Hospital Medicine

Physician-patient relationship

I. Problem/Challenge.

Unique Implications of the Hospitalist-Patient Relationship.

Barriers to a Good Beginning.

The hospitalist faces a unique challenge due to the nature by which patient relationships are introduced. Patients would generally meet their hospitalist for the first time. Unlike elective visits, patients do not have the opportunity to choose the practitioner. Unexpected acute illness, acute-on-chronic illness and morbidity, characterize the majority of inpatient encounters. Complex transitions of care are also typical. The hospital environment lends a feeling of vulnerability, a lack of control, and privacy. These circumstances challenge relationship establishment and development with patients and families. It necessitates that trust is established quickly and as early as possible in the relationship.

Medico-legal Implications.

The hospitalist-patient relationship is a decidedly transient. The end of such a relationship and transition of responsibility to the primary care physician must be clearly defined by the hospitalist.

II. Identify the Goal Behaviors.

Main Goal: Aim for a Relationship-Centered Hospitalist-Patient Relationship.

Execute Skills and Techniques That Foster Meaningful Therapeutic Relationships

Effective physician-patient relationships result in effective care. The ideal behaviors include the proper execution of a relationship-centered interview and an effectively negotiated plan of care. The crucial skills to possess to achieve these objectives include the ability to:

  1. Establish a common agenda for the hospitalization.

  2. Explore the patient’s perspective through reflective listening.

  3. Express empathy throughout the relationship.

  4. Involve the patient in decision-making.

Know the Medico-Legal Implications of a Hospitalist-Patient Relationship.

A physician-patient relationship is said to begin once a practitioner attempts to diagnose or treat an illness or provide counseling. The preceding statement is subject to broader interpretation. A relationship can be terminated on mutually agreed terms. The improper or premature termination of a physician-relationship may constitute abandonment. The hospitalist should be aware of the unique medico-legal implications of a transient relationship and in this context, must responsibly set the stage for safe transitions of care and turn-over of responsibility.

III. Describe a Step-by-Step approach/method to this problem.

The Approach Towards an Optimal Hospitalist-Patient Relationship, as adapted from The Cleveland Clinic REDE© Model of Healthcare Communication. Therapeutic relationships can be divided into three phases, with each providing a critical element in relationship-building.

Phase 1: Establish the Relationship.

  • Convey value & respect with the welcome.

  • Collaboratively set the agenda.

  • Demonstrate empathy at the beginning and throughout the relationship.

Phase 2: Develop the Relationship.

  • Engage in reflective listening.

  • Elicit patient narrative.

  • Explore the patient’s perspective.

Phase 3: Engage the Relationship.

  • Share diagnosis & information.

  • Collaboratively develop treatment plan.

  • Provide closure.

  • Convey information through dialogue, not monologue.

Steps, words, and/or actions for each phase:

Phase 1: Establish the relationship.

  • Convey value & respect with the welcome.

    1. Review chart in advance & comment on their history.

    2. Knock & inquire before entering room, if possible.

    3. Greet patient & companions formally (using title & last name) with smile & handshake.

    4. Introduce self & team to patient & any companions; clarify role(s).

    5. Position self at patient’s eye level.

    6. Recognize & respond to immediate signs of physical or emotional distress; attend to patient’s privacy.

    7. Make a brief patient-focused social comment, if appropriate.

  • Collaboratively set the agenda.

    1. Orient patient to elicit a list of presenting concerns.

    2. Use an open-ended question to initiate survey, e.g. “I’d like to get a list of all the things you’d like to address today.”, or “What concerns brought you in today?”

    3. Ask patient to list all concerns for the visit or hospital stay.

    4. Summarize list of concerns to check accuracy.

    5. Ask patient to prioritize concerns, e.g. “Of all the things you brought up, what’s most important to you?”

    6. Propose agenda that incorporates patient & provider priorities

    7. Obtain patient agreement.

  • Demonstrate empathy at the beginning and throughout the relationship.

