There is no doubt that the United States is in the midst of a maternal health crisis. In fact, a new study found that the U.S. has the highest maternal mortality rate amongst 11 high-income countries.[1] Further, we are one of the few developed countries where deaths related to pregnancy or childbirth are actually on the rise.

In fact, American women today are 50% more likely to die in childbirth than their mothers were. Moreover, there is a significant racial disparity in outcomes. According to the CDC, black women have a maternal mortality rate that is nearly three times higher than white women.

Despite these devastating statistics, providers are in a unique position to have lifesaving impacts on our pregnant patients, especially women of color, through more thoughtful education and support.

ADD_THIS_TEXT
 

As an OB/GYN, I am acutely aware of the health care gaps that contribute to maternal morbidity and mortality in the U.S. A report from nine maternal mortality review committees estimated that over 60% of pregnancy-related deaths were preventable. Further, it cites better patient/provider engagement and empowerment as one of the main opportunities for improvement.

But how do we do this, especially in the midst of the COVID-19 pandemic that has added many outside stressors and barriers to consistent care?

Impact of COVID-19 on the maternal health crisis

Moms-to-be these days have a lot to deal with. They must manage their risks related to the novel coronavirus as well as the uncertainties related to the upcoming flu season. And, they must do it while also handling the usual pressures of being pregnant.

Moreover, patient/provider relationships have had to shift drastically. Many health care appointments have transitioned to virtual care or other forms of digital communication.

The usual course of prenatal care includes about 15 prenatal and postpartum visits, including services like ultrasound. The shift away from in-person visits drastically changes a woman’s pregnancy journey. Further, many Americans are outright canceling or postponing care because of fear of contracting COVID-19.

Related reading: Fear of COVID-19 Keeps Patients from Seeking Medical Care

The Path to Better Health Study by CVS Health found that 41% of respondents are not tracking their personal health information, such as weight, blood pressure, or cholesterol. In an environment where providers may not have regular contact with their patients, this is an alarming trend.

This suggests that many people who are, or may become, at risk for a chronic condition could develop complications that go undetected. This is especially concerning in maternity care because chronic conditions increase the risk of pregnancy complications.

Further, COVID-19 has highlighted longstanding and deep-rooted racial disparities within our health care system. The pandemic has disproportionately affected communities of color. This places our most at-risk patients in an even more vulnerable position.

Black women are also at an increased risk for chronic conditions. Further, the Path to Better Health Study revealed incidences of chronic disease in African American women more than any other ethnic group.

The maternal health crisis: identifying opportunities for intervention

Despite these myriad challenges, the pandemic has also provided an opportunity for adaption and change. As providers, we should embrace the critical role we play in our patients’ lives, specifically through better:

      • communication
      • education
      • advocacy  
      • empowerment

This is especially important when caring for those most at-risk for complications.

We know that focusing on empowering women works. For example, studies point to positive outcomes related to feelings of self-efficacy in pregnancy. These include: 

      • reductions in perinatal depressive symptoms,
      • reductions in preterm birth, and low birth weight.[2] [3]

As providers, we need a multi-pronged approach to ensure we are providing the kind of additional support women need along their pregnancy journeys:

1. Be ready to adjust.

Aetna initiated its “Time for Care” campaign in order to encourage patients to continue seeking health care during the pandemic. A national survey of 4,400 Americans was conducted to inform the design of the campaign.

It found that 50% of pregnant mothers are not confident that their primary care physicians have put the necessary measures in place to prevent the spread of COVID-19.

This suggests that we have work to do to help patients feel safe in health care settings. We have to adjust and provide new, safer, ways to care for patients.

This may mean implementing and encouraging the use of telehealth. It might also mean making sure proper protocols, such as the CDC recommended steps, are in place when in-person visits are necessary. 

Changes, whether large (moving to virtual care platforms) or small (implementing masking and distancing guidelines) can have a positive impact on patients’ trust. 

2. Listen to, advocate for, and empower patients

Women are often overlooked or underserved in health care.  This is especially true for women of color.

For example, studies have found that Black female patients can experience racial bias when it comes to pain treatment. For example, African American patients who reported pain were 22 percent less likely than white patients to receive medication from their doctors.

We need to make sure that we actively listen to and advocate for our patients when they raise concerns about their health. That can help them feel encouraged and empowered throughout their health journey.

One way to initiate this approach is by learning about your patient’s status so you can ask questions relevant to their health. Also, when appropriate, encourage patients to bring outside support (e.g., a loved one, family member, or doula) into the clinical setting. This can help provide extra encouragement or advocacy in times of need.

Regardless of what steps you’re taking to do so, it’s imperative that moms-to-be feel empowered to speak up throughout their pregnancy. To create the kind of environment where that’s encouraged, we need to not only actively listen to our patients but believe them.

3. Be a champion of education and communication

Putting educational resources directly into expectant patients’ hands, either in-person or digitally, can be a great way to spark dialogue and encourage good decisions.

One way Aetna aims to help in this space is through a new initiative aimed at preventing preeclampsia. Preeclampsia is one of the leading causes of maternal death in the United States. The program consists of sharing kits containing educational materials on the risks of preeclampsia. It also provides information about the use of low-dose aspirin as a proven, low-risk intervention.

The initiative works to encourage and empower high-risk patients to start conversations with their providers about their pregnancies. The program is also notifying in-network OB/GYNs of this outreach and urging them to discuss risk factors with their patients.

By arming patients with education, we can empower them to ask informed questions and open those additional lines of conversation.

Leading the change in the maternal health crisis

Trust is critical when it comes to building better patient/provider relationships. We know that such relationships provide a solid foundation for effective treatments and better health outcomes.

There is no one, perfect solution to ending the maternity crisis in the United States. However, good communication and building trusting relationships with our expectant patients provide an opportunity to help our patients feel safe getting care during COVID-19.

Further, by prioritizing, empowering, and educating our patients, we can all play a part in improving patient/provider communication. At the end of the day, we all want to be part of a solution that ensures our patients are getting the care they need.

References

[1] Tikkanen R, Gunja, M, et al. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, The Commonwealth Fund, November 18, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries – accessed 11/18/20.

[2] Weinstock M. The potential influence of maternal stress hormones on development and mental health of the offspring. Brain Behav Immun. 2005;19(4):296–308. doi: 10.1016/j.bbi.2004.09.006.

[3] Yim IS, Glynn LM, Schetter CD, Hobel CJ, Chicz-Demet A, Sandman CA. Risk of postpartum depressive symptoms with elevated corticotropin-releasing hormone in human pregnancy. https://pubmed.ncbi.nlm.nih.gov/19188538/


Published 10/19/20. Updated 11/18/20.

All industries need translators and interpreters who are trained in different languages. Although some items, symbols, and/or actions may be universally understood, you still need to convey subtle meanings and instructions across cultures. It is especially important to overcome language barriers in healthcare. That is why the need for medical translation and interpretation is so critical.

Translation and interpretation activities in the health domain are numerous. They can range from simultaneous or consecutive interpretation, translation of medical files, correspondence between doctors and patients, and much more. This article will provide a complete overview of language translation and interpretation in healthcare. We will attempt to answer the questions:

  • Who does it?
  • How does it work?
  • How much does it cost?

And we will provide some predictions for the future.

Medical translation vs medical interpretation

In the language services industry, we differentiate between two concepts related to transferring the meaning from one language to another: interpreting and translation.

  • Interpreting refers to the act of real-time, in-person transferring of communication from one language to another.
  • Translation refers to written documents and is usually not carried out in real-time.

These activities are distinct and require different training and skillsets. However, it is common to use the term medical translation and medical interpretation interchangeably. I will try to point out the distinctions as we explore the profession in this article.

Why medical translation and interpretation are so important

Medical translation and interpretation together comprise one of the most sensitive fields within the industry of translation. Unlike some other forms of translation and interpretation, there is zero-tolerance for mistakes in healthcare.

This is because incorrect translation might harm someone’s health or well-being. It could lead to interventions, like surgery or prescription of powerful medications that are associated with a risk of serious complications. Thus, it is clearly an activity that has to be carried out by highly proficient people who exercise a great deal of concern in order to ensure the quality of their work.

  • Worldwide patterns of migration drive demand

The medical translation field has become even more critical with the rise of migration. Large numbers of people move from one country to another without speaking the language. When they require health care, particularly in emergencies, they can be in trouble without interpreters.

For many people who are outside the industry, it may seem surprising that there is such a high demand for language interpretation in medical services. However, statistics show that it’s anything but surprising. For example, in the US, more than 45 million people don’t speak English as their primary language. And, an additional 21 million said that they don’t speak English “very well”.

  • The impact of international tourism

Along similar lines, until the onset of the COVID-19 pandemic, international tourism was increasing every year.  Again, this can lead to people becoming stranded in emergency rooms where they cannot speak the language. Again, this is where medical interpreters come in.

  • Medical tourism and interpretation

Another opportunity for increased demand in healthcare interpreting is medical tourism. This is an industry that has been on the rise with the expansion of international flight connections and globalization in general.

Medical tourism occurs when people from countries, like the United States with a high costs of healthcare choose to get services in countries where healthcare is high quality, but much cheaper. They often combine it with a vacation.

It is most often done in the fields of cosmetic surgery and dentistry. However, you can now find overseas opportunities to receive a broad range of services, including joint replacements, organ transplantation, and cardiovascular surgery, amongst others.

