What Do You Expect From a Doctor? Six Habits for Healthier Patient Encounters

Journal Club Discussion. What do you expect from a doctor? Six habits for healthier patient encounters. Loxterkam, D. (2013). Annals of Family Medicine. 11(6).

What is expected of us? As third year medical students, we are often preoccupied with this question. Our grades and clinical evaluations depend on meeting, or exceeding, these expectations. With all the pressure, we often forget to ask ourselves, "what do our patients expect of us?" Dr. Loxterkamp's thoughtful essay reminds us of this question, and encourages us to reflect back onto why we decided to enter the field of medicine in the first place: to serve people.

Our patients will expect us to be competent physicians. They expect us to be able to figure out what is going on with them, and to be able to fix it in the best way available by modern medicine. They expect us to be informed on the latest advances, and to be able to answer all of their medical questions. They expect that we pass no judgment on them and be as non-biased as possible, regardless of their political, social, or spiritual views. They expect us to keep the information they share with us confidential and to protect their secrets as avidly as we would protect our own. Above all, they expect us to act as a helping hand and that they can come to us at their most vulnerable moments and be listened to and cared for no matter what.

We rarely get an opportunity to ask, "What do we expect of ourselves?" Aside from the obvious "don't kill anybody", most of our responses revolved around many of the concepts brought up in Dr. Loxterkamp's article. We expect to be able to communicate effectively with our patients, carefully eliciting hidden agendas and essentially finding the patient's true needs. We expect that at every patient visit, we will strive to get the patient to a "better place", be it with a cure, a better understanding for both parties, or with helping the patient achieve acceptance or comfort around their current situation. We expect to leave every experience with the feeling that it was a "good encounter", regardless of the outcome or diagnosis. Essentially, we expect to connect with every patient not in a doctor-to-patient sense, but in a human-to- human sense.

We then must ask ourselves if our expectations are realistic. Perhaps they are not always attainable, but they can serve as a goal to strive for throughout our careers, constantly pushing us to be the best we can. We believe that we will often be able to meet our expectations, and both we and the patients will benefit. We will not always be able to deliver a "quick fix" for many patients, regardless of their expectations. We will not always be able to cure somebody of their chronic diseases, or give a demanding parent antibiotics for their child's cold, but we can work as a team to arrive at an understanding or compromise.

Dr. Loxterkamp writes about how patients expect their physician to operate by a "moral compass" and always put others' needs above their own, but how people define a "moral compass" can vary. To us, being guided by a moral compass means following the four cardinal rules of medical ethics: beneficence, nonmaleficence, autonomy, and justice. Beyond that, it implies that the physician should care just as much about their bedside manner as one does about their knowledge base. The physician is constantly weighing the risks, benefits, and costs, and working out what each individual patient needs.

The author further writes that patients expect physicians to listen, look, touch, and plan. These are things that we hear in passing in class, often assuming that they are common-sense points that aren't worth reviewing when we have the seemingly insurmountable number of medical facts we need for multiple-choice exams. However, it's helpful to be reminded of just how powerful following these guidelines can be in our interactions with patients. There are obstacles to following these four basic rules, but they are often very possible to work around.

First of all, you must listen. We are taught that if we just listen without interrupting the patient will tell us most of what we need to know in two minutes or less. In our limited clinical experience this is often true. It does happen, however, that a patient will lose focus, or try to present more problems in one fifteen minute visit than is realistically possible. Many of us are still trying to figure out how to handle these situations. Redirecting the conversation is often difficult, and we find that we often have to resort to interruption at some point. What the patient most needs to realize is that you acknowledge all of there problems and that you think they are valid, so it is necessary to make that apparent. This can be done by focusing on what is most important to the patient, or what you as a physician believe are the most urgent problems that need to be addressed at that moment. Then encourage the patient to follow-up for the other problems at a future appointment. Not only will this validate the patients needs, but it will show him that you are listening and are concerned about addressing all of his/her issues.

Secondly, you must look. Body language is incredibly powerful at influencing the perception that a patient has of you. The electronic records often make this difficult. Find a way to ignore the computer in the first few minutes of interaction with a patient, making sure to keep eye contact. Maybe its easier to just jot notes down on a piece of paper at first, and fill in the medical records later. When you must look at the computer, explain what you are doing to the patient, possibly even allowing them to see what you are doing. This will not only show them that you are indeed still listening, but it will also allow the patient to feel more involved in their own health care.

