|Year : 2019 | Volume
| Issue : 1 | Page : 1-5
Listen, care, and going extra mile: Guiding principles for physicians and teachers in health-care profession
Department of Medicine, Ross University School of Medicine, Miramar, Florida, USA
|Date of Submission||29-Nov-2018|
|Date of Decision||20-Dec-2018|
|Date of Acceptance||24-Dec-2018|
|Date of Web Publication||18-Feb-2019|
Dr. Vijay Rajput
Ross University School of Medicine, 2300 S.W 145 Avenue, Suite 200, Miramar, Florida 33027
Source of Support: None, Conflict of Interest: None
In the medical field, emphasis has been on the development of trust between the physician and the patient, similar to that of a teacher and learner. This is because a solid foundation of trust benefits patients' overall care and students' learning. Trust is critical because it allows the patient to believe that the doctor is there to give them the best care possible. Trust improves the physician–patient relationship because the patient believes he or she is receiving high-quality care as a result. It is important for residents and physicians to be aware of their behavior in their interactions with patients and learners, even if the interaction is only for a few minutes. This awareness is key for the development of trust and long-lasting benefits for clinical care and medical education. Physicians and teachers should develop three crucial skills to develop trust early with their patients and learners: (1) listening, (2) caring, and (3) going the extra mile for patients and learners. These attributes, when applied to patient care and teaching, will travel far in a physician's career and be beneficial to their patients' overall health. This article will explore these three skills and examples of their applications, which medical professionals can use in their day-to-day practice in light of a time-restricting, multitasking, and technologically advanced world.
Keywords: Clinical care, learner, patient
|How to cite this article:|
Rajput V. Listen, care, and going extra mile: Guiding principles for physicians and teachers in health-care profession. Indian J Med Spec 2019;10:1-5
|How to cite this URL:|
Rajput V. Listen, care, and going extra mile: Guiding principles for physicians and teachers in health-care profession. Indian J Med Spec [serial online] 2019 [cited 2019 Jul 24];10:1-5. Available from: http://www.ijms.in/text.asp?2019/10/1/1/252473
| Introduction|| |
In the past century, trust has become an important characteristic of physician–patient interactions because it can speak about the likelihood for patients to seek care, their treatment adherence, and their overall experience interacting with their physicians. Patients from varying socioeconomic status, race, ethnicity, gender, and sexuality backgrounds tend to self-report higher rates of satisfaction with their health visits when there is also a high degree of trust and comfort with the physician or health-care provider. In other words, the more a patient trusts his or her physician, the more likely he or she will continue treatment and have a higher rate of treatment adherence. There are several attitudes described in literature regarding building trust between patients and physicians, which provide insight into how the trust forms and evolves over time. As both a practicing physician and medical educator over the last 25 years, I strongly believe that there are three key skills and/or attitudes medical professionals should implement in their day-to-day practice that can help build trust: listening to the patient, caring for the patient, and going extra mile (or even 100 yards) for the patient and learner.
| Listen to the Patient|| |
Listening is the very first linguistic skill that humans acquire as early as living in their mothers' wombs. The act of listening is a multidimensional process that needs to consist of cognitive, affective, psychomotor, and social elements. The way a physician chooses to employ listening with their patients surprisingly varies from physician to physician. One distinctive feature of listening I have come to found effective and meaningful in patient interactions is when the physician physically sits down and listens to the patient. If a physician consistently makes the decision to stand during patient visits, it can indicate a sense of hurry, or distractedness, a feeling that the physician is “on-the-go” and does not have time to have a proper conversation with the patient. This aura of distractedness is harmful to the patient because it can allow the patient to believe the physician does not care for him/her and, as a result, may not make conscientious decisions about his proper medical care.
A caring physician starts to build trust with the patient by also listening to the patient's individual fears, emotions, and anxieties about his or her health status and care. The goal for a physician is to be able to assist patients in addressing these complex emotions and finding a way to cope with them and ultimately move past them as well. One article in the literature demonstrated that, when physicians empathized with their patients, they were more likely to listen to their patients' doubts and fears. As a result, patients reported not only a better quality visit, but also better medical care as well. To be a compassionate physician or teacher, he or she must demonstrate cognitive and cultural empathy toward all his/her patients and learners.