Naturally, medical tourism’s only issue is the language and cultural gap. This is why many organizations who are dealing with these types of medical services often have language interpreters on call.

Language barriers healthcare medical-tourism

The increasing popularity of medical tourism is one of several drivers for more and better medical translation services (Graphic source: iStock)

According to experts, both medical tourism and telemedicine will increase the demand for interpreting in healthcare services in the near future.

What is language translation in healthcare settings?

In general, medical translation (encompassing translation and interpretation) is defined as any process of translation that serves healthcare professionals to provide the necessary treatment for patients who speak (or read) another language.

As you are aware, it’s incredibly important that medical professionals are able to communicate with their patients effectively. As I have mentioned that’s not the case, the entire care and treatment process is endangered. Medical interpreting and translation, therefore, primarily deal with these tasks:

  • simultaneous interpreting of doctor-patient communication
  • translation, including but not limited to, of any of the following documents: 
      • doctor-patient written correspondence
      • patient’s medical history in another language
      • lab test results, findings, and so forth.

When you need any type of medical translation, you should contact experts who are experienced in that particular field. Don’t contact just any translation agency or company – it’s important that the company you’re working with has had previous experience with these types of documents because they have special terminology.

You need to specify if you need medical interpreting or medical translation

When you’re looking for language services, you need to specify whether you’re looking for interpreting or translation. If you want someone to be in the hospital or at a doctor’s appointment with your family member, look for interpreting services.

If you want to get a medical document, lab test results, or any other written document translated to another language, you’re looking for a translation.

The benefits of interpreting include an opportunity to have a private, intimate conversation with a doctor and to ask questions as they pop up into your mind. It’s also much faster than translation because it has to be done in real-time. The drawback is that there is more room for error as the interpreter has to react quickly and sometimes under pressure.

Translation, on the other hand, is done at a much slower pace. As a result, the translator has the opportunity to step back and take the time needed to decrease the chances of error. However, this may not be applicable in a medical setting because information usually has to be processed as soon as possible.

Put your self in the patient’s shoes when thinking about medical translation and interpretation

Just imagine a regular visit to the doctor and being unable to explain what the issue is. Simply put, healthcare heavily relies on the patient’s subjective and objective description of what they are experiencing. Further, care and treatment depend on the fact that patients understand, trust, and listen to doctors’ instructions. In fact, non-native English speakers in the US often report that they are unsatisfied with the medical care they receive and they risk medical errors more than native speakers.

Unfortunately, the vast majority of healthcare organizations do not provide sufficient interpreting services. Usually, people who help non-native speakers are found “randomly.” They are family members or friends who speak both languages, not trained interpreters.

There are many problems with involving family members in interpretation including violating the patient’s privacy, failure to fully translate what the patient said because of embarrassment on the part of the patient or the family member. Sometimes there is a failure to fully understand the question or the answer.

Unfortunately, in many healthcare settings, patients have to rely on family members or secure healthcare interpreting services on their own. Sometimes the healthcare organization will help find the interpreter but the patient will be charged for the extra expense. Sometimes, the patient has to find a language professional on their own and pay out of pocket.

Telephonic services for medical interpretation

Another increasingly used language service is hiring telephone interpreters in a medical setting. In recent years, many big translation and interpreting companies have started expanding their offer portfolio to cover this service as well.

If you’re considering hiring a telephone interpreter in a healthcare setting, make sure they are certified medical interpreters. The issue with tele-interpreters is that many people and organizations around the world offer this service with varying quality. Unfortunately, it may be hard to differentiate between expert interpreters and amateurs.

If you’re sure you have access and cooperation set up with a certified medical telephone interpreter, that’s a good solution. If you’re not sure, it’s better to opt for some other interpreting options.

The price of medical interpretation and translation

The greatest issue with language interpretation in healthcare is that organizations don’t contract with regular interpreters because of the financial burden these services may impose.

Among all translation niches and fields, medical is one of the most expensive ones. Also, simultaneous interpretation is notably more expensive than a written translation.

Affordable services that can help you with medical translations are widely available. You can search the internet for medical interpretation and translation services to see what kinds of prices are being charged.

You will find that the pricing may differ wildly from one organization to the next. For example, some healthcare clinics offer free interpreting services for patients who don’t speak the language. Others will charge it as an additional service along with your medical bill.

Remember, the benefits far outweigh the costs when you decide to hire a professional medical interpreter compared to a non-trained professional.

How to carry out professional and accurate language interpreting in healthcare?

If you’re a healthcare professional who is communicating with a non-native speaker for the first time, a patient who doesn’t speak a foreign language or an intermediary, here are some of the basic tips to keep in mind during the interpreting process:

  • Introduction

It sounds obvious, but it would surprise you how many times people forget about this. Present all the people who are taking part in the conversation: patient, patient’s partner, parents, and so forth.

  • Speak slowly

Keep in mind that someone will be translating everything you say. Slow down the tempo and speak clearly. This is especially important if you are a naturally fast speaker.

  • Speak to each other

When an interpreter is present, many people feel like they should speak to them instead of the doctor/patient. You should talk directly to the doctor/patient instead.

  • Take breaks more often

Don’t combine dozens of sentences and questions and wait for the interpreter to make sense of all that. Take frequent breaks from speaking to give the interpreter enough time to present what you just said.

  • Set aside more time

When you have an appointment with an interpreter, it will last at least twice as much as a “regular” appointment. Make sure you take that into consideration when you schedule these types of appointments.

For many people, this is a new situation that takes some getting used to. Namely, a visit to the doctor is, for most people, a private and intimate process. It involves communication about your personal issues with a person you trust.

When an interpreter enters this equation, the social dynamics of the doctor-patient conversation can become a little awkward. Nevertheless, it’s a prerequisite for good understanding and to ensure that a patient receives proper care.

Related Content:  
Listen to Your Patients – They’re Telling You the Diagnosis!
5 Things Not to Do When Delivering Bad News to Patients

Conclusion

Medical interpretation is sensitive. It is best when it is carried out by professionals. If a healthcare organization doesn’t have its own interpreter (which it probably doesn’t), you can hire someone to help you. Make sure you hire someone with experience in healthcare particularly because mistakes really can be costly.

Avoid getting interpreting services from amateurs and non-trained persons if at all possible. As you probably know, even the tiniest bit of information that’s exchanged in doctor-patient communication is important. Omitting something or adding a fact that’s not there can seriously harm care and treatment. To avoid this, I recommend you work with professionals.

A winding road along the estuary, embellished with a touch of fall, brought me back home after a grueling night on call. Leaves that were strewn all over the path ruffled as I turned into the gate of my abode. It was time for me to wake. And, I was pondering on the indomitable spirit of my dying patient.

Andy was a stalwart with a great work ethic

Andy was a jovial countryman from the west coast of Ireland. Having grown up in a Catholic stronghold, he was a stalwart of a great work ethic. Always dressed in his tweed coat and paddy hat.

He was a bachelor all his life and a true ascetic to the core. He would stay up all night to nurse a sick calf. Or he might go for hours without food just to help the sheep get enough grazing on a rare sunny day in the summer. (Ireland is very well known to have four seasons packed in one day.)

His convivial yet subdued, nature made him a sought-after figure in his local community. People flocked to the neighborhood pub just to have a stout with their favorite farmer.

He did not care much for maintaining his popularity. He was the first in town to welcome refugees from war-ravaged states even when the vast majority of people opposed their arrival and settlement.

For months, he provided food and minded their infants. His relentless acts of kindness made the whole town reflect and eventually, embrace the refugees and care for them like their own.

And, then Andy became a patient

On a mild summer morning, I had just started seeing patients on a bustling medicine ward. It was a chaotic confluence of multiple healthcare professionals. There were physical therapists, occupational therapists, speech pathologists, dialysis technicians, along with nurses and doctors.

The junior doctor staff having just started the academic year were scrambling to gather patient information. While nearly spilling my morning coffee, I was paged by a family practitioner who wanted to discuss a patient.

He said he had a seventy-three-year-old who had never been to a doctor. This is common in many parts of rural Ireland. Andy presented with increasing shortness of breath that was precluding his day-to-day farming chores.

He was not upfront about the duration of his symptoms and kept underplaying them. He was only at the doctor’s office on the insistence of his friend who happened to notice his discomfort even with menial tasks. His lab results revealed severe renal dysfunction.

Meeting Andy for the first time

I finished my clinic visit with Ms. McCurdy, a lady in her late sixties of German-Irish descent. We had had a long discussion where she was vehemently complaining that her son refused to come back from Australia.

As I escorted her to the front desk, I spotted Andy standing in the corner of the waiting room, with his perpetual smile. As he scuttled towards me into the consultation room, I could see he was perceptibly short of breath. But also that he was trying his best to avoid displaying it.

Related content: My First Patient, My First Death

We fell into a conversation about his village. It was an upcoming tourist destination given multiple movies had been shot there in the recent past.

He was abreast of all the current news despite not owning a computer or smartphone. “You cannot replace the paper, them gimmicks are making us dumb,” said the insightful countryman. I could see firsthand why he was such a beloved figure.

Diving deeper into Andy’s medical problems

I decided to delve into the matter of the hour.  And I was perplexed since we could not elicit any causes to explain the renal failure. Given his fluid overload, I wanted to admit him to the hospital to administer diuretics.

