- Dr. Lalit Chawla
E#7: Frameworks I: Patient communication The Introduction, How to Start & Frameworks
Knowing how to introduce oneself can be challenging and awkward especially if you tend to be an introvert and feel hesitant to make the first move when meeting someone. There are definite do’s and don’ts to getting off on the right foot to building rapport, trust, and making yourself and the patient at ease.
(This is the core of the transcript from the podcast. The Intro has been removed and some areas improved for reading ease.)
In today’s episode we’re going to talk about Frameworks; How to communicate more effectively with patients from the very beginning.
One of the hardest things in engaging in any conversation, especially with the patients, is knowing how to start. I used to struggle with this, and I know so many of my colleagues also struggled with this.
I’ve seen how some doctors communicate well and how others don’t spend any thought on how they communicate at all and leave it entirely to chance. I’ll share an embarrassing story with you, of how I screwed things up in the past. I generally don’t have a problem connecting effectively anymore since I learned to apply a useful framework.
Everything requires a framework, whether you are making a cake, building a house, using ACLS, or engaging in a clinical encounter.
Let’s talk about what about the whole concept of frameworks. A framework is a format, an outline, or a blueprint that keeps a person on track and organized. If you think about everything that’s ever really been done successfully there’s always framework involved whether it's writing a book, cooking a meal, - building a house or even interacting with another person.
If you look at Stephen Covey‘s book ‘7 Habits of Highly Effective People,’ (which was voted by Time as one of “The 25 Most Influential Business/Personal Management books”), it was built on a very clearly defined framework. Here are 7 habits. If you do them well, you will be highly effective and successful. For example:
Habit 1 - Be Proactive!
Habit 2- Begin with the End in Mind. What do you want your life to be like?
Habit 3- Put First Things First.
Habit 4- Think Win/Win!
A baker uses a framework to bake a cake: They need to gather the correct ingredients; they need to use the proper equipment; they need to use the proper temperature and timing; and they require the knowledge and correct step by step process on how to bake a cake.
A builder uses a framework to build a house (literally!): They need to understand local building codes; they need to gather the adequate materials, equipment and skilled trades; and they require the knowledge on how to build a house.
Even in medicine we use many frameworks. The ACLS, ATLS is so successful because it was built on a framework of ABCDE (Airway, Breathing, Circulation, Disability, Exposure). This framework was created as a result of an experience a physician had when he and his family were in a car accident. There was so much disorganization among the rescue workers that they didn't know what to do or when to do it. Thanks to the level of chaos of that event, we now have the framework of ACLS. Now, all healthcare workers had a uniform protocol to follow when trying to save a life.
As an introvert, it can be so easy to caught up and become nervous and anxious about the clinical visit, especially when you hear it's something complicated...
Now personally, as an introvert, I know it’s so easy to get caught up and become nervous and anxious about the clinical visit, or even about the main reason the patient is coming in. The anxiety can be compounded if we know the issue may have additional complications. For example, they may be bleeding heavily, have severe pain, be extremely anxious or suicidal etc.
We can also become sidetracked when a person comes in with multiple complaints and we can get lost in terms of how to conduct ourselves and how to navigate the situation appropriately.
I know I can still get lost, and what brings me back is this framework that I’m going to share with you. It’s helped many clinicians stay on track. Don’t let the simplicity fool you. Simple is sound and unforgettable.
So, creating a framework in the clinical setting or any other relationship interaction, is as simple as remembering that there are only three parts. Warning: I know this may seem simplistic or basic, but this framework has saved me and many others. Bear with me as I explain this.
The three parts are: the Introduction, The Middle, The Conclusion of the interaction.
Any time that I’ve had a great clinical interaction, I have done all three of those areas well. There is a distinct introduction, middle and conclusion. And whenever I’ve had a clinical interaction that has felt incomplete or went sideways, it’s because I’ve missed one of the three. The most common part that doctors forget is how to conclude the visit, but I’ll be talking about that on a later podcast. Today I want to talk about the introduction.
"Hi John, I'm Dr. Chawla, this must be your mother?" (nope it's my wife!)
A proper introduction is a key to setting the stage for a favourable interaction. As the old saying goes, “you only have one shot at making a good first impression.” And it certainly applies here. The introduction can be hard, especially when you’re nervous or you’re shy, and you don’t know what to say to the person.
You can end up with an awkward silence, or end up saying something that can sound silly. I did this once when I was working in the ER. A young man, who was wearing athletic spandex that cyclists wear was brought in hobbling by a woman. I stupidly walked in the exam room all chipper like and said: “Hi John, I’m Dr. Chawla and this must be your mother?" And you know what they say about assumptions, never assume because you can look like a donkey. I certainly did since that lady wasn’t his mother but rather his wife! Needless to say, I had to work hard to get my foot out of my mouth, which I don't think I did all that well either.
Now I'd like to share with you four key essential areas that doctors and health care providers either find hard to do and/or don’t do consistently.