Beyond the patient room, it is just as important for physicians and teachers to learn how to listen to their patients and learners over the phone. This is a challenging subskill to master. The physician must rely on nuances in the tone of voice of the patient. For example, a physician would have to notice the meaning behind stuttering or wavering of the voice as opposed to analyzing physical or body language cues in a face-to-face interaction. A physician should not only identify and understand the patient's tone of voice over the phone, but also learn how to control the way they speak to their patients. If a physician tends to demonstrate a hurried tone of voice, or subtle annoyance or impatience, the patient will notice this. These patients want to have faith in their physicians to not only give them their attention at the doctor's office, but to also give reliable and medically sound advice over the phone. This greatly applies to the situation when a physician is talking to either the parents or guardians about their sick child over the phone. The doctor should ensure that he/she is sensitive to their situation by altering his or her tone over the phone. It is up to the physician to employ a sympathetic voice instead of sounding distant or hurried.
Another challenging issue of listening and building trust with patients is tending to those who need the assistance of an interpreter. In America, about 21% of the population speaks a different language, and most of these patients need a professional interpreter. Patients need a trained, adult interpreter instead of using children who understand English because most young children do not fully understand how to relay diagnosis and treatment information. In addition, the most important piece of advice regarding interpreters is for physicians to maintain eye contact with the patient, not the interpreter, whenever they speak. Although the patient cannot understand what the physician is saying, simple eye contact demonstrates that the doctor cares for the patient and that they want the patient fully involved in the decisions for their own personal care. In return, when the patient speaks, small gestures coming from the physician such as eye contact and nodding go a long way in building trust. When it comes to listening, however, some patients will continue to talk and talk, sometimes about things irrelevant to the patient care. The physician's role here is to let the patient speak for a few minutes and to kindly bring them back to the relevant aspects of their care. This may be tricky because a physician does not want to abruptly or rudely cut off the patient in mid-conversation. Nonetheless, it is an important skill to master because a physician should always bring the focus back to the patient's needs at hand. In addition, a patient may provide critical information for a doctor as he/she is leaving the patient room, a phenomenon referred to as the doorknob sign. Physicians should pay close attention to their good-bye interactions with patients because they may provide the most critical information that a physician needs to help aid treatment and care. Overall, when building a foundation of trust with patients, physicians should ultimately focus on the characteristics of listening, not talking or lecturing because facilitation is a key for treatment recommendations.
Listening to learners
There is a push for active learning in medical education. Active learning is a process of engaging students in problem-solving, reflection, and self-assessment through participation and contribution. A nonexpert teacher usually facilitates this active learning. Active listening skills are critical to master to enhance learning in an in-group environment and for all facilitators to be able to guide their small group sessions. Active listening skills also play a critical role for students who are struggling academically who may need some more attention from empathetic teachers. If teachers listen empathetically to their struggling students, they would be able to build a trusting relationship. Almost all techniques used with patients and physicians are applicable to learners in all educational processes.
| Care for the Patient|| |
The second skill that doctors and teachers should have in their utility belt is their ability and commitment to care for the patient and learner. Ultimately, there is a key difference between treating and advising a patient and learner and caring for that patient and learner. Medical professionals should exhibit a degree of cultural humility (also known as culture humbleness), which is the ability to understand and respect a patient's culture, but not necessarily know everything about that culture. It is impossible for a medical professional to learn every small detail about a patient's culture. Nonetheless, physicians can demonstrate understanding and awareness of cultural factors in a general sense that influences patients' decision-making for their care. This cultural awareness allows them to build trust with their patients. These same attitudes can help with the learner as well.
Furthermore, in an inpatient setting, if medical professionals can “melt away,” or in other words remove themselves from the rest of the world and give their 100% attention to the patient, they have the best chance of building trust. This can be true even in a short period spent with patients. In an outpatient setting, if possible, doctors should walk to the waiting area and escort the patient to the room, especially in times when they run late for the appointment. This way, the doctors themselves can apologize if they were running late or if it was a busy morning instead of patients receiving that information from a nurse or other staff member. If someone other than the doctor escorts the patient to the room, and he or she sits in a gown in for 15–30 min, it can create anxiety for the patient. However, if the doctor escorts the patient to the room, it already fosters a more trusting environment because it shows that the doctor is with the patient every step of the way. Physicians and teachers should always call the patients and learners by their name every time they address him/her because it shows that the patient's care is personalized and that they are not thinking of any other patient while they are in the room. Physicians and teachers may also develop the bad habit of checking their phones constantly, which indicates to the patient and learner that the doctor and teacher are not mentally present or paying attention to their needs. This idea of a physician being “checked out” also creates a high level of mistrust coming from the patient. Although multitasking is effective in other areas of day-to-day life, in this case, it is not. Doctors should refrain from texting back right away because it alienates the patient and his/her trust. In cases of true emergencies, doctors should excuse themselves politely and indicate that it is an emergency. However, it is dangerous for a physician to tell the patient that they will be right back. He or she might have to see an upward of 15 patients or more and may not have time to come back. It would be detrimental to promise the patient that he/she will be back, thus creating a situation that engenders more physician distrust. A counter argument that comes up often in caring for the patient is the idea that medical professionals do not have enough time for each patient because they have to see many during the day. While this is true, I challenge the idea that 2 or 5 min is not enough for a successful patient interaction. Even a physician that has 5 min or even 2 min can show that they care for the patient. It is all about quality not quantity. My mentor, Dr. Viner, once said to me that within 30 s of a patient–physician interaction, the patients could automatically sense whether the doctor is there to treat them or to care for them. Time is not what the doctors need; it is focus and attention to their little behaviors and cues that can build trust with their patients because they are good at sensing body language and all other nonverbal cues.
