February 2008 | Welcome to Finding Balance eNews.

The keys to effective patient interactions
What are the ingredients of an effective clinical interaction? Is it when we are enjoying teaching the patient what we know? Is it when the patient’s need is the greatest and we feel most useful? Or is it just ‘the right-time/right-place’ for the two of you? All of these are likely effectors of our clinical outcomes and the patients’ experience of us. With this in mind, how can we maximize our interactions and outcomes? The following keys should guide you in this direction:

Be Present
This may seem obvious, however it is not always easy to do. The state of presence takes practice. In essence, it is the ability to quiet the noise in your head long enough to focus on the person before you. Your capacity for presence can be enhanced with short and long term practice. The best of the long term practices for this purpose would be mindfulness meditation. The best short term practice would be empathetic listening – ask yourself how you would feel if you were this patient. While this in ‘projective’ in nature, it enhances your presence emotionally.

Be Open Minded
Don’t presume that you know what is going on for the patient at this visit, ask them. While this may sound simplistic, many of us, especially seeing a patient for the first time, project our beliefs on the patient. For example, seeing an obese elderly woman, our first tendency is to think about dietary issues, physical activity, diabetes and cardio-vascular risk. These presumption will lead to ask about these things when, in fact, this patient may be there for sexual dysfunction. Your focus on the “obvious” distracts the patient from their core reason for being there and diminishes the likelihood that they will ask you about this difficult issue.

Know Your Limitations
We all are limited in our abilities to help and heal the patient. Ask yourself honestly, if you are able to help this person before you. If the true answer is yes, go for it, if it is no, is there another resource for this patient? Anything short of this is deceptive and wastes your time; their time and they will not have their desired outcome.

Go at the Patient’s Pace
In helping patients to make lifestyle change there are two, almost opposite approaches, rapid all-encompassing change or slow, small gradual change. The key to knowing which way to go is knowing the patient.

For example, Mr. (or Ms.) Speedy, the high powered, entrepreneurial patient with heart disease, will want to see changes with their next lipid test or exercise test. With this patient, a rapid series of life style change will work well. They will see quick results, feel better faster and see rapid changes in objective parameters. This difference will motivate them towards continued progress. However, maintenance can be a challenge to Speedy. This person will need to develop a support system around them for long term success; flying solo only works in the short run. Help them to identify ways of finding support. For Speedy, this may be an exercise group, with the same people each week (or multiple times per week). The Speedys of the world like to be surrounded with people who are working hard to be healthy and like to help others when they stumble. This gives them a sense of meaning and motivates their further change. Over many years, this need for external gratification by helping others diminishes and Mr. Speedy realizes that he is really doing this work for himself and the people he loves.

The opposite end of the spectrum is Mr. (or Ms.) Couch Potato. Couch Potato has had many years of vegetative existence. If you gave Couch Potato the regimen you gave Speedy, they would purchase the supplement, buy the exercise equipment and sit on the couch looking at it, getting depressed. This, in the long run, is more harmful than beneficial to them.

What is the healthy approach to Couch Potato? Developing the will to change should be the first step with this person, before the implementation of change. Roberto Assogioli, the renowned Italian psychiatrist, suggests that allowing the person to master small, meaningless tasks develops the positive attitude and motivates a person towards healthy change. As an example, he describes asking the patient to stand on a chair, once a day for five minutes at a time. The first time they do this, they will feel silly and restless. The next day they will feel bored but confident and by the end of the week, they will have mastered chair standing. Assogioli used this with patients who where profoundly depressed, giving them new tasks each week until their confidence grew.

How can we apply this to Couch Potato? You may want to ask them to eat one healthy food each day. This allows them to try something new without eliminating their comfort foods. You may want them to walk for 5 minutes each day. Tell them, even if they want to do more, only do 5 minutes. Let them master each small step before they move on to the next. While these gradual approaches may try your patience, they will greatly enhance the lives of your patients.

Be Positive
Our patients need our encouragement and congratulations with each success. Don’t forget to remind them of what they are doing well.

Be “Lovingly In Their Face”
Sometimes a strong hand is needed when a patient is using defense mechanisms which work against them. With each visit, there may be new reason why they didn’t follow your recommendations. Be careful about ‘buying in’ to these defenses. For most of us this is clear with addicts, but you may wish to think of each patient as an ‘unhealthy life style addict’. With this in mind, people pleasing co-dependent behavior on our part is detrimental to their health. You may even reach a point where you have to say “If you’re not willing to do the work, I can’t help you any longer.” Honesty is healthy!

Manage Anxiety
Anxiety increases catecholamines and cortisol. This state leads to a diminished cortical function in detailed discrimination. For example, if a car is coming at you at 60 MPH your thought process is “Car-Jump” not “Gee, that red Ford pick up is running at 60 MPH. I therefore need to jump 10 feet to the left.” The jump reflex I a meso-limbic brain process, not a cortical one, so under stress we use our ‘mid-brain’ and have less need for upper cortical discriminatory function. How does this affect the physician patient relationship?

The average patient in your office experiences stress in being there. They may be there to talk about issues which provoke anxiety or fear. In reality the majority of patients have some amount of stress in your office. With this, they have higher catecholamines and cortisol. This then diminishes their cortical capacity (and yours too if you are not relaxed). With diminished cortical capacity, they are less likely to understand what you are trying to teach them. It is therefore important to help you patient relax. Here are some tips:

• Use soothing music and lighting.
• If you use dressing gowns, make them comfortable and non-exposing.
• Use comfortable furnishings. Generally furnishings that are found in the home serve this purpose.
• Use humor. This helps you and the patient to relax.
• Be human. Pretension isolates you from the patient.
• Use touch. Touch is relaxing for most patients, but not all. Start with touching the patient below the elbow and see their reaction. Hugs heal, but may be too much for some, especially the first time around. Ask permission!

Be Real
Maintaining a real adult to adult relationship with a patient (or parent) helps to ease patient anxiety. It also lets the patient know that you are a compassionate human is who looking out for their best interest. This then motivates the patient to please you with positive changes. When this relationship is maintained, patients are more likely to adhere to recommendations you make, come back to see you regularly and sue you less frequently. They are more likely to be respectful of your time and office visits become more efficient and effective. Not bad for just being a human! (Ruth Freeman, A psychodynamic understanding of the dentist-patient interaction, BDJ May 22, 1999 v. 186(10)).

Just for fun
A good friend of mine sent me a link to a lecture by Randy Pausch. Randy is a professor at Carnegie Mellon. This last lecture series was designed to allow faculty to give the lecture that ‘they always wanted to give’. Randy is dying of cancer and this is truly a ‘last lecture’. It is a bit long, but worth it.