Touching is probably the most personal of these principles. People's levels of comfort vary, and it is important to be attune to contextual, social, and cultural cues in these situations. However, patients have come to expect a physical exam of some sort. It is one of the honors in medicine that patients give us permission to examine their bodies so that we can accurately understand the problem and diagnose. The physical exam is one way we connect with the patient as well as showing that we are actively involved in their care, and are unafraid of them. Touch can also take place outside of the physical exam if the situation calls for it such as a comforting pat on the back, or even a hug can go a long way with patients. To some students, this is possibly the most difficult of the four tasks to accomplish, because one has to be excellent at reading people and at reading cues, as well as be able to demonstrate comfort with personal touch.

Finally, you must plan, and include the patient in the development of the plan. A plan is a tentative and educated guess. Furthermore, it is a negotiation or agreement that both the patient and physician contribute to. It is important for both sides to voice their reasoning or explanations for their respective desires and decisions. Creating a plan together allows the patient to be more active in their health care, which encourages setting and meeting goals and increases adherence to life style changes and medications. It also helps the patients know what to expect regarding the future of their health, which can help calm their fears and anxieties, as well as help them realize the limitations about what can be done. To make sure that the patient understands the plan, you must gauge the patient's medical literacy during your interactions and talk at their level. Then you can assess their level of understanding by having them repeat back what you just told them.

Throughout the rest of our careers, how do we keep these ideals alive? We may become jaded with all the paperwork, red tape, and patient load, eventually finding that we have less and less time per patient interaction. Perhaps medical practices will have to essentially change so that we can devote more one-on-one time with each patient. Until then, we need to keep reminding ourselves of why we decided to join this profession in the first place. Many of us join because we have a desire to improve the lives of individuals and communities. We care and want to do what is best for our patients, treating each one for the individual person that he or she is. Some clinics and hospitals now write guidelines for patient interactions that include many of the points that Dr. Loxterkamp brings up, but without intrinsic motivation, they can seem insincere. We think that it is to follow these principles, because establishing rapport and trust is paramount to providing the best care.

Dr. Loxterkamp leaves us with the note given to him by his patient's parents. It's the kind of note that all of us hope to receive some day, and serves as a kind reminder that even in situations where we don't know what is going on and have to defer to others for help, as long as we try our best our patient's will always appreciate our honesty, integrity, and general humanity. This appreciation is often a reason we joined this profession, and is indeed one of the greatest joys of medicine.

Competing interests: ?? None declared

This article can be summarized up in one word, compassion. Taking the time to understand the patient and giving them time to express themselves is important. Patients prefer a compassionate over a brilliant uncaring diagnostician. While most patients hold doctors in high regard, flawless and self-confident maybe an overstatement. This is especially becoming true given the new technology that is coming to the workplace. With the advent of computer-based electronic medical records, patient-doctor interaction is becoming lost. Personality of medicine is replaced by systematic programming designed to improve efficiency and cut costs. This takes the human out of the interactions between the patient and doctor and creates an atmosphere that appears generic, cookie cutter, and lifeless. The more doctors are viewed as part of the system and a right rather than a privilege, the less they will be respected and the less therapeutic the relationship will be. Thus again, the end result is decreased efficiency.

Interpretation of body language is probably the most underestimated or underrated part of the patient-doctor interaction. The problem lies in that there is no scientific way to measure and document this phenomenon, so it is observed but generally ignored. This aspect of intentional and active listening allows objective verification of subjective statements. The meaning and interpretation of the intentional listening and body language in healthier patient counters is probably buried somewhere in the phrase "clinical judgment". Most patients are happier with leaving the final decision to their doctor and in fact expect this behavior. Paradoxically most patients prefer doctor center care versus patient centered care if done with compassion. Many providers may go too far when trying to incorporate their patients into the clinical plan. This inevitably generates the patient thought "you're the doctor why are you asking me?" and devalues the confidence and trust society extends to doctors. Like most things in life, there needs to be a balance. In this case it is between personal attention and confident delivery of solutions.

This is where the art of medicine comes in. It's not really about patient centered care versus doctor centered care rather it is providing the best quality care regardless of barriers and constraints, and especially tailoring the care to the individual patient's needs.