Another way for a physician to show he or she cares is to follow-up with a phone call 1–2 days after the patient visits, instead of having the nurses do it. In medicine, the interactions between physician and patient during the entirety of care make up a team sport. Caring is a team effort and thus it is important for every single team member to know what caring means to them and what skills they need to possess to achieve it. This article does focus primarily on doctors and teachers; however, there are other team members who can exhibit caring, especially when doctors perpetuate the culture of caring to everyone else on the team. For example, the second a patient walks into the door for his or her doctor's appointment, the receptionist can set the tone for caring right away. The receptionist can smile at the patient and engage in friendly conversation. They can ease some of the anxiety of the patient right away just by being a friendly face. This demonstration of caring by the receptionist and other staff cannot be created through marketing and advertising. The real way to learn and understand caring is through the patients who show gratitude to the people who are helping them. They share their gratitude with other people by word of mouth and tell the people in their lives that a particular doctor is trustworthy. The real patients themselves must spread the word of their trust with their medical professionals.
The care for learners
Dr. Noddings has been exploring the idea of caring in education for the last three decades. The significance of the attitude toward teachers and learners and each other is less understood. We put great stress on individualism as a traditional model in the society. It is a universally accepted, cultural notion that “teachers know best.” What society does is they accept and support individualism and hierarchical obedience in education. In other words, the idea that “all teachers care” is not universally true. The teachers who work hard at their teaching still may not embrace the relational sense of caring. However, having a caring relationship can provide the foundation for many successful pedagogical activities.
The interaction between the teacher and learner is judged in a context of the students' prior work and assessments. A caring relationship that facilitates learning will involve both the learner and teacher. The theory of social capital posed by Coleman in the late 1980s can help explain this phenomenon. The theory tries to analyze the changes in the relationships among people that facilitate actions. Social capital is less tangible than physical and human capital. Social capital in a teacher–student relationship which is based on the investment that both parties put forth. The caring effect, similar to patient care, can provide the learner an assurance that caring and committed relationships will foster success. The caring teachers also motivate learners or students who are struggling, by using strategies such as reflection and listening. The students who perceive that teachers care for them put more effort into learning as well. It is a great and simple way to develop habits that allow teachers and learners to find out more about the students' interests, family, and life in general. It is a caring gesture when teachers get to know their learner as humans by asking questions like where they were born, where they grew up and went to high school, what college they attended, what they studied, and what their life is like outside school. This action does not take more than 3–4 min, but it helps teachers develop a caring relationship with their students. This allows teachers to make connections between studies and global existential questions.
| Go Extra Mile (Or Even 100 Yards) for the Patient|| |
The third skill or attitude that can build solid trust between the health-care professional and patient is the physician's ability to go the extra mile (or even 100 yards) for his or her patients. This means that the physician is willing to engage in practices that go beyond what he/she is expected to do or is not written in the physician's job description. To even go 100 yards for a patient signifies that even if the doctor does not do something extravagant or extraordinary outside of his/her normal daily work, a small act of kindness or action can make a patient's day. These small gestures can make an overall huge difference for patients and even for their illnesses.
Physicians who go extra mile or even 100 yards for a patient sometimes do a job that could have been done by a nurse, patient care assistant, or even a janitor. For example, an old woman who has severe osteoarthritis may have trouble opening milk and juice cartons. If a doctor is in the room and sees the carton unopened or sees a patient struggling to open it, the doctor should assist him or her in opening it. Even though a nurse or some other volunteer could have done that job, a doctor who takes the time to do it shows patients that he or she cares for them in a way that is just not just scientific or strictly medical. Another example is if a doctor hears a patient ringing a bell or walks by a room and notice that the patient needs a urine bottle or some other equipment. This physician can make the choice to provide that service for the patient. The same thing could happen if a physician also takes note of someone's birthday coming up and buys a patient a small cake or desert from the cafeteria. Even spending $5 on a cake can set apart that doctor and show that he or she is willing to go the extra mile to care for patients and their well-being.