However, in no way could I convince him to stay. The diligent farmer had to return to his farm and go to festivities organized by a refugee family. He promised to take the medications I would prescribe and to attend urgent radiological tests.

A couple of days later, as I finishing seeing one of the last patients on a ward round, Andy’s kidney ultrasound report arrived. It showed evidence of polycystic kidney disease.

I called him to discuss the results and to see how he was doing. He said in the quintessential country brogue- “Grand doctor! How are ya? You must come down to the village for a pint.”

Andy understood the seriousness of his disease 

Further conversation revealed that he now remembered that as a child he was told that both, his father and aunt, had succumbed to a ‘kidney problem’.  This information gave further evidence to the fact the familial disease is what afflicted him.

Over the next few weeks, Andy came to our clinic every fortnight. He demonstrated an understanding of the disease that confronted him. Further, he understood that dialysis was an eventuality and that his age would be a limiting factor for transplantation.

He knew that having to undergo dialysis would interfere with all of the activities that he valued the most. These included his farm, his community, and above all, the work for the refugees.

His stoic resolve married with his disarming personality left me, and others, in awe of the man. There was not an ounce of despair that he displayed. Instead, he imbued a sense of hope into patients of similar disease severity as he waited in the room with them.

It had come to a point that other patients would come asking if he was at the same clinic as them, instead of asking if their doctor was in or on time.

The disease was unrelenting

The disease was now, however, unrelenting. He was gradually starting to lose weight and exhibit signs of malnourishment. He developed temporal wasting with hardening of skin texture, and above all, his eyes were beginning to lose that radiance that formed a large part of his magnetism.

Andy was still toiling away looking after the cattle and being at the forefront of his altruistic endeavors. But it was perceptible that all this was wearing him down like never before.

I invoked the conversation regarding dialysis again. I explained that it may help alleviate his symptoms. But I could sense that he had made up his mind. He would not indulge in anything that would impede his autonomy.

Dialysis would mean the end of what he valued most in life

He was clear that going on dialysis would mean the end of all his work that he valued the most. Forgoing dialysis meant that he would only have a few months left.

It seemed that this was a fact that he had already absorbed. He was determined to dedicate the rest of his time doing what he enjoyed the most.

Nausea with vomiting was unresponsive to the strongest anti-emetics. And, it had now started to consume him. It was combined with intermittent distress in breathing.

He still did not display any sign of despondency. Having being cognizant of the paucity of time he had left, he had already made provisions for his childhood friend Ian, another astute cattle farmer, to assume care of his farm. Having amassed significant savings, he set up a trust that would look after the refugees and the homeless that he had been tirelessly tending to.

In a phlegmatic manner, he remarked, “It is better than I expected. I have an idea of when the time is going to come and I know that I am not going to suffer.” 

I could sense the clinic nurse had become a devotee of the Andy clan and was holding back a tear. So was I.

The final stretch – the indomitable spirit of my dying patient

Andy finally got admitted to the hospital due to his unremitting respiratory distress. A few shots of diuretics brought mild relief and his smiling disposition returned. The antecedent grave moments dissipated into space, temporarily.

Related content: Is it Better to Plan for End-of-Life? Or Strategic Aging?

I could sense that he had prepared himself for the final stretch. His discomfort with respiration was in resurgence. Once, when he pursed his lips to catch his breath, he voiced, ending with his classic humor:

“There’s a lot more pain to come if I let this go on. I don’t want those who seek strength from me to see me suffer. It’s alright, it’s time you go on and look after them younger folks,”

The morphine pump, to help abate his symptoms, was switched on. Nature would now take over. Devoid of any distress, Andy passed away two days later.

Our patients end up redeeming us

Andy turned around many lives. I was one of them. It is our patients who end up redeeming us.

In medicine, we often worry about a research grant not being approved or an academic position not attained. We bristle at its stifling bureaucracy.

These things often make us forget that the real prize is attending to those that made us go into the profession in the first place. We can be consumed by the impertinent. But, it is patients like Andy who end up being a beacon when these winds take us off course.

There is inspiration waiting to be derived from experiences that meander into our path. This happens even if all too often we fail to notice.

Selfless beings who exemplify the act of giving without any incentive and show the community that embracing the ones in need ends up making us indomitable.

Related Content:
Reflections on Death with Dignity
Early Experiences with Death Informed a Physicians Choices about Life

Andy’s funeral was in the church where he was baptized

The church where Andy was baptized, a baroque basilica set against a lush landscape, was also the venue of the funeral. Light pierced the multi-colored clerestory rendering a kaleidoscopic effect. Ian stood at the altar and recited Andy’s favorite poet, Dylan Thomas:

“Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light”


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First published, 4/20/2018, it has been reviewed and updated for republication on 4/30/2020.

A while back, I was seeing a patient in my primary care office. A few minutes into the visit, I needed to look up a laboratory test result on the computer in order to share the results with her. Because the tests were done outside of our health care system, the search took longer. Then an error message popped up on the screen alerting me to a potential drug interaction. I had to handle it before I could proceed.

Eventually, I found the results and started to tell the patient, still looking at the screen. When she didn’t respond, I looked over to see that her chair was empty. She probably told me that she needed to go to the bathroom. Maybe I just didn’t hear her.

My attention was so focused on the screen that I didn’t see her leave even though she was sitting right next to me. I was talking as she walked back into the room. Realizing what happened, I was embarrassed. It made me wonder what I’d do if I were a patient, seeing that the doctor was looking at the screen and wasn’t really there. I wondered what I would do if my doctor was distracted.

Cognitive load

Modern life places extraordinary demands on the brain. Electronic media have only made the challenges more daunting.

Cognitive load refers to how hard your inner operating system—your “working memory”—is working. If you’re doing a simple task, it’s not working very hard. If you’re doing a task that requires intense focus, it’s working harder.

If you’re trying to do two complex tasks at the same time, you become cognitively overloaded. You may ignore important details and make mistakes.

It’s safe to assume that your doctor’s cognitive load is always high and her working memory is stretched. Cumbersome electronic medical records and endless documentation requirements have added to physicians’ cognitive load. Many struggle to get back on track. They might try to simplify, and, in doing so, they miss potentially important nuances that can make all the difference.

Multitasking

Like everyone, doctors try to compensate for lack of time by multitasking.

But humans are not capable of multitasking. We switch between tasks, first one, then the other. Especially if the tasks are unrelated such as checking a patient’s medical record while trying to conduct a conversation. It is then that task switching doesn’t go smoothly.

We don’t hear what was said, information gets lost, and we forget. Psychologists call it “interruption recovery failure.” It’s at those moments when we realize that the urban myth that we only use 10% of our brains cannot possibly be true. It seems like we absolutely need every neuron that we have.

So, what should you do when your doctor is distracted?

What should you do when you notice your doctor is trying to multitask or is not really listening? First, recognize that it’s not her fault, rather it’s the nature of the practice of medicine today.

Then, make it easier for your doctor to listen. Use short sentences. Don’t repeat yourself unless she hasn’t understood. Most importantly, help the doctor focus on what’s most important. Prioritize your concerns and be willing to defer the less important ones to another visit.

Sometimes, it’s best to wait a minute until you see that the doctor completes a task before introducing another. While she’s refilling your blood pressure medicine is not the time to talk about your chest pain or your depression. Instead, wait until she can make eye contact and is not distracted by a task that might be essential to your care.

Attention-grabbers

Some words, images, and sounds capture our attention more than others. Many of these mental “circuit breakers” are innate, such as loud noises, bared teeth, and red blood.

Other attention-grabbers are learned. Doctors pay more attention to words that suggest a serious condition (chest pressure, high fever) than words that suggest less serious conditions (an itch, a runny nose), appropriately so.

Unfortunately, though, doctors, through their training, learn to ignore things that they shouldn’t, such as emotional expressions. If a patient expresses a fear or a worry, there’s only a 10% chance that the doctor will respond.

Symptom prioritization

Doctors also prioritize specific, localized symptoms over non-specific, global symptoms (“It hurts all over”). In short, doctors learn to favor the biological, the physical, the specific, and the concrete.

So, if you’re a patient, how can you help your doctor know that you’re worried? That you do hurt all over? Here, clarity and gentle persistence pay off.

Emphasize that your concern is important. Be specific when you can. If your concern is emotional, nonspecific, or vague, preface your statement with “I wish I could be more specific, but it’s distressing and concerning to me and I’d like to understand what’s going on.” It may be possible that there is little that can be done, but at least you’ll be more likely to get a clear answer.

Related content:
Listen to Your Patients. They’re Telling You the Diagnosis

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Daydreaming

Everyone daydreams. In fact, there’s a whole body of research on the merits and perils of daydreaming.

Daydreaming is a manifestation of the brain’s “default mode” in which we aren’t focused on anything in particular and the brain is scanning its internal landscape and the outer landscape for dangers, opportunities, and affiliations.

As a patient, though, the default mode doesn’t do you much good. It has little to do with information coming from the outside world.

Sometimes, we can tell when someone else is daydreaming. Perhaps they have a far-off look. That’s where refocusing comes in.

If your question or concern hasn’t been addressed fully and the other person seems like he is elsewhere, gentle redirection is helpful. You might say to your doctor, “I’m not sure I understood what you’re planning to do about my elbow.” Or try saying something else, short, specific, and respectful that helps the doctor get back on track.

