As clinicians, we think a lot about the medications and modalities we administer. But regardless of whether we're using pharmaceuticals, botanicals, nutritional strategies, or physical modalities, the outcomes obtained from the medicines we give will be strongly influenced by the ways in which we interact with our patients.
Unfortunately, most of us seldom contemplate how we talk to our patients. Have you ever considered the ingredients of an effective clinical interaction? Are the words you use and your manner of speech encouraging and empowering your patients to move toward greater health? Do they help activate a patient's own innate healing abilities, or do they unwittingly reinforce a patient's deep-seated defeatist attitudes and unhealthy feelings of powerlessness?
When do you feel you are most able to help your patients? Is it when you are excited by playing the role of teacher? Is it when the patient's need is the greatest and you feel you have an effective solution? Is it some sort of unpredictable "right-place, right-time, right-person" chemistry that happens between you and certain patients?
These matters should be as important to us as knowing the right indications for that new insulin sensitizer, or understanding the herbal alternatives to prescription COX-2 inhibitors. The way we communicate with our patients is a major influence on our clinical outcomes. With this in mind, here are a few keys that can help guide you toward more effective communication:
Be Present: For a holistic practitioner, this may appear obvious. But with the intense stresses of modern medicine, clear presence is not always so easy to maintain. The state of presence takes constant 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 long-term practice for this purpose is mindfulness meditation. The best short-term practice is empathetic listening. Ask yourself how you would feel if you were this patient. While in this "projective" state, you enhance the emotional aspect of your presence.
Be Open-Minded: At the same time as you try to cultivate empathy, it is essential not to presume that you know what is going on for the patient at this visit. Always ask. While this may sound simplistic, many of us, especially seeing a patient for the first time, project our own beliefs onto the patient. For example, seeing an obese elderly woman, your first tendency may be to think about dietary issues, physical activity, diabetes, and cardiovascular risk. These presumptions will lead you to ask about these things when, in fact, the patient may be coming to you seeking help for sexual dysfunction. Your focus on the "obvious" distracts the patient from her core reason for being there, and diminishes the likelihood that she will ask you about this difficult issue.
Know Your Limitations: We all are limited in our abilities to heal another individual. In each clinical situation, ask yourself honestly if you are able to help the person sitting before you. If the true answer is "Yes," then go for it! If the answer is "No," think about other resources you can recommend for this patient. Anything short of this is deceptive; it wastes your time, as well as theirs, and they will not reach their desired outcome.
Tailor Your Pace to Their Style: In helping patients to make lifestyle changes—a key component in managing many common chronic diseases—I've found that people tend to take one of two almost opposite approaches: rapid all-encompassing change or slow, gradual, incremental change. The key to knowing which way to go lies in knowing the tendencies of each patient.
For example, Mr. (or Ms.) Speedy, the high powered, entrepreneurial patient with heart disease, will want to see changes with their next lipid measurement or exercise test. With this patient, a rapid series of big lifestyle changes will work well. The will see quick results, feel better faster, and delight in tracking the changes in objective parameters. This will motivate them towards continued progress. It is rewarding to work with these "gung-ho" types … at least at first.
Maintenance can be a challenge for Speedy. These radical-changers will need to develop a support system for long-term success; flying solo only works in the short run. So, you need to help them find support. This may be an exercise group, with the same people each week (or multiple times per week).
Mr. and Ms. Speedy like to be surrounded with people who are working equally hard to be healthy. They enjoy helping others when they stumble; it gives them a sense of meaning, and motivates their further change. Over many years, this need for external gratification by helping others diminishes, as Speedy realizes that he or she is really doing this work for themselves and the people they love.
The opposite end of the spectrum is Mr. (or Ms.) Couch Pillow. Couch Pillow has had many years of vegetative existence. If you give Couch Pillow the same "major changes" regimen you give Speedy, he or she will likely purchase all the supplements, as well as the exercise equipment, and maybe even a new running suit … and then just sit on the couch looking at it all, getting ever more depressed. This, in the long run, is more harmful than beneficial to them.
What is the healthy approach to Couch Pillow? Developing the will to change should be the first step, before implementation of major changes. Dr. Roberto Assagioli, the renowned Italian psychiatrist, suggested that allowing the person to master small, meaningless tasks develops the sort of positive attitude that motivates a person towards healthy change.
A simple example of this would be to ask the patient to stand on a chair, once a day for five minutes at a time. The first time a patient does this, he will feel silly and restless. The next day he will feel bored but confident, and by the end of the week, he will have mastered chair-standing. Assagioli used this with patients who were profoundly depressed, giving them new tasks each week until their confidence grew.
How can we apply this to our Couch Pillows? You may want to ask them to eat one new healthy food each day. This allows them to try something new without eliminating their comfort foods. You may ask them to walk for 5 minutes each day, telling them that even if they want to do more, they should 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 that work against him. With each visit, there may be a new reason why he or she didn't follow your recommendations. Be careful about "buying in" to these defenses. For most of us this is clear when dealing with addicts; think of some of your patients as "unhealthy lifestyle addicts." 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 diminished cortical function, and an absence of thoughtful 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 is a meso-limbic brain process, not a cortical one. Under stress we use our 'mid-brain' rather than the upper cortical discriminatory function.
How does this affect the physician patient relationship? The average patient in your office experiences stress just by being there. He or she may not be feeling well, and may be there to talk about issues that provoke anxiety or fear. Biochemically, he or she has elevated catecholamines and cortisol, and this diminishes his or her cortical capacity (and yours, too, if you are not relaxed). With diminished cortical capacity, a patient is less likely to understand what you are trying to teach. It is therefore important to help your patients 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, home furnishings serve this purpose well.
- Remember that humor can be great medicine; it helps you and the patient to relax.
- Be human. Pretensions isolate you from your patients.
- Do not be afraid to touch. Gentle touch is relaxing for most patients, but not all. Start with touching the patient below the elbow and watch the reaction. Hugs heal, but be aware that this may be too much for some, especially the first time around. Always ask permission!
Be Real: Maintaining a genuine adult-to-adult relationship with a patient (or parent) helps to ease 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. They will 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 (Freeman R. A psychodynamic understanding of the dentist–patient interaction. BDJ. 1999; 186(10)).
Remember that your words to your patients can be extremely powerful; they can facilitate healing or they can do unintended harm. In this realm of communication lies the true art of medicine. So, be careful, but more importantly, be human!
Lee Lipsenthal, MD, ABHM (1957-2011): was founder and director of the Finding Balance in a Medical Life program, which led workshops for individual physicians, their families, their practices as well as large medical IPAs and hospital systems. He was also a founding member and past-president of the American Board of Holistic Medicine. Dr. Lipsenthal authored several books, including: Finding Balance, and the popular, Enjoy Every Sandwich, published shortly after his death.