Competing interests: None declared

It's all about connection. When we walk into our patient's room for the first time, one of our top expectations is that we will connect. Of course, while we also have the expectation that we will be able to address our patient's concerns and work together to come up with a plan, we want to have a genuine conversation with our patient so they will feel comfortable talking with us, and in some way, trust us, even as students. We don't want to portray any power or authority, but we want to work with our patient as a team member in their health care. We want and hope the patient has some sort of confidence in us, even as students, and feel that we are playing a beneficial role in providing care. Ideally, the goal is for us to be able to balance these two roles; not demonstrating too much authority, but conveying competence and gaining the patient's confidence, which is one of the top challenges of being a student doctor.

We find that we struggle with being able to convey this appropriate amount of competence. Between not having the full scope of medical knowledge, and not quite knowing the appropriate boundaries of our role as medical students, we struggle with how far we should go with our patients. What results should we explain with them? What questions should we answer? Should we give our thoughts if the patient asks? We find that our level of comfort varies, but we all end our explanations and education with "But we'll confirm this with the physician", even though this may limit our credibility. Or, maybe this will strengthen it? Past experiences may also influence how the patient views the student doctor. They may fully understand our role, and may even see it as an advantage by having an extra set of eyes concerned about them and thinking about their medical issue and wellbeing. Past experiences with student doctors may also become a barrier if the patient has had a negative experience with a student. We hope that the amount of time we are able to spend with our patients will help gain their trust and will help us build the connection that we seek.

The author describes how the two focal facets of physicians include not only being competent, but also having a moral compass. During our discussion, we found there is a lot of ambiguity with the term "moral compass", and to each of us, this means something slightly different. Overall, we interpreted the author's meaning of moral compass simply as putting the patient's needs above our own. However, this was also controversial in our discussion. This brings the discussion of autonomy, beneficence and our own moral beliefs. We may believe a treatment is in the patient's best interest, but what if the patient doesn't feel the same? They have the right to refuse, even if we feel it is in their best interest. We all want to put our patients' needs first, but appreciate it is not always clear-cut. We also understand putting our patients first may mean sacrificing our own personal needs. We all selected medicine knowing this was the nature of the work, and wanting to do the most good for the most people. However, we want to be cognizant of the need to take care of ourselves so we can give to our best capacities. Our goal is to give the best care to the patient, as we are able with the knowledge and resources we have available.

The author gives six habits that all physicians should develop to become better providers and we discussed our thoughts on each.

# 1. Identify: Make sure that the role of the provider is not ambiguous to the patient. In larger hospital settings, especially in teaching facilities, it can be confusing for the patient to know who is in charge of different aspects of their care, and even in regards to who is coming in and out of their room. We agree that it is necessary to clarify the scope of each provider's role in the patients' care and identify who is who. While this is necessary, it is important not to portray the physician as the "captain of the ship." We do not want to take away due credit from the non-physician roles as they contribute to patient care as well.

# 2. Listen. We all agree this is important, and we all go into patient visits with the best intentions to listen patiently, but even in the short amount of time we've been doing our clinical work, we can appreciate the challenge of this. Time constraints are real, and very challenging to manage. While most patients do follow the "2 minute rule", there are always the few patients who are quite verbose. One of the ideas we shared with each other about redirecting our verbose patient was to acknowledge the patient's concerns while at the same time setting an appropriate agenda for the time given and asking for a return visit. Most patients are very understanding of the provider's time constraint. We also noted that non-verbal cues are essential for the physician to demonstrate while the patient is speaking to show acknowledgement and to validate.

# 3. Touch. The author describes the importance of touch and how this can convey a physical connection between the patient and the provider, a connection between two people, and how it can form intimacy that can invite communication and reassurance. While most agreed that touch can reassure the patient that we are there for them, and find it crucial, it was also discussed that we should be aware of different contextual and cultural circumstances. We must use our best judgment to determine which patients will accept touch and patients who may feel it is an invasion of personal space. Most of us agree that a touch on the shoulder during the heart and lung examination is the most acceptable area, and that it could even seem sterile and perfunctory to perform the exam without some form of this touch. The question of asking the patient for permission to touch was also discussed and some thought it would not appear as genuine, while other felt it gave the patient some level of control in the interaction. Some of us acknowledged that gently touching the patient might even be more for ourselves, for us to feel that connection as well.