Of course, as a patient, it’s not your “job” to help the doctor think. However, in reality, we all help each other think, all the time. It is part of being social beings. It’s what I call “shared mind.”

Collective distraction.

When everybody’s distracted, no one is listening. You might think that would result in a continual disaster in medicine. Fortunately, not.

Health professionals speak a common language. We have shared mental models for managing straightforward illnesses. We compensate for the lack of communication by invoking protocols.

This approach works for simple, routine, and predictable problems. But it can all fall apart when dealing with more complex situations. With the vast amounts of information available in the electronic health record, doctors frequently suffer under the illusion that there has been communication when, in fact, it has not really occurred.

Open notes and patient advocates

It’s like drinking out of a firehose; the important messages often impossible to find. One solution might be “open notes,” doctors’ notes in the medical record that patients can see and review. Even then, sorting through your own medical records works only if you’re not critically ill and if you’re medically literate.

When you’re sick, your attention should be on your illness and not the doctor’s mental state. Here, three minds are better than two. Bring a family member or a friend along who can advocate for you. Pick someone who can be at your bedside when you’re at your most vulnerable.

Case managers, guides, coaches, and navigators (if they’re available) can also help everyone focus on what’s most important.

Minding your own mind

There are many more ways in which distraction plays out in healthcare and other endeavors in which small errors can spell large consequences.

As a patient, you should be mindful, too. Being mindful of your own mind. Pay attention to your own state of attention or distraction, your cognitive load and your emotions. This will help you be mindful of others’ minds, too.

I believe that mindfulness is contagious. The more you can be aware of attention-grabbers, cognitive load, daydreaming, and collective distraction in your own life, no matter what you do, the more focused you can be when you’re in the doctor’s office. This awareness is also the key to good relationships and to knowing yourself better in general.

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First published 4/23/17, this post has been reviewed and updated for republication.

Fumbling the delivery when delivering bad news to a patient about a new cancer diagnosis or another illness with a particularly poor prognosis can lead to lasting negative effects on the patient and their families. This can irreversibly damage the doctor-patient relationship.

There is a great need in our health care community for educated and insightful communication. Physicians have a duty to be honest with their patients while making them feel safe and reassured.

A cancer diagnosis, unsuccessful procedure or an unwanted test result causes fear and confusion in the patients we’ve sworn to protect. The reality is that some physicians are ill-equipped to handle what comes next.

Here are 5 tips on what NOT to do when delivering bad news to patients:

1. Don’t assume you have the training

Delivering a medical diagnosis in clinical terms and explaining how that will impact the rest of a patient’s life are two different methods of communication. While 91% of surgeons believe delivering bad news is an essential skill as a physician, only 40% felt they had received appropriate and effective training to deliver it.

Although compassion and empathy are innate qualities, specific education and training can sharpen and improve these physician attributes. Traditional medical education does not necessarily address these issues formally.

Many studies have found a wide divergence in curricula that teaches physicians effective behaviors and communication strategies. In some trials, a brief intervention was all that was required to improve physician empathy as rated by patients.

      • Teaching compassion in medical school

Many courses on compassion and caring are new to medical schools. In the past, physicians had considered kindness and understanding a given. No professional training was provided on the topic. Admittance into medical school was enough of a test to gauge communication skills.

As a thoracic surgeon who has practiced for more than 14 years, I’ve been fortunate to guide patients through life-changing decisions every day. Yet, there is always something I can learn from every new encounter.

The skills of kind, compassionate yet effective communication isn’t written between the lines of diagnostic textbooks. Luckily, more medical schools are realizing the importance of healthy patient interaction.

      • Delivering bad news

Regardless of what we have been taught as health care providers for communicating with patients, it’s easy for each delivery of bad news to feel like the first time.

Luckily, there are more resources than before to help patients through one of the most difficult days in their lives. From online emotional training to virtual reality, there are many opportunities to broaden your communication skills and provide the best support you can for your patients. Here are some tips:

2. Don’t forgo building a relationship

Sometimes you might be tasked with delivering bad news to a patient or a family member you’ve only met minutes prior. However, there is no substitute for building a foundation of trust.

This is true even if provided with only a short amount of time to do so. Simply electing to ignore that requirement could cause lasting harm. Figure out what your patient is looking for in their provider and show them you can be that for them every step of the way.

      • Trust

Bonding with a stranger is something we have to do with every new patient. How do you ask someone you’ve never met to trust you with their life? First impressions matter. Take these things into consideration:

            • how you dress
            • how you speak
            • what your body language is saying
            • how you move about the room
            • how your staff interacts with you

Trust is hard-fought and well earned. It is the foundation of a healthy doctor-patient relationship.

      • Learn about your patient

You’ll want to know the patient as much as you can beforehand:

          • Review their chart, medical record, and scans BEFORE you enter the room.
          • Memorize all of the pertinent facts.
          • Do NOT type on your computer or ruffle through papers in front of them.
      • Make the patient feel special

Even if you have a very busy clinic, make every patient feel that they are your only patient that day. They are your No. 1 priority.

Schedule a longer appointment to allow ample time for discussion. By providing a generous appointment window, you give yourself time to learn your patient’s preferred method of communication and a good deal of their personality.

      • Engage with the family

Introduce yourself to the patient and everyone in the room. Take a moment to learn their names and relationships.

Initially, avoid using humor or touch to establish a relationship with patients or family members with whom you’re not yet familiar. You may do so as the encounter progresses based on cues you observe from the patient and their family.

      • Family support

Provide a safe space for the patient to tell you which family members they would like in the room. Ask the patient how they would prefer that others be involved in their care and any discussions about their health.

Making sure a patient has familial support (whether in person or via telephone in certain circumstances) when receiving bad news is important, The patient should have the space they need to process the news alongside loved ones who will provide the most support.

However, avoid undue stress from too many reactions, hysteria and negative emotions in the room. Be a pillar of strength as everyone in the room will look to you for leadership and guidance. Be in control while allowing enough latitude for the patient and family to express their emotions.

      • Family dynamics and cultural considerations

If the patient is someone who has been in your care for a long time, consider their personality and family dynamics, and identify coping mechanisms they may have used in the past. Being sensitive to a patient’s cultural and religious background or specific fears can go a long way in earning their trust.

Related Content:
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3. Don’t Muddle the Message

Many providers are used to delivering mundane clinical information in a matter-of-fact way. You may find it acceptable in many visits to list off laboratory results and CT scan terminology only to end with “your lungs look good.” This usually elicits a sigh of relief from the patient. However, the delivery of bad news must be framed differently and not allow room for misinterpretation.

      • Deliver the message clearly and directly

          • Use every day conversational language you know the patient will understand
          • Tailor your vocabulary and terminology to your patient’s social context and education level.
          • When using medical terminology, pause frequently and provide an unrushed explanation before moving on.
          • Drawings or images of CT scans can help them understand as “images are worth a thousand words.” Remember that patients often forget the words you said but they will remember an image you showed them.

The patient is about to face a million difficult decisions and a million more worries and fears about their personal life. At the moment you are delivering the news, most patients do not want to know the science or medical vocabulary to describe their illness.

      • Identify how much a patient wants to know.

Each patient must know the truth and how it will affect their future but gauge the level of detail the patient is willing to discuss. Some patients prefer that their physician discuss all of the scientific details.

They want to know the precise statistics about their chances of cure. They want to learn about possible complications and side effects of treatments. And, they want to know what science says about the rate of survival.

Others prefer no details but simply to hear that their physician will take care of them as if they were his/her own family member.

      • Give the patient time to react

Some physicians become nervous when delivering bad news. This leads them to continue speaking after the initial pronouncement. It is a way to avoid a long period of silence which makes them uncomfortable.

It’s likely your patient is not absorbing much after that first shock. So instead of talking, be silent, wait for a reaction and provide frequent pauses. Keep eye contact, slowly approach the patient, observe them and react to their verbal and non-verbal cues.

      • Don’t ask “do you have any questions?”

Don’t ask “do you have any questions” and expect an immediate response. The patient may not have enough time to form their thoughts. Instead, ask “what questions do you have?” That will prompt your patient to search for their biggest concern and phrase it as a question.

Giving the patient time to breathe and letting their first concerns rise will help you target the most important topics your patient wants to discuss.

Related Content: 
4 Ways You Can Improve Patient Engagement
Non-Technical Skills for Surgeons Can Be Life Savers

4. Don’t sympathize, empathize

Sympathy is easily confused with empathy but often is less useful and potentially harmful. While sympathy expresses feelings of pity or sorrow, empathy portrays the ability to understand and relate to someone else.

Remarks such as “I know how you must feel,” or “I had a family member with the same issue” only makes the discussion about yourself. Providing empathy requires understanding what the patient is processing and reacting accordingly.

      • Effective tactics for empathetic communication include the following: 

          • Sitting versus standing during patient interaction in order to be at the same eye level
          • Detecting patients’ nonverbal displays of emotion
          • Recognizing cues from the patient and responding to opportunities for physical contact (hand on the shoulder, knee or an embrace)
          • Nonverbal communication such as eye contact and body language
          • Verbal reinforcement of acknowledgment and support
      • Reassure the patient that they are in good hands

Anticipate how the patient will want to process the news and what it will take for them to feel safer, more reassured and in good hands.  It’s fine to say “I’m sorry” but follow with an observation of what they might be feeling. For example, “This must come as a shock but let’s talk through how we are going to treat this.”