    1. Recognize emotional cues and respond “in the moment”.

    2. Demonstrate verbal empathy using the SAVE mnemonic.

      S – Supportive Statement: “I’m here for you. Let’s work together.”.

      A – Acknowledge what they’ve gone through or what they’ve done: “This has been hard for you.”, or “I’m sorry for the wait. I value your time.”, or “I wish there were better alternatives.”

      V – Validate: “Most people would feel the way you do.”, or “Anyone in your position would feel upset.”

      E – Emotion-naming: “You seem sad.”

    3. Demonstrate non-verbal empathy.

      • Embrace the pause.

      • Open, forward leaning posture.

      • Facial expressions of care, concern, and curiosity (e.g., raised eyebrows).

      • Head tilt or nodding.

      • Moving closer to patient.

      • Appropriate touch.

      • Gentle tone, slow pace to speech.

Phase 2: Develop the Relationship.

  • Engage in reflective listening: Listening in such a way as to understand & acknowledge what is being said nonverbally & verbally using continuers such as “mm-hmm”, “I see”, “go on” or brief statements summarizing the underlying meaning or emotion “What I hear you saying is…” or “Sounds like…”

  • Elicit patient narrative: The narrative is the history according the patient’s own words and perspective. Use open-ended questions to initiate the patient narrative. e.g. “Tell me about your headaches… what else can you tell me?”

  • Explore the patient’s perspective.

    1. Know the person not just the patient.

    2. Elicit the values, beliefs, and experiences that shape their perspective.

    3. Goal is not to presume and assume but rather be curious to explore and open to learn.

    4. Do not presume that your goals and expectations are the same or aligned at the onset.

    5. Using the mnemonic V.I.E.W., ask about the patients.

      V- Vital activities (occupational, interpersonal, intrapersonal): “How does it disrupt your daily activity?”, or “How does it impact your functioning?”, or “What made you decide to come in now?”

      I – Ideas: “Often people have a sense of what is happening. What ideas do you have about it?”, or “Do you know others who have had similar symptoms?”

      E – Expectations: “What are you hoping we can do for you today?”, or “What outcome do you hope to achieve with treatment?”

      W – Worries (concerns, fears): “What worries you most about it?”

Phase 3: Engage the Relationship.

  • Share diagnosis and information.

    1. Orient patient to the education and planning portion of the visit.

    2. Present a clear, concise diagnosis.

  • Collaboratively develop treatment plan.

    1. Describe treatment goals and options (including risks, benefits, and alternatives).

    2. Elicit patient preferences and integrate into a mutually agreeable plan.

    3. Check for mutual understanding.

    4. Confirm patient’s commitment to plan.

    5. Elicit potential treatment barriers and need for additional resources.

  • Provide closure.

    1. Alert patient that the visit is ending.

    2. Affirm patient’s contributions and collaboration during visit.

    3. Arrange follow-up and consultation with other team members.

    4. Provide handshake and a personal goodbye.

  • Convey information through dialogue, not a monologue. Information through a “lecture” or a monologue is retained at around rates of 10% or 25% at best. Providing information in chunks and allowing the patient to explain what he knows, may increase retention by 60%. Counsel patients through a dialogue using the A.R.I.A. mnemonic.

    A – Assess using open-ended questions.

    What the patient knows about diagnosis and treatment.

    How much and what type of education patient desires/needs.

    Patient treatment preferences; health literacy.

    R – Reflect: Use reflective statements restating meaning and emotion.

    I – Inform patient in context of patient’s perspective and preferences.

    Speak slow and provide small chunks of information at a time.

    Use understandable language and visual aids.

    A – Assess patient understanding and emotional reaction to information provided.

Benefits.

