbal tools. The use of endearing names is another important ancillary form of expressing compassion. These techniques are detailed in the chapters, First Names, Endearing Names, and Touch and Delivering Bad News.