      • Be self-aware in your responses

Ask yourself if it is something you would want to hear in their situation. By offering hope with realistic interventions can begin to shift the conversation toward treatment. If a cure is not realistic, be upfront about that fact but offer encouragement about the treatment options and supportive care.

5. Don’t be afraid

The first time you deliver bad news to a patient and don’t get the reaction you were expecting is eye-opening. In fact, every encounter is an opportunity for improvement and fine-tuning.

Compassionate physicians may be afraid of showing too much emotion during the visit. Instead, they become overly clinical and direct when a family expects a certain level of compassion.

Conversely, a physician who overcompensates by becoming too emotional can lose the trust of the patient or family, seeming weak, inexperienced or not in control. This will diminish their sense of hope and sense of being in good hands.  

      • Your patients will expect a certain level of confidence and strength

They will lean on you for support. Rather than focusing on how the patient will react, have confidence in yourself to identify what they will need when they do react. Do not undervalue your experience but take note of where you can improve.

The bottom line when it comes to delivering bad news

Health care communication is a complex and evolving field. Every doctor-patient relationship is different, and it takes a trained eye and an open heart to successfully navigate each one.

Related content: Listen to Your Patients: They Are Telling You the Diagnosis

Implement methods of empathy and nonverbal communication in your practice. Be a keen observer and pick up cues from your patient and family members. Become familiar with different personalities and identify how they cope with various problems.

It’s never easy to completely upend someone’s life with a piece of bad news. It is especially difficult when you are dealing with someone you may have met only moments prior.

It takes guidance and experience to make that person feel like they are in good hands. With the right amount of confidence, empathy, and hope, you may find remarkable gratification in providing unwavering support when your patient needs you the most.

Listen to your patient; he is telling you the diagnosis.

This was what the great physician William Osler taught his students in the late 19th century. His words are still true today. In Osler’s time, most of what physicians dealt with were new or acute conditions. Because of that, determining the diagnosis was paramount.

Today, although we* still struggle with diagnosis and management of acute conditions, we also must deal with a plethora of chronic conditions that require longitudinal care. Because of this, more than ever, we must appreciate the key role the patient and their caregiver plays in their healthcare.

We have wonderful medical training. We are also surrounded by amazing technologies and brilliant specialists that we can summon at the click of a mouse. However, doctors and other health professionals must understand that we specialize in and are knowledgeable about medicine. But the patient is a specialist in and has special knowledge about him or herself.

For this reason, we should view the patient as a partner in her own health and healthcare. Only the patient can provide that unique perspective.

The importance of listening to patients

First, we must gather information about the patient’s health complaint and the history of their current illness. This fact-gathering exercise is essential to diagnose the patient’s condition. 

However, it is essential that we take the time to listen to the patient rather than interrupt after only 12 seconds as studies have shown is typical of physician-patient encounters. We must have a dialog that includes thoughtful questions and reflection. By taking the time to do this properly, we can avoid much unnecessary testing and specialist referrals.

Beyond that, we must listen to the patients to learn details of their perspectives of their health problems and social situations. This includes assessing any barriers they have to health and healthcare.

Without this as a foundation, it is impossible to care for the person before us. Again quoting Osler,

“The good physician treats the disease; the great physician treats the patient with the disease.”

Related content:
The Blues Taught Me to Really Listen to My Patients
Pear Pressure: A Medical Student’s Introduction to Empathy 
5 Things Not to Do When Delivering Bad News to Patients

The patient and physician together should set the treatment goals

Once this is done, the patient and physician together, not the physician alone, should set the treatment goals. What outcomes are important to the patient? For example, the patient may wish to play ball with his grandson. Using his controller medications for his chronic lung disease may be our goal, but in this case, it may help him achieve his goal.

In these days of “quality measures”, it is tempting to use medicine’s metrics as a proxy for the patient’s. But patients are much more likely to participate in their care if they are working towards goals that are meaningful to them.

Along those lines, unless the patient is unconscious (or in restraints), no treatment plan can be successful without the patient’s participation. For example, only about half of patients take their prescribed medications.

ADD_THIS_TEXT
 

Studies have shown that patients are much more likely to participate in a care plan if they are involved in developing the care plan and the rationale explained. Involving patients in their care planning and setting health goals involve shared decision-making and require that patients have adequate information to participate in this process.

The patient is an underutilized healthcare resource

In 1976, Warner Slack at Harvard Medical School wrote that

[T]he largest and least utilized healthcare resource is the patient him/herself.” 

Dr. Slack had spent nearly a decade studying computer-mediated patient interviewing. He concluded that patients, as the primary source of their own health information, should be encouraged to provide that information directly to improve care.

In his day, extant technology only permitted those interactions to take place in the physician’s office. Today, however, we have digital health technologies that can acquire data directly from patients in an ongoing way wherever they may be.

By doing this, we can monitor patients’ symptoms, health status, biometric data (such as weight, blood pressure measurement, and blood glucose), and progress against their care plans as often as necessary. This can improve outcomes at a low cost and expand health system capacity to manage more patients.

Patients and caregivers are valuable sources of feedback

Finally, patients and caregivers are valuable sources of feedback. Ideally, we should encourage feedback after every encounter with clinical care. We should learn from the feedback while recognizing that patient satisfaction is only one of many measures of high-quality care.

For example, a patient who was given antibiotics on demand for a viral respiratory infection may be highly satisfied but has received low-quality care. Incorporating patients and families feedback in aggregate through a patient-family advisory committee is also an important way for physicians to hear the patient’s voice.

The figure lists types of information gathering activities in relation to traditional clinical appointments.

Types of Information Gathering for Office Visits

Figure 1: Types of information gathering in relation to office visits

Engaged patients are the best partners in their care

Engaged patients are the best partners in their care. This requires us to provide them the data they need to be active participants, including access to their care plans as well as the rest of their medical record.

But we must also provide tools that encourage engagement, including:

  • Using a variety of communication modalities (such as e-messaging and video chat)
  • Providing easy ways to schedule appointments
  • Make it easy for them to request prescription renewals.

By reducing friction in care delivery patients will be more likely to engage in their healthcare. This should lead to the following:

  • improvements in clinical outcomes
  • reduction in cost 
  • improved patient and clinician experience

Call to action: Listen to your patients

Osler’s 19th-century admonitions have enduring relevance even today. But I propose we extend Osler’s maxim to reflect the realities of modern healthcare:

“Engage the patient; she is not only telling you the diagnosis but is integral to all aspects of her health and healthcare.”


[*] I have written this in the first person plural from the perspective of a physician, but it equally applies to other clinicians.

[†] In the remainder of this paper, I have omitted mention of the caregiver, but that should be assumed.

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This post was first published on April 3, 2017, as a part of our partnership with Health Rosetta Principles. It has been reviewed and updated for republication.

Time constraints make it difficult for the average physician to think about their patients holistically. After all, they often see a different patient every 20 minutes.

Within this tight timeframe, the physician must consider and provide recommendations that account for the unique needs of the patient. That includes their health history and circumstances in their life that may impact their health.

On top of that, during each appointment, physicians are responsible not only for delivering high-quality care but also for fostering a relationship with each and every patient. This can be difficult given the heavy workloads most physicians already bear.

However, taking the time to form a relationship with each patient is absolutely critical to patients’ health and wellbeing. This is especially true for women, who face systemic and disproportionate barriers to accessing quality healthcare.

Medical training teaches us that every patient is different. However, we are not necessarily taught how to account for these differences. Nor do we learn how to address the challenges some face when trying to access costly treatments or medicines.

Policy, regulatory or managed care limitations are often out of our control, such as insurance not covering the birth control option the patient wants. Changes to federal funding could make this even worse, directly impacting a physician’s ability to offer the best options to women with lower incomes.

The “red tape” and politics related to these issues can drive physicians to avoid discussing them with patients. However, physicians cannot ignore these very real barriers many women face.

A holistic approach is critical in women’s health

Treating the whole patient is especially critical in women’s health where many physicians find themselves inadvertently providing “one-stop-shop” care. While women ideally would go to a variety of physicians to take care of all their concerns, the reality is that many turn to one physician for most of their needs.

This doesn’t mean that physicians should work outside of their primary specialty. But they should be prepared to listen to all concerns presented by patients and consider a holistic approach for their care. No matter the physician specialty, this can include asking about sexual/reproductive health, mental and physical health.

Physicians can use this information to refer a patient to the proper specialists and to provide her with relevant information and resources. It also gives the physician a better idea of the patient as a whole, which makes it easier to provide medical advice and treatment tailored uniquely to her.

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Overcoming the stigma related to talking about reproductive health

When it comes to discussing reproductive health, specifically, we must be mindful of the lifetime of the stigma some women have faced when talking about their reproductive health and sexual history. It is not uncommon for women to hide certain symptoms of reproductive health problems. For example, they may be uncomfortable discussing their sexual health and menstrual cycles.

Women may also be afraid to raise concerns with their physician for fear of asking a “dumb question.” This fear can prevent women from having quality conversations with their doctors. It can also lead many to leave the physician’s office with unasked questions and a lack of information about the best treatment options for them.

Physicians can play a pivotal role in overcoming this issue by educating and empowering their patients. First, we can give patients the opportunity to ask about these topics. We can open safe dialogs about their experiences with the following topics:

  • menstrual cycles,
  • contraceptives,
  • sexual health,
  • mental health
  • domestic violence
  • and, other topics that the patient’s wellbeing.