Empathy skills and conflict-resolution skills can be learned and practiced. Effective physician-patient relationship sets the stage for improved health outcomes, compliance, patient satisfaction, diagnostic accuracy, patient safety, patient trust, healthcare savings, and physician satisfaction. Literature also suggests reduces medical errors, malpractice litigation and physician burnout.

Establishing a trustful relationship can prevent accusations of abandonment or breakdowns in the relationship. The initial phases of establishment and development, like rapport building, discovering the patient’s agenda and responding with empathy all add meaning to the relationship. These will be helpful when managing difficult relationships where conflict is involved, therapeutic boundaries are being tested, where emotions run strong and/or if the conversation is difficult.

From an organizational point of view, initiating a system of care that seeks to discover the patient’s expectations might be far more productive than assuming what patients want to meet expectations. Healthcare organizations have sought to highlight relationship-centered behavior and train staff in these methods.

Unplanned Relationship Terminations.

While generally avoidable, unplanned deteriorations of the physician-patient relationship do occur, usually in the context of strained relationships. In this context, it is best to involve your own hospital’s legal or risk management department. The patient should also be allowed to air grievances to an independent third party as established by the risk management protocol of your organization. If medical errors are involved, relationships become decidedly complicated.

Secret Information About Patients.

For a patient that decidedly meets criteria for medical decision-making capacity, all communications are to be held in strict confidence until permission to disclose to third persons is given. Hospitalists must be familiar with the regulations set forth by Health Insurance Portability and Accountability Act of (HIPAA) of 1996. Any Protected Health Information (PHI) should be kept in a reasonably secure database that is not discoverable.

Gifts from Patients.

Patients may occasionally need to express appreciation of a practitioner’s care. There are no clear guidelines on the subject matter. Several references suggest that a thank you note, a bouquet of flowers or other simple inexpensive gestures are generally welcome. In contrast, questions are raised when a physician accepts gifts that are extravagant or of significant monetary value. Admittedly, value is a relative term, and often left up to individual judgement.

As with gifts from the pharmaceutical industry, the proposed screening questions are:

  1. Will my acceptance of this gift raise a reasonable amount of scrutiny into my clinical and ethical judgement?

  2. Will it call into question misguided motivations on my part for the treatment and management of the patient in question?

Answering yes to any of these questions, may point to a decision to not accept the proposed token of appreciation.

IV. Common Pitfalls.

Physician-Patient Relationship Killers

Entering the Room Unprepared:

In order to avoid "foot in mouth" syndrome, do enter the room armed with good background knowledge of the case as well as recent events.

Failing to Set Expectations/ Mismatched Agendas:

A patient may have totally different therapeutic goals than that of the medical team. At the beginning of a relationship, these should be explicitly uncovered, discussed and reconciled with realistic goals. Otherwise, the practitioner runs the risk of not meeting most, if not all, of the patient’s expectations.

Not Knowing Patient’s Personal Situation:

Treatment plans are at high risk of failure if the patient’s personal and socio-economic situation are not factored into management and therapeutic planning.

Lack of Empathy Skills:

The lack of perceived empathy from the patient is a common reason for litigation. An empathetic statement adds meaning and understanding to a relationship.

The Unintentional Doctor-Patient Relationship:

Do understand that medical advice given outside of a hospital or office may unintentionally herald a doctor-patient relationship. These chance encounters may place the patient at-risk for an incomplete evaluation and lack of formal follow-up. "Curbside" patients should be counseled to seek medical care in the correct setting to ensure proper follow-up to the medical complaint.

Lack of Awareness of own Hospital’s Risk Management System:

Nearly every hospital is mandated to have a process for recording patient grievances, as well as a systematic approach to risk management. These resources are best utilized when a hospitalist is plagued with a troubled or dysfunctional physician-patient relationship. Stakes are higher if the grievance is in the context of patient harm and/or medical errors.

V. National Standards, Core Indicators and Quality Measures.

Joint Commission Standards for Patient-Centered Communication.