Introducing yourself particularly applies to a new patient you’ve never met or a patient that you may know, but he or she brings someone new, such as a spouse, friend etc.
So, the simple thing to do is, smile and say your name. Over the many years I’ve practiced, I’ve seen many new and veteran doctors working in the ER or hospital come in and start talking. They assume because they are wearing a stethoscope or scrubs, that the patient knows they are a doctor. And they feel they don’t need to identify themselves to the patient or their family. They dive right into the scenario or problem at hand. I certainly understand that, and I’d be lying if I didn’t do that in the past as well, but that is not the right thing to do.
Introducing yourself is a necessary sign of respect for the other person. It’s basic common courtesy. There is a tension and fear that the patient already has and it can be heightened when we don’t start the interaction right. Introducing yourself is one of the consistent things we teach young medical learners and residents. As a clinician, we are engaging in, developing and fostering a relationship. This even applies if we know that we will never see that patient again; we are still - developing a micro- relationship. When I introduce myself, I can see it sets them at ease and that in turn makes me feel relaxed too. When you get off to a good start, it gets things warmed up so to speak.
A little known fact is that small talk is important, necessary to create connections. It's easy to do, let's explore some topics of small talk.
The other thing is to show some enthusiasm that you are happy to be there even if you may not be. We’ve all been physically, mentally, emotionally, and socially tired but, as my mentor who taught me how to be a World Class Illusionist always said, “Professionals do even if they don’t want to!” He always seemed to point that out when I was especially - tired and didn’t want to rehearse, or do the training for a Death Defying Escape.
Enthusiasm is essential as well, especially when you meet children. It tells them right away that you are friendly. I’ll simply say, “Hi Kathi, how are you? It’s great to see you." Or “how's my friend today?” Children always smile, and they instantly know that you’re not mean. Of course, everything should come from an internal place of genuineness. Say what makes you comfortable. I’ve never had a child say, “I’m not your friend.” Or “I’m not your buddy.” It just doesn't’ happen. Also addressing them by their name is especially important too. And then, I might lead into some small talk.
2. Small Talk
To be honest, - when I first started in clinical practice I didn’t know the value of small talk, but it is hugely vital, not only making the person feel comfortable, but also it also makes you feel comfortable as you get into the dialogue. Small talk will give you those few seconds you may need to breathe and get settled in.
Once I realized the value of small talk, I started doing it more consistently, and I noticed the conversations became better. Small talk is a good part of the whole introductory process, and It sets the stage for comfortable conversation and starts building trust. And trust is so important for the patient to share information in a more complete and truthful manner. This, in turn, results in better shared care solutions that you make together.
But when you don’t make small talk or introduce yourself, the whole experience will feel rushed and insincere. You’re saying to the person: “Let’s get on with this, I’m too busy to even introduce myself to you, or to talk about other things that are not medically related. This not a personal interaction, it’s simply business.” It’s a very consumer-oriented approach. And that’s not good medicine, in my opinion.
There needs to be an element where the person is warmed up; that they know you’re ready to listen and that you want to give them your undivided attention. This also applies if you know the person well and you have a long history with them. Just because we’ve been a good listener in the past, doesn’t mean we can stop now. This little advice applies to personal interactions as well. When I’m not paying attention, even a little bit, my wife and kids know it, and they help me dial my focus back in. Nothing was more embarrassing than when my four-year-old son asked me, “Papa, why are you looking at your phone again while we are playing?” And he was so right! I just wasn’t present with him”.
The small talk doesn’t have to be long, that’s why it’s called small talk. So, I’ll start with a rhetorical question, or ask them about the weather. "Is it hot out? Is it raining still?” Or “We sure had a lovely weekend, didn’t we?” Small bits of information help set the stage and it helps us both relax. Finding a simple question is much easier than one may think,
At any given time, there is some special event coming up in the year, like major holidays such as Christmas, Valentine ’s Day, or summer break. Almost every month has a long weekend and you can ask if they have any plans, or better yet, how their weekend was?
At any given time, we’re either entering a weekend or coming out of one. If it’s a Monday, “how was your weekend” if it's a Friday “any special plans for the weekend?”. If it’s Wednesday, “how's your week been so far?”
Just keeping that in mind makes it easy to begin and it is surprising how it relaxes the patient. It also shows that you’re a human being who is willing to talk about something that is not big/or heavy right away. It shows a more holistic part of you.
Both you and the patient know that there’s going to be something of more of substance coming up very soon, and there’s no rush to get into it quickly. Small talk only takes a few seconds, and it hardly goes into minutes.
Look for clues from something obvious that can be turned into small talk. If they are reading a book, or knitting etc. ask them about that. It gives you a little insight into their hobbies. It should always come from a place of honest curiosity and genuineness. So, remember the small talk.