By prompting our patients and asking in-depth questions, we can kickstart a good conversation that empowers the woman to speak openly about her health needs.

Women need to understand their options

We also need to ensure that patients are aware of all their options. You would be surprised at how few women I speak with (or even doctors) know that there are 18 FDA-approved birth control methods. The best available treatments for that individual patient may not be considered if a woman or her physician are not educated on the options.

Related Content: Getting Your Doctor to Really See You  

Far too often, I hear horror stories about women who had issues with their contraception. Too often, these negative experiences cause women to stop using contraception altogether. Only later do they learn that there was a better option that was more suited for them.

I have also met countless women who were prescribed a contraceptive that was unaffordable because they didn’t have insurance for whatever reason. Both cost and insurance play a huge role in a woman’s ability to obtain medicines. We must keep this in mind in the examination room when discussing recommendations with patients.

Physicians need to understand the woman’s experience more broadly

While women are all too familiar with the obstacles they face, their physicians may not be. It can be easy for us to not look at the broader picture when we are speaking with our patients. Instead, we should be looking closely and reading between the lines.

We should ask ourselves the following questions:

  • Does she sound like she is afraid to share her sexual history?
  • Does she allude to a lack of open conversations about birth control with her family or friends?

Physicians can take this opportunity to put themselves in the patient’s shoes and see it from their perspective. We can try to understand why they are scared. And what we can do to make them feel more comfortable.

Physicians’ role in women’s lives

Physicians can play a powerful role in combating the systemic challenges women face in accessing healthcare. Once physicians become more aware of the different issues faced by patients, we can then arm them with the right information.

Simply asking a question that a patient is afraid to bring up herself can make a huge impact. It can spark a conversation. When we create an open and honest dialogue with our patients, we empower them to ask more questions and educate themselves.

Patients who are informed can achieve better health outcomes, including those that are related to reproductive health.

Understanding nuances such as stigma, affordability and other challenges women face in accessing healthcare enables physicians to provide better, more personalized care.

We may not be able to solve every problem, but we can push ourselves to understand the whole patient and guide them toward the best treatment options.

Only with a concerted effort can we make the exam room a safe, educational and empowering space that allows every woman to have more productive and personal conversations about her health.

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This post was first published on August 26, 2019. It was reviewed and updated on March 10, 2020.

After 40 years as a practicing physician, I have concluded that the burden of treating chronic diseases has grown so enormous that more pills and procedures will never be enough to cure the ills of my patients. Over those years, I also came to realize that we as physicians are failing to take sufficient advantage of one of our most powerful available tools: the ability of our patients to practice self-care.

Consider the most recent data from the Centers for Disease Control and Prevention.

  • Six of every ten adults in America suffer from a chronic illness.
  • Four out of ten have two or more chronic conditions

Clearly, we can never expect to stem this rising tide of disease unless we can design medical practices to promote serious behavior change. We also need to cultivate, as never before, the power of patients to take care of themselves.

Determinants of health

We have long known that some 80 percent of health is determined by factors outside of the doctor’s office. These behaviors include activities such as,

  • not smoking
  • moderating alcohol use
  • consuming healthy food
  • engaging in regular exercise
  • managing stress

These are all vital components of chronic disease self-management. Improving these behaviors empowers patients to become responsible stewards of their own health and yields tangible improvement in outcomes. 

Robust evidence from numerous disciplines confirms that practices such as therapeutic yoga, massage, mind-body practices, nutritional counseling, journaling, and others can enrich patients’ physical, emotional, and spiritual functioning. Yet self-care remains the subject of numerous myths and misperceptions among patients.

I believe that physicians can play a crucial role in expanding their patients’ understanding and enabling them to make important lifestyle changes to significantly improve their health.

What a new survey tells us about chronic illness self-care

Earlier this year, Samueli Integrative Health Programs commissioned two nationwide surveys by the Harris Poll. These polls involved more than 1,000 patients as well as more than 300 family medicine and internal medicine physicians.

ADD_THIS_TEXT
 

The goal was to try to better understand how America’s doctors and their patients view and discuss self-care in their personal lives and in their conversations with each other. This is an important first step for thinking about systemic change.

Our surveys yielded new insights about a critical communications gap between doctors and their patients when it comes to taking the time and the initiative to engage in conversations about self-care that can improve health and even save lives. Among our key findings:

  • Seven in 10 physicians said they believe their patients would benefit from discussing self-care with them
  • Yet 75 percent of patients said they haven’t discussed any self-care with their doctors.
  • Almost half of physicians (46%) believe that their patients would not be interested in discussing it
  • But a strong majority of patients (72%) say they actually would like to have such discussions.
  • Most respondents (73% of consumers, 92% of physicians) consider adequate sleep to be a vital part of self-care
  • But only 40 percent of physicians discuss sleep habits with their patients during office visits.

Additional findings

Majorities of patients said they wish they could talk more to their doctors about non-medical factors that are important in their lives. They also want to discuss their life goals.

Our findings showed a sharp disconnect between patients who said they seek more help and physicians who may believe that they are already helping. For example:

  • 81 percent of physicians said they refer their patients to mental health professionals,
  • But only 18 percent of patients said they received such referrals
  • 78 percent of physicians said they refer patients to a dietician or nutritionist
  • Yet only 19% of patients report such referrals.

Patients and physicians are shying away from more self-care discussions for a variety of reasons.

Time and money are cited as the primary roadblocks:

  • 44 percent of consumers believe self-care is only possible for people with “enough” time
  • 35 percent believe it requires “enough” money
  • More than one in four (28%) also said they feel guilty about taking the time to indulge in self-care

Chronic Illness self-care misconceptions

There are some central misconceptions about self-care including the following:

  • Many patients see it as a costly indulgence, equating it with things like buying luxury skin-care products or treating themselves to a shopping spree.
  • During stressful times, people often treat themselves with unhealthy behaviors, like drinking alcohol or bingeing on a tub of ice cream.

But self-care is really about finding healthier ways to nourish your body, mind, and spirit.

Majorities of patients reported awareness of the importance of getting enough sleep (66%), eating healthy foods (62%), taking care of their mental health (60%), and exercising (59%).

Doctors can play an important role by emphasizing these behaviors and suggesting other simple options such as journaling, reading, meditating, going on a walk, chatting with a friend, or playing with a pet. These are all effective ways to decrease stress and increase well-being at little or no cost.

What about complementary and alternative medicine? 

It might surprise some physicians to learn that our poll found strong support for Complementary and Alternative Medicine (CAM) practices such as yoga, meditation, acupuncture, massage, chiropractic, biofeedback, and other options.

  • Sixty-one percent of consumers said they have seen or used CAM practitioners and techniques in the last two years
  • 69 percent said they wished their physicians offered these options in their practice.
  • People who use CAM reported that they typically spend $100 a month on these practices.

It’s interesting to note that doctors themselves appear to feel defeatist about their own self-care:

  • 81% of physicians say it’s very important personally for them to practice self-care
  • But only 57% report doing so often
  • More than three-quarters (78%) said they don’t have enough time for it themselves.
  • A majority of physicians (56%) said the demands of their job prevent them from practicing self-care
  • 20% said they don’t practice it because they struggle to change their own bad habits.
  • Nearly one-quarter of physicians cite burnout as preventing them from focusing on self-care.

The tangible benefits of engaging in chronic illness self-care conversations

In my own practice, I have seen the tangible benefits of engaging in personal, patient-centered conversations that extend beyond conventional medicine. I offer my patients an Integrative Health & Wellness Visit. And, I do what I call a HOPE Note.

This is an interview with patients that focuses on what matters to them in their life. We also discuss how they can improve their personal determinants of health.This interaction creates a collaborative approach that enables me and the patient to become true partners.

Self-care that includes addressing the physical, emotional, spiritual, and social realms has enabled my patients to maintain or improve their health and well-being. It also helps them prevent or cope with chronic illness. Promoting self-care becomes the cornerstone of integrative health and good medicine.

The bottom line

Our survey showed us that patients have a strong desire for their physicians to be involved in more aspects of their health beyond prescriptions, test results, and diagnoses. They want a fuller partnership and relationship where they can discuss their health and well-being in other, deeper ways that impact them. As physicians, it’s important that we listen to these desires and adjust how we are treating our patients.

Related content:

Reshaping Patient Engagement in a Multicultural World

Data-Driven Self-Care Will Transform Chronic Disease Management

Mr. Humphrey was a relatively healthy guy, but he always knew that he had a family history that put him at risk of developing pancreatitis. So when he developed persistent symptoms—abdominal pain, fever, and nausea, he finally visited his doctor. She diagnosed him with pancreatic inflammation and immediately referred him to the University of Alabama-Birmingham’s (UAB) Pancreatobiliary Disease Center.

There, he was seen not by a single specialist, but by a multidisciplinary team that included pathologists, surgical and radiation oncologists, and others—including me, an interventional radiologist. Mr. Humphrey was particularly fortunate to be able to receive advice, counsel and a treatment plan that benefited from a broad range of medical perspectives, providing him the highest quality of care and peace of mind. If we could offer care like this to all our patients, imagine what we could do for them.