# 4. Look. EMR makes it difficult to look at the patient while taking notes and documenting at the same time. Luckily, most of our generation is comfortable with computers and typing, which makes it easier to document while looking at the patient. Unfortunately, the EMR also requires a ton of clicking, which cannot be done blindly. The group discussed managing this by positioning the computer screen and the patient in a way that can allow easy visualization for both the patient and student doctor, and where the patient can also see the screen so there is a shared connection of what is going on and so the patient feels they are a part of the care. This will also decrease the division between the student doctor and the patient during data input. It is also important to try to minimize the silence during data input; this can be achieved by letting the patient know what we are doing or by providing verbal cues as the patient is speaking. We also agree that it could be helpful to take the HPI first without the computer, and provide full eye contact and verbal feedback during this time. After that, we could log into the computer and start data input.

# 5. Plan. Outline specific steps that will lead to the patient's recovery. As medical students, it is challenging to create a collaborative plan, illicit what expectations the patient has, and then to modify these expectations with medical knowledge. It is important that the patient has a level of involvement with the plan, even if it is limited to assessing feasibility of plan. It is essential to identify barriers in carrying out the plan, especially in regards to lifestyle modifications. One area that we are unsure is whether we, as providers, should always offer all possible options to our patients. We have to consider standard of care, benefit vs. risk, and cost to the patient and society. Is it our responsibility to offer every option, even if it could cause more harm to the patient? This made us identify the complexity of the balance between autonomy and beneficence. We decided that ideally the provider would offer the options they are knowledgeable, skilled, and comfortable to provide, but also provide information about options they are not so comfortable with and acknowledge limitations. This may include presenting why they are not comfortable with these options, a possible referral to someone who is, and transparency when the provider lacks the expertise regarding the options.

# 6. Follow up. It is extremely important to follow through with our patients and make sure all loose ends are tied. This will not only provide the best care to the patient, but also gain their trust. For the many patients with chronic diseases, there is no "end", but in order to provide adequate care, we need to continually follow the labs, results, etc. While the majority of the time spent following up on our patients is non- billable hours, this should not dissuade the provider. We discussed whether or not it is even possible to follow up on all of our patients? How do we keep these patients in the healthcare system and continue to provide the best care? Some providers may have so many patients; it would be easy to lose a patient to follow up. Even though it is important for the provider to keep up, the patient also has some accountability in their care. They must have ownership of their health care and be proactive in their follow up.

The article demonstrates the power of care and concern, and how displaying this concern to our patient can be more powerful than addressing the actual medical illness that brought them to the provider. We also found how important reflection is as student doctors; doing a self-check and evaluating where our values stand. We all have different ways of interacting with patients, and we have realized that seeing how our peers and mentors would react to certain situation is a meaningful learning tool during this discussion. This article is a great conversation starter and we were able to reflect on our own practices and the practices of each other; to share ideas, techniques and experiences to help each other move forward in our training. In the end, we hope to never forget that patients are people first.

Competing interests: None declared

The World Health Organization's Alma Ata conference in 1978 defined primary care by the presence of four attributes. It is: - The first point of contact - Continuous healing relationship - Comprehensive services - Coordination of care across the continuum

Dr. Loxterkamp's piece elegantly describes the value of relationship - value not only to the patient and family but to the clinician. Too many policies and payment models erode this relationship.

Payment insufficient to the full scope of primary care keeps PCPs on a hamster-wheel schedule. This insufficient payment may be fee-for- service or capitation. If insufficient, we end up with too many patients and too little time to attend the full scope of patient and family needs.

Policies and regulations regarding quality improvement and cost containment fall disproportionately onto primary care. Various well- intended programs require increased data entry and attending to EMR/registry. Without significant changes in payment, these initiatives divert precious time away from meeting the full scope of our patients' needs.

High performing primary care is the foundation of high performing health systems. Any system that would deliver high quality population health management that results in improved outcomes and consequently leads to reduced unnecessary expenditure would do well to: - finance the full scope of primary care - apply human and technical resources to support the full scope of work in primary care - carefully review quality reporting requirements. Keep those that are clearly consistent with Triple Aim outcomes, ditch the tangential minutia that provide merely the impression of doing something, and automate whenever possible.

L Gordon Moore MD

Competing interests: ?? None declared