Using the Humanism Pocket Tool for Patients With Challenging Behaviors

THE INNOVATION

How can clinicians stay humanistic—respectful, empathic, and compassionate—with patients with complex behavioral, social, or physical issues? In our interprofessional patient-centered medical home for homeless Veterans, we designed a compact set of techniques, summarized on a pocket card, and termed the Humanism Pocket Tool (HPT). It comprises heuristics for interacting both with patients and team members, because staying compassionate requires a culture of humanism within the clinic.

WHO & WHERE

We are clinicians in a Veterans Affairs teaching clinic focused exclusively on homeless Veterans. We designed the HPT to help experienced clinicians and trainees from multiple professions maintain compassion for this challenging population.

HOW

Clinicians learn that their brains are equipped with inborn, automatic, emotional responses biased to protect them from people who might be dangerous, infectious, or time-consuming. These emotions can sneak up on them and replace compassion with fear, disgust, or anger. To counteract these unproductive responses, clinicians learn to (1) coach themselves; (2) be warm; (3) listen actively; (4) condense each patient’s personal story into a highly compact form, termed a “Vivid Vignette”; (5) use the Vivid Vignette to identify the patient in progress notes and in conversations with colleagues, so as to inspire and coordinate care; (6) appreciate differing professional perspectives on the patient; and (7) know their team members as people. These last 3 HPT techniques build a willing, creative, and effective team whose members support each other to stay humanistic.

To illustrate, consider a clinician who is about to evaluate a patient new to the clinic. In the medical record, she reads that he is a:

“…55-year-old male, recently released from prison after his third incarceration for violence…”

Noticing stirrings of anxiety, she arranges for appropriate and proportionate safety precautions and tells herself, “I may feel apprehensive and I can choose compassion” and “I’ve got a strong and compassionate team.” This allows her to begin with a warm greeting, use curiosity and active listening, build rapport, obtain medical history, and understand the patient’s personal story. She learns of his dedication to family and ardent desire to avoid incarceration. All 3 prior incarcerations were for violent responses to a racial epithet—responses he felt helpless to control. With the patient’s approval, she embeds the following Vivid Vignette into her initial evaluation, and employs it whenever she discusses the patient with colleagues:

“…Marine Corps Veteran, loving father and thrilled new grandfather, plagued by violent responses to a highly offensive racial epithet…”

In doing so, for herself as well as for her team, she deconstructs stereotype-based expectations. The Vivid Vignette inspires her team members to focus their efforts on solving this problem, beginning with a thoughtful discussion of racism, implicit and explicit biases, and stereotyping.

LEARNING

The skills in the HPT sustain us daily, enriching our work with patients with complex behavioral and physical needs. The Vivid Vignette, a refreshing adaptation of the long-championed practice of narrative medicine, is contagious and reminds us of the transformative power of patient care. The Supplemental Appendix, available at http://www.annfammed.org/content/16/5/467/suppl/DC1/, presents an extended user’s manual containing detailed instructions, our conceptual framework, and case examples. We continue to refine the pocket card and the manual based on our experiences and those of our collaborators. Although designed for teams treating challenging populations, we believe these techniques may help all clinicians strengthen their humanistic attitudes and behaviors.