Benefits of a multidisciplinary specialist team

Every patient is unique and often care cannot and should not depend on the individual skills of any single specialist. While many medical specialists have the expertise to treat these conditions, if a practitioner works alone, he or she is often working within a narrow professional silo.

That could blind them to holes in treatment, means of treating unaddressed symptoms, and alternative approaches that can actually be life-saving or life-restoring. Pancreatobiliary conditions are particularly complex and notoriously difficult to treat. They may seem innocuous at first, but without optimal management, they can be fatal.

The Pancreatobiliary Disease Center

Until 2018, our facility had a patchwork of working relationships among multiple specialties. However,  we knew there was room for meaningful improvement. That’s why we established our multidisciplinary model for collaborative, patient-centered care.

Our model brings together 13 specialty providers who meet every Wednesday morning. Instead of a haphazard system based on quick “hallway consults” among physicians, our team benefits from formal scheduled presentations of approximately a dozen cases each week. This enables us to have a healthy, holistic discussion of each patient’s needs. It also allows us to better coordinate each patient’s ongoing care.

In Mr. Humphrey’s case, this allowed specialists from surgery, interventional radiology, diagnostic radiology, and endoscopy to review his images and clinical history in detail. We were able to place his clinical course within our multi-disciplinary, algorithmic approach to pancreatitis and then tailor it to his specific needs.

Interventional radiology was able to provide an image-guided drainage of his infection. After hospital discharge, he was seen in the surgery clinic with notes about output and clinical symptoms sent to the interventional radiology clinic. This allowed for easy coordination of care when manipulation of the drain was required.

Managing as a multidisciplinary specialist team

Ultimately, as a team, we were able to manage this difficult illness in a relatively short period of time without invasive surgery.

Significantly, we have also developed cross-specialty protocols for various conditions, from cancers to cysts, to outline where every team member fits within the care plan. These established roles ensure we are all on the same page and the process itself builds trust and enhances the value of each specialty’s approach.

Related content: 3 Qualities of Successful Football Teams that Healthcare Really Needs

Having support from our hospital leadership has been critical to our success. Their backing has helped to nurture the model into a large-scale effort. The goals are to:

  • treat even more patients and
  • improve patient outcomes and
  • improve patient satisfaction.

But beyond these improvements, our team has been able to build capabilities and relationships among physicians to grow personally and professionally. We believe we are moving the field forward.

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Collaboration can scale

Our model is just one example of how collaboration on this scale can work wonders for patient care. But there are many medical facilities that have not had the motivation or capability to do so. I can speak from my personal experience that this goal can be accomplished with a few steps.

1. Acknowledge gaps

It starts with honestly acknowledging the gaps at your institution. Ask yourselves: What is missing in your procedures and outcomes that could benefit from this kind of collaboration? Where can specific improvements be made in patient care? And how do we do it?

2. Face-to-face communication

Hold open, face-to-face conversations with other specialists to begin forming partnerships, and most importantly, trust. Taking the time to meet with each other and show that you value others’ opinions will help to form a professional bond between providers. It also fosters a team mentality.

3. Get buy-in

Finally, when you’ve accomplished those goals, getting buy-in from top leadership and from the relevant players in key hospital services will build momentum for change. These relationships are key to making sure you have the resources and personnel to generate a meaningful transformation.

Related Content:  What Do Patients Think About Team-Based Care?

The bottom line

Above all, you will be able to create a new mindset among your colleagues: Instead of asking “What can I do for this patient?” we now ask “What is really best for this patient?”


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Case study: Failure to communicate

A 42-year-old patient arrived for her annual gynecologist appointment complaining of a self-detected breast lump. She had several questions about her condition and wanted to tell her doctor about a family history of breast cancer.

The doctor was in a hurry, therefore, he advised her to talk to the staff. However, the staff was busy with other patients. They told her to call them later. However, the patient did not call.

The gynecologist ordered a mammogram but did not include the patient’s complaint of the breast lump on the requisition. The mammogram was read as “normal” but the report noted a “very dense stromal pattern.” This reduces the sensitivity of the study for the detection of cancer.

The radiologist did not recommend an ultrasound and described the mammogram as “normal” in the report to the gynecologist. Therefore, a follow-up appointment was not scheduled.

Several months later, the patient scheduled another appointment with the gynecologist when she noticed the breast lump had increased in size. Subsequently, she was unfortunately diagnosed with breast cancer and scheduled for surgery.

Related content: The Anatomy of a Good Doctor

Missed opportunities to engage the patient

What were the missed opportunities to help engage this patient in her healthcare? If the doctor or his staff took a little more time, would the patient have asked her questions and provided additional information? This possibly could have resulted in an earlier diagnosis?

Cases like this reveal the importance of engaging patients as a strategy to prevent adverse outcomes. When patients do not feel involved in their care, they are less likely to follow through with treatment, keep the physician informed, and follow the treatment plan.

Patient engagement has emerged as a key component of reducing the likelihood of an adverse outcome.

Further, when patients are angry, they are more likely to sue. Similarly, patients are more apt to file a claim when they feel like they are not being heard or their questions are not being answered.

Patient engagement is a quality measure

Active patient engagement is a quality measure of the Institute for Healthcare Improvement’s Triple Aim Initiative, a framework targeted at optimizing health systems

“to improve care, improve population health, and reduce costs per capita.”

Opportunities to engage patients begins when they first contact your practice. And, it’s not just the physician who is responsible for fostering patient engagement. It is, in fact, a critical strategy that must be incorporated into all levels of your practice. That includes the receptionist answering the phone, the physician doing check-ups in the exam room, and everyone else in between.

At each level, the question that must be answered is “Does the patient feel his or her needs are being met?” For engagement to occur, everyone has to make the patient feel involved.

Through effectively promoting patient engagement, physicians and practice staff can enhance patient safety by reducing the likelihood of adverse outcomes. This also reduces the likelihood of a malpractice claim.

Related content: Re-shaping Patient Engagement in a Multicultural World

4 things you can do to improve patient engagement

To achieve engagement, physicians must be aware of the patient experience within their practices. Consider the following tips:

 1. Learn what your patients are experiencing

Doctors should conduct regular tests on their systems and processes to see what patients experience in each of the following scenarios:

        • when they call for an appointment
        • walk into the waiting room
        • or talk with office staff

Doctors can even use family members or friends as testers and solicit their feedback on the experience. From there, physicians should identify any system weaknesses and take appropriate measures to improve them.

2. Get feedback through surveys

Ask your patients to provide feedback about their whole experience with your practice and their satisfaction with their treatment. Measure patient engagement through Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys from the Agency for Healthcare Research and Quality (AHRQ)

  3. Create an open communication channel

When a patient is first seen at your practice, tell them they will get a survey to provide feedback about their experience with your practice. Be sure to use this as an opportunity to open the door to additional communication. In addition, make sure a patient feels comfortable airing complaints about any aspect of their treatment, your practice, or their relationship with you or your staff.

   4. Train your staff

Based on feedback from patients and on identified process weaknesses, conduct trainings to educate your staff on patient engagement and its importance at all levels within your practice.

Additional patient engagement strategies

Some additional strategies you can use to improve patient engagement and communication at your practice can be found in these videos:

Don’t Interrupt. Let Your Patient Talk

Successful Communication Techniques

Four Elements of Successful Communication Training


This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. It was first published on May 1, 2016. It was reviewed, updated, and republished on September 9, 2019.

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Doctors are regularly deluged with advice on how to engage patients. But how can you, as a patient, get your doctor to truly engage with you as a person? Your health and even your life could depend upon it.

By “engage,” I don’t mean just the doctor not interrupting after 11 seconds. That’s the average time a patient talks before the doctor interjects, said a study published in July 2018. This is down sharply from the “leisurely” 18-23 seconds patients on average spoke uninterrupted in studies from 1984 and 1999.

This rapid interaction may be fine when you’re trying to figure out if you have a broken ankle. However, that perceived absence of empathy can significantly harm your physical and mental wellbeing if your problems are more complex. At a recent Society for Participatory Medicine (SPM) conference (I’m a member), three strategies stood out for patients to short-circuit being given short shrift.

How to respond when your doctor interrupts

1) Individual flair can ignite conversation

Kate Sheridan was 11 years old when she was diagnosed with Lyme disease. Over the next three years, she was referred to more than 30 doctors and was hospitalized five times. The complications from her condition, Kate wrote in a blog post for the Mayo Clinic, changed her from a straight-A student to someone unable to read or write. She went from being a competitive athlete to being bedridden and from an extrovert to feeling isolated.

That feeling of isolation was reinforced by periodic, panicked visits to the emergency room. “The first few visits all saw the same pattern ­– I was a diagnosis, passed from hand-to-hand until discharge,” she wrote.

Then, when Kate was in 11th grade, a chance comment by an emergency medical tech about her colorful sneakers sparked an idea. She deliberately ordered oversized, multi-colored shoes. These “gave me a talking point with my providers and a reputation in the Emergency Room,” she wrote. “With every new diagnosis and treatment, the sneakers became louder.”

Shoelaces were soon replaced by scraps of cloth, and Kate splashed the shoes themselves with neon paint. Gradually, she emerged “as the goofy kid with the weird sneakers,” not just a “patient” ­­– and her care changed. For example, nurses took more time to be gentle while inserting an IV. And, of critical importance for someone with a complicated medical history and multiple medications, “doctors were willing to hear my whole story and not just a summary. When I had my shoes, I had my voice.”