"thank you for being so patient"
3. Respect Their Time
And by this I mean, if you are late seeing them for their appointment time, apologize: "sorry to keep you waiting”. They know you’re busy, but making that statement shows you value their time and that you care. Be genuine, obviously.
I suspect that many doctors don’t say this and it may create a bit of divide and disconnect. Patients, for the most part, know we are busy and that things happen in the world of medicine. You should take that quick two seconds and say something that acknowledges their patience. That builds good rapport. If you find it hard to say sorry, then thank them for waiting patiently. It’s a small gesture, but as my mother used to say, “It’s the little things make the biggest differences in life.”
4. Appropriate Dress, Language and Eye Contact
One thing I’ve seen more of in the last few years, and has become somewhat of an issue, but not often talked about is how doctors are physically presenting themselves.
I bring this up because I’ve worked with doctors, and young medical residents, who have presented themselves in a ‘not so professional’, or ‘sloppy’ manner. I’ve had to tell some young learners that they need to at least iron their shirts and comb their hair and even wash their face.
This may seem a bit moody on my part, picky or even unnecessary, but I believe every profession has a certain standard. Policemen wear specific gear, as do fireman, and paramedics as well. They physically present themselves in a way that projects that they care enough about themselves and that they can take care of you. Because in one sense, some patients may be thinking, "If you can’t take care of yourself, how can you take care of me?" I believe that when you enter into the workplace, especially as a doctor, that the attire we have on conveys a certain level of respect, and self-dignity. It’s a subtle message but a really important one from my perspective. When you look professional, you are essentially saying to the world, “I’m alert, bright and ready to pay attention to your concerns and to listen to you." Your physical attire can represent your emotional state as well. Obviously, if you are working in the ER or Operating room, you won’t be wearing a three-piece suit or a fancy ballroom dress, but clean scrubs are totally appropriate. That is common sense, but as they say, “Common sense is not very common.”
And then there is the aspect of our body language and how we speak.
As an introvert or someone shy, we can forget, that how we physically carry ourselves will significantly affect how others see us; not to mention affect how we feel and look at ourselves. Lots of research shows, that if you feel scared, shy or hesitant, your body reacts accordingly. If you’re depressed your shoulders come in, your head goes down, and your speech slows down. Our physiology and psychology are so interconnected as one. Fortunately, if we change our body to sit and stand more upright, eyes brighter, and head up, that will trigger our brain and our psychology to function better as well. If you’re smiling, it’s hard to be negative. If you’re laughing, you can’t be angry or upset. We also end up using better language. We also listen better. The result is, we are in a better state to help others better. In the end, it creates a better work environment and we feel more energized, more fulfilled.
Good, gentle eye contact with the patient conveys respect, but for people who are shy, that is something we tend to avoid a little. And of course, there are different cultural variations in terms of how much and how long the eye contact should be.
Occasionally, the patients we see may be more of an introvert as well, so you don’t want to overdo it and stare at them without blinking; that can scare them off. Part of the art of medicine is to know how to adjust your body language accordingly. If you haven’t listened to my interview with the leading expert on body language, Mark Bowden, Episode 5, you should take a listen. He talks about common mistakes that people make with their body. His books are incredibly helpful as well.
Which reminds me, here’s a quick tip that I share with my medical students and residents: Avoid using the computer when you are talking to the patient. Now, that can’t always be done, but if you need to use it, take a moment and ask them if it’s okay and let them know what you are using it for. So many times we are in with a patient, but we’re clicking away on the keyboard as we try to listen to them while either looking up information or sending off a medication script. Too much multitasking makes the interaction feel rushed or unsettled. There is a ’correct balance’ where you can use the computer appropriately and be present with the patient; rather than merely getting what you need to be done ASAP. Be mindful, especially if the computer is positioned awkwardly and forces you to have your back against the person in your office. Poor positioning can make interaction very difficult. If you can change your workspace to function more effectively, it’s worth the cost to do so. The price of preventing mental fatigue, personal irritability and an unsatisfying patient interaction is priceless. As I mentioned, I’ll talk about the details of physicality in more detail in another podcast. I want to give it the time it deserves.
I’m going to summarize this podcast, but I wanted to give you a little information about the next episode which is: the MIDDLE aspect of the clinical visit: How Do We Start the In Depth Conversations and what’s happening for a patient? What are the right questions to ask? When to use certain types of questions? I have some real golden strategies that have proven to be extremely useful for me over the years. Here’s a quick summary about this podcast
1. Remember that Frameworks are essential for creating success in any endeavor; including the clinical interaction.
2. Starting the visit by introducing yourself and saying their name as well
3. Be enthusiastic, even if you don’t want to, it definitely puts a smile on the children’s faces
4. Create small talk and Keep it Simple
5. Respect their time, acknowledge if you are late and thank them for their patience
6. Dress Appropriately
7. Remember, changing our physiology improves our psychology. It’s easy to change the way we think by simply changing the way we sit or stand.
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(A special thanks to the talented William Brown who edited the above transcript)