These new and revised standards stipulate that:

  1. The hospital should have a written policy on patient rights.

  2. The hospital informs the patient of his/her rights.

  3. The hospital treats the patient in a dignified and respectful manner that supports his or her dignity.

  4. The hospital respects the patient’s right to and need for effective communication.

  5. The hospital respects the patient’s cultural and personal values, beliefs and preferences.

  6. The hospital reflects the patient’s right to privacy.

  7. Existing paper forms or computer data entry screens use the term; "patient’s preferred language."

  8. The medical record must identify the patient’s race and ethnicity. The hospital should have policies prohibiting discrimination based on at least 11 factors: race, age, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression.

Laws and Regulations.

The Emergency Medical Treatment and Active Labor Act (EMTALA).

The Patient Safety and Quality Improvement Act.

State and Federal Credentialing and Licensing.

Society of Hospital Medicine (SHM) Core Competencies.

SHM core competencies were published in 2006 and are a series of articles that outline a proposed approach to hospital medicine education. Core competencies relevant to this module are found in section 3 (Healthcare Systems):

  1. Risk management.

  2. Patient Education.

  3. Patient Handoff.

  4. Patient Safety.

  5. Professionalism and Medical Ethics.

  6. Risk Management.

  7. Transitions of Care.

  8. Communication.

Readmission Rates.

Readmission rates may be a key metric affected by the quality of the physician-patient relationship.

HCAHPS.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally uniform survey of discharged patients. It is mandated by the Centers for Medicare and Medicaid services. HCAHPS and patient satisfaction standards are further discussed in a separate module ("Patient Satisfaction").

VI. What’s the evidence?

Windover, A, Boissy, A, Rice, T, Gilligan, T, Velez, V, Merlino, J. "The REDE model of healthcare communication: Optimizing relationship as a therapeutic agent". Journal of Patient Experience. vol. 1. 2014. pp. 8-13.

Frankel, RM, Stein, T. "Getting the most out of the clinical encounter: the four habits model". J Med Pract Manage. vol. 16. 2001. pp. 184-191.

Randolph, DS, Burkett, TM. "When physicians fire patients: avoiding patient "abandonment" lawsuits". J Okla State Med Assoc.. vol. 102. 2009. pp. 356-358.

"The core competencies in hospital medicine: a framework for curriculum development by the society of hospital medicine". J Hosp Med. vol. 1. 2006. pp. 2-95.

Van Herck, P, De Smedt, D, Annemans, L, Remmen, R, Rosenthal, MB, Sermeus, W. "Systematic review - Effects, design choices, and context of pay-for-performance in health care". BMC Health Serv Res. vol. 10. 2010. pp. 247.

Anderson, J. "Is it better to give, receive, or decline? The ethics of accepting gifts from patients". JAAPA. vol. 24. 2011. pp. 59-60.

"A new look at the hospital patient grievance process". Hosp Peer Rev. vol. 34. 2009. pp. 141-144.

Hickson, GB, Clayton, EW, Entman, SS, Miller, CS, Githens, PB, Whetten-Goldstein, K, Sloan, FA. "Obstetricians’ prior malpractice experience and patients’ satisfaction with care". JAMA. vol. 272. 1994. pp. 1583-1587.

Kandula, NR, Malli, T, Zei, CP, Larsen, E, Baker, DW. "Literacy and retention of information after a multimedia diabetes education program and teach-back". J Health Commun. vol. 16. 2011. pp. 89-102.

Spath, P. "When does a complaint become a grievance? Part 1". Hosp Peer Rev. vol. 25. 2000. pp. 12-14.

Tan, AS, Moldovan-Johnson, M, Parvanta, S, Gray, SW, Armstrong, K, Hornik, RC. "Patient-Clinician Information Engagement Improves Adherence to Colorectal Cancer Surveillance after Curative Treatment: Results from a Longitudinal Study". Oncologist. 2012.

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