One other specific action a physician can take to demonstrate caring is to involve the family. I will say to a patient, “Let's talk to your daughter together on the phone,” while I am in the room with the patient instead of calling the daughter separately from my office. I have noticed that when physicians do this, the patient is grateful for having a voice in the conversation as opposed to feeling left out of the conversation or that their opinions about their care do not matter. Sometimes, I even find myself drawing a simple anatomical diagram on the patient's napkin or notebook about their diagnosis to show them exactly what is happening inside the body in a cartoon form. This engages the patient and makes sense to him/her to be able to visualize what the issue is, making it an effective strategy. In addition, if given the opportunity, the doctor should wheelchair the patient down to the X-ray room or wherever else the patient is going in the building. The patient will appreciate having that time to talk to the doctor, whether it be about the care or about the day. While all these jobs are examples of tasks that are usually done by other hospital staff, the doctor can do these small things to create a high degree of trust between the patient and physician. Small gestures may not be part of the job description, but they are just as important when building trust.
| Go Extra Mile (Or Even 100 Yards) for the Learner|| |
Conventionally, teachers try to aim their instruction mostly to students who fall in the middle of the traditional bell curve. There are always the typical 5%–10% of students on both extreme sides of the curve, who either are struggling in the course or are doing exceptionally well compared to their peers.
Those that are struggling with the academic material need to do more than the required syllabus. In other words, these students need extra guidance and special mentoring that is outside the classroom and academic support activities. Many struggling students require more engagement and a deeper dive into how their inadequate study habits, poor critical thinking, and life circumstances impede their progress as medical professionals. The individualized extra steps teachers can create for these students will help them tremendously in their careers and learning. These steps are micro in nature, which means that their progress requires individual focus on availability, skill development, and sensitivity to both needs and challenges. Although necessary, it can be difficult to define what these extra steps are. I encourage teachers to think of these steps as not written in any faculty or teaching handbook, but found during specialized time in office hours and in real-life experiences mentoring these students. A successful teacher will remember that each student is different and may require a different set of steps to reach their potential. These students can benefit from extra steps that are not found in the typical course work. It is also up to these students to create meaningful connections with their teachers in both research and scholarship. Connecting the right students to the right mentor/faculty will require extra steps to help guide them that way.
Overall, this essay gleans five take-home messages as follows:
- Trust is critical for the physician–patient relationship because when patients trust their physicians they are more likely to adhere to treatment and perceive that they are receiving better quality care as a result
- The three skills for developing trust are listening to the patient, caring for the patient, and going the extra mile or 100 yards for a patient
- Listening to the patient includes examples such as physically sitting down with a patient in the room, using an interpreter for a patient when needed, and employing empathy when talking to a patient in person and over the phone
- Caring for patients means going beyond just treating them as medical diagnoses; instead, physicians should strive to see patients as human beings with worries and concerns and assist them in coping with them
- Physicians should go the extra mile or even 100 yards for their patients because the smallest of gestures can go a long way in showing a patient his or her physician cares.
I would like to thank Ms. Meera Rajput for her critical editing and review of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goold SD. Trust, distrust and trustworthiness. J Gen Intern Med 2002;17:79-81.
Brennan N, Barnes R, Calnan M, Corrigan O, Dieppe P, Entwistle V, et al.
Trust in the health-care provider-patient relationship: A systematic mapping review of the evidence base. Int J Qual Health Care 2013;25:682-8.
Canpolat M, Kuzu S, Yildirim B, Canpolat S. Active listening strategies of academically successful university students. Eurasian J Educ Res 2015;60:163-80.
Kee JW, Khoo HS, Lim I, Koh MY. Communication skills in patient-doctor interactions: Learning from patient complaints. Health Prof Educ 2017;4:97-106. [doi.org/10.1016/j.hpe. 2017.03.006].
Camarota S, Zeigler K. One in Five U.S. Residents Speaks Foreign Language at Home, Record 61.8 million. Center for Immigration Studies; October, 2014.
Wittink MN, Walsh P, Yilmaz S, Mendoza M, Street RL Jr., Chapman BP, et al.
Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors? Patient Educ Couns 2018;101:214-20.
Luc JG, Antonoff MB. Active learning in medical education: Application to the training of surgeons. J Med Educ Curric Dev 2016;3. pii: JMECD.S18929.
Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA 2005;293:1100-6.
Coleman JS. Social capital in the creation of human capital. Am J Sociol 1988;94;s95-120.