Kate, often too sick in high school to attend classes, is now pursuing a master’s degree at the University of Oxford.

2) Appeal to the physician as both scientist and healer

To paraphrase the famous Michael Jordan commercial, what turned the tide wasn’t just “the shoes.” Kate and her parents also painstakingly assembled a spreadsheet for her doctors that tracked her symptoms, both mental and physical, and the effects, good and bad, of the treatments.

“Data has power,” Kristina Sheridan, Kate’s mom, told the meeting. (Kate was in England.) “We produced this chart from her voice.”

The strategy of explicitly appealing to the physician as both scientist and healer – to logic and emotion alike ­­– is what saved Doug Lindsay’s life.

Lindsay was someone who loved to dance, play banjo and tell stories until, at age 21, he suddenly found himself barely able to sit or walk. His symptoms resembled a severe case of chronic fatigue syndrome. Confined to a wheelchair, he dropped out of college and quickly began to feel invisible.

As an article about his predicament put it, “Sick, the guy who never had trouble finding an audience couldn’t get doctors to listen to him.”

“Sick and terrified,” Lindsay began reading medical textbooks. Searching for a condition that was rare, he came upon a disease of the autonomic nervous system. Fourteen years after his life was shattered, now healthy, a strong-voiced advocate striding back and forth in front of an audience, Lindsay recounted where he began and what changed.

“I wrote to doctors,” Lindsay said. “They responded, ‘Problems like what you say you have don’t exist.’ But I said, ‘They could.’”

So began an arduous journey to enlist physicians and researchers as collaborators in, first and foremost, finding a diagnosis. In this case, that turned out ­to be adrenal gland hyperactivity known to affect just 32 patients worldwide. The next step was discovering (or, as it turned out, Lindsay actually helping his doctors invent) a possible treatment. Finally, and perhaps the hardest job of all was enlisting a physician to perform a largely untested surgery.

Each of these tasks consumed years of effort. Although Lindsay’s painstaking research and persistence won respect, persuading doctor after doctor to accept the difficult challenge his illness posed remained a constant struggle. Lindsay says he eventually realized that if he wanted empathy and support, he had to provide both in return.

“I had to show them I cared about the position I was putting them in,” Lindsay related. “I had to tell them that if they failed me, it would still not harm their self-concept as healer. [I had to tell them], ‘You can help me. It’s within your power.’”

3) Let technology pave the path

Clinicians know, of course, that they sometimes have an empathy deficit. In 2013, a Cleveland Clinic empathy video that quietly showed what we don’t see on the inside of the strangers who surround us in the hospital and clinic became a surprise viral hit, sparking tens of thousands of views and bringing tears to the eyes of many who viewed it. Two years later, MedStar Health’s “Please See Me” video emotionally captured the need for open and honest doctor-patient communication.

Still, overstressed providers too often experience compassion fatigue that interferes with their ability to empathetically listen to patients. One possible aid that was voted “most patient-centered” at a health tech meeting held in concert with the SPM conference, comes from a company called PatientWisdom.

Founded by Gregory Makoul, a researcher in doctor-patient communication (full disclosure: also a former colleague of mine Northwestern University), PatientWisdom’s mobile platform lets patients tell their stories. It then shares them in summary form with the entire care team via the electronic health record. Headings include, “This makes me happy,” “Health priorities/goals,” “My agenda,” “Biggest barriers to staying healthy” and “What I wish my doctor asked me.”

Said Makoul, “PatientWisdom has found the sweet spot between digital and personal.”

Separately, a group of patients working with the Society to Improve Diagnosis in Medicine is developing an online toolkit designed to communicate to doctors based on the logic they’ve learned in medical training – your story, but on their terms.

A leader in that effort, kidney cancer survivor Peggy Zuckerman, is a realist. The toolkit, she says, “helps the patient tell his story…in a way that MIGHT get the doctor to hear your complete story.”

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4 Ways You Can Improve Patient Engagement

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A review of twenty-eight trials published in the Journal of the Royal Society of Medicine last month quantifies what many doctors already knew: communicating empathy and positivity improves a range of patient outcomes.

Two true stories motivated me to do a lead review. Archie Cochrane relates the first. He was a doctor in a prisoner-of-war camp during World War II. One night the Germans dumped a young Soviet prisoner in his ward. The soldier was badly wounded and had pleurisy (holes in his lungs). He was screaming. Cochrane didn’t want to wake up the other prisoners, so he took him to his private room. He had no morphine, just aspirin, which wasn’t working. He felt desperate, and he knew very little Russian and there was no one in the ward who did. He finally instinctively sat down on the bed and took the soldier in his arms. The screaming stopped and the prisoner died peacefully in Cochrane’s arms shortly after. It wasn’t the pleurisy that caused the screaming—it was loneliness. Cochrane instinctively understood what was needed, and did something about it.

A more recent story involved my late friend and colleague George Lewith. Lewith was a doctor who was known for being kind and optimistic with his patients. In the early 1980s Lewith’s colleague Bruce Thomas said positivity might give patients a good feeling, but it didn’t have any health benefits. In response, Lewith challenged Thomas to do a trial comparing his encouraging style with Thomas’s (apparently sometimes grumpy) style. Thomas accepted, hoping to prove that Lewith was wrong.

 

The Thomas’ trial

To prepare the trial, Thomas took a stack of cards and wrote “positive” on half of them and “negative” on the other half. (Being positive is part of being empathic, as long as you don’t lie—even patients with serious illness want to be told the truth and they want to be offered hope.) He shuffled the cards and put them in a drawer beside his desk. As patients came to visit, he first checked to see whether they had a life-threatening illness that needed ra eferral to a specialist or an ambulance. If they did, he referred them or called an ambulance. Otherwise, he drew a card from the drawer.

  • If he drew a “positive” card, he said he knew exactly what was wrong with them. If they didn’t need any medicine, he told them confidently that they would be better in a few days. If they needed medicine, he said it would definitely make them feel much better very soon.
  • If he drew a “negative” card, he told patients, “I cannot be certain what is the matter with you.” If no treatment was prescribed he added, “And therefore I will give you no treatment.” If a treatment was prescribed he said, “I am not sure that the treatment I am going to give you will have an effect.”

As a backup plan, he told patients to call him if anything changed. He treated 100 patients with a negative consultation and 100 with a positive consultation. In the end, he found that 64 percent of the patients who received positive consultations got better within two weeks, whereas only 39 percent of the patients with negative consultations got better. He published his results in a 1987 article called “General practice consultations: is there any point in being positive?”

There were problems with the trial, especially the lack of blinding. Since Thomas knew which patients got the positive consultations, this could have influenced the results. But in the years since Thomas’s study, dozens of higher quality studies have been done with many different kinds of outcomes, and it has become difficult to doubt the results.

 

Our systemic review and meta-analysis

Our recent mega-study with twelve randomized trials confirmed that doctors who use positive language reduce patient pain by a similar amount to drugs. Other trials show that positive messages have numerous benefits, ranging from helping Parkinson’s patients move their hands faster and increasing “peak flow” (a measure of how much air is breathed) in asthma patients, to reducing the amount of pain medication patients use.

To be sure, even positive messages can be bad if overdone. Some serious illnesses don’t get better, so telling patients with these illnesses they will get better is a lie. However, even in these cases, patients like to be offered hope. In fact, palliative care doctors who work with dying patients emphasize how important it is to communicate in an honest yet hopeful way. This means being honest about the disease and at the same time helping them plan for the things that they can accomplish, such as a last visit with their grandchildren.

Our review suggests Cochrane’s and Lewith’s communication experiences aren’t just the stuff of stories. Empathic and positive communication seems to improve conditions ranging from lung function and length of hospital stay, to pain, patient satisfaction, and quality of life. From related research, we also understand more and more about how positive empathic communication works. First, you need empathy to make the right diagnosis. Without it, patients may not share symptoms, especially embarrassing ones. Next, an empathic practitioner will help put a patient at ease and reduce their stress. Dozens of trials suggest that relaxation reduces pain, depression, and anxiety, and even lowers the risk of heart disease. Also, being positive activates the patient’s brain in such a way that the patient makes his or her own pain-killing endorphins.

Our review had some limitations. For example, the studies in the review were small, and blinding is hard to achieve, since doctors know if they have been trained to provide additional empathy. The effect was also small: for example, empathic and positive communication reduced pain by an average of half a point on a ten-point scale. Nonetheless, this small effect is important, especially if we take harms and drug options into account. Many commonly used over-the-counter drugs, on the other hand, barely outperform placebos for back pain, cancer pain, and many chronic conditions, yet they can have serious side effects. By contrast, a key finding of the study was that positive empathic communication does not seem to harm patients.

 

Conclusions

We are beginning to understand more and more about how empathic positive communication works. First, you need empathy to make the right diagnosis. If you don’t understand what is really wrong with the patient, then you can’t make the right diagnosis. Also, an empathic practitioner probably helps put patients at ease and reduce their stress. Relaxation has been shown in many other studies to reduce pain and depression and have a generally positive effect on health. The way a positive message seems to help is biological. When a patient anticipates a good thing happening (such as when the doctor says something positive or hopeful), this activates parts of the brain that help the body make its own drugs, like endorphins.

Whether or not doctors prescribe drugs, adding a dose of empathy will probably boost the drug’s effect without risking any harm to the patient. And for some patients, a dose of empathy is all they need.