Monday 19 November 2012

Advice for new doctors and nurses: Day 19 #NHBPM

When I sit down to think of the advice I'd give new doctors or nurses it comes down to one word, rapport. Take the time to build rapport with your patients and you will alleviate a large percentage of the potential problems that can arise for both parties.

It's a simple concept really but one that is often overlooked or relegated to an after thought in practice. It is often seen as a luxury that time-poor practitioners simply cannot afford. But in reality it can be established quickly and can make your professional life much easier, and more satisfactory, in the long run.

As a practitioner it was the cornerstone of my practice. Whether in an acute or sub-acute or rehab setting, rapport building was the first part of any assessment process. It was also integral to encouraging patients to participate in treatment or management. But it is now as a patient myself, that I can truly appreciate just how important the development of rapport can be. It influences my health care choices in ways I truly didn't understand and impacts upon both who I seek out for treatment and who's information I trust.

I actively seek out doctors and nurses who can genuinely listen and seem interested. Those that can understand that whilst I come to them for a particular problem, that problem does not live in a vacuum. A moments kindness or compassion can go a long way. In turn, if I find a doctor or nurse who is unwilling to treat me as a person, is intent only in seeing my illness or injury, is rude or cold, I go elsewhere. If a medical practitioner is unwilling to listen to what I am saying how am I to trust that he or she fully comprehends the issue at hand or the treatment they have prescribed.

Remember there is a person behind the illness or injury.

Rapport is a skill that requires practice like any other. Some are natural rapport builders and some need to apply themselves diligently to master the skill. But either way, it is a skill set that is vital to good practice.

A quick look on any patient forum or support group, and it is apparent that much of the dissatisfaction with the medical system reported is linked to how particular medical staff made them feel. A doctor who tells a patient they cannot help them or doesn't know what is causing their symptoms, yet makes them feel heard and understood, is much preferred to an expert with little to no bedside manner. Illness is scary and confronting. The system is such that as a patient you are often left feeling disempowered and isolated. You want to know that your doctor or nurse has your best interests at heart and that they are invested in your care. If that feeling isn't present a patient is far less likely to trust advice given or follow treatment plans.

Patients remember a doctor or nurse who made them feel human. Sadly, because that experience can often be the exception rather than the rule. They remember the doctor who listened to them and took that extra five minutes to make them feel like they matter. Conversely, patients will remember, and tell others, about the doctor or nurse who made them feel nothing more than a diagnosis or a body part. That negative experience will then colour future interactions in the medical system. Clinical skills are vitally important but rapport is often what will seal the deal for patients.

Patients share information. 
Often they will seek out recommendations from fellow patients 
for doctors and nurses who are known to have a good bedside manner
 on top of good clinical skills.
Whilst those who develop a reputation for dismissive or condescending interactions are avoided, particularly in small patient communities. 

In an age where doctors and nurses are time poor it can be thought that there simply isn't time for rapport building. But the reality is that it can happen incidentally during an assessment, whilst you are taking obs or just in a the general appointment. It's not complex. It can be as simple as small talk about a current sporting event or asking about a patient's family. It can be asking a patient if they have any specific questions that they want to ask, or how they feel about a potential treatment or prognosis. It could be taking into account they have small children when you are suggesting a hospital stay or the cost of medications you prescribe. Even a frank discussion about possible medication side effects can help with compliance. As a nurse or doctor you don't have to necessarily 'fix' these issues. But acknowledging they exist will go a long way in making a patient feel heard and understood.

Patients are no longer content to sit back and passively receive information and direction from their physicians. They want a partnership. And if you can create that experience for a patient, compliance and better treatment outcomes occur. It means your patients are more likely to give you the information you require for accurate diagnosis or treatment. It can also alleviate potential medical mistakes and injuries eg the growth of alternative medical practices means patients can be on multiple alternate therapies whose effects are often unknown or can interact with traditional medications. If these remain an unknown for fear of dismissal or ridicule by the treating health professional they can have potentially serious consequences.

Patients need to feel like they matter and that their doctor or nurse truly cares. Illness can be scary and confronting. You are often seeing a person at the worst time in their life. Your patient doesn't care that you have to see 20 other patients that day. In that one moment they want to know that you have their best interests at heart. That at some level you understand what they are going through. And that their well being is important to you.

The majority of patients don't understand medical jargon. Being able to communicate complex medical procedures or illness processes in a simple relatable and conversational manner is a skill unto itself. Taking the time to make sure that your patient understands what you are trying to convey is essential. Often patients don't fully understand or misunderstand what they are told but are afraid to ask. Established rapport means they are more likely to ask for clarification.

Conversely, many patients have difficulty articulating their medical issues. If they feel rushed or that pressured vital information may be missed. They may need time or prompts to help them clarify the issue at hand. Or simple trust to be able to share what they are experiencing. For example, I had a patient referred who was notoriously late to inpatient appointments and was deemed avoidant and uncooperative. Initially, her response was always that she was absent minded and would simply lose track of the time. It was only when she finally felt comfortable to reveal that she could no longer read clock faces (something that she found very confronting) that it was found she had visuospatial difficulties relating to a previously unknown infarct. A digital clock resolved her time management issues and she was referred on for stroke review and follow up. Without developing trust this issue may have remained undiscovered and future stroke risk factors not addressed. Others may be embarrassed to discuss certain issues particularly in regard to sexual, toileting or gynaecological difficulties instead talking around the issue or avoiding it altogether. If rapport is established the likelihood such issues will be reported, and therefore treated appropriately, are greatly increased.

Rethink how you communicate with your patient. Not just in what you say, but how you say it. Are you talking to, or with your patient? Think about your body language. Think about whether you are actually listening to what your patient is saying or have you already made your mind up. Use the conversation as part of the hypothesis testing process. Know without a shadow of doubt that a patient can tell within the first 5 minutes whether you care or are truly interested in what they are saying, and they will act accordingly.
Those initial days finding your footing can be difficult. It is both exciting and daunting to finally work in your chosen profession. You are armed with a wide clinical knowledge base and you are keen to apply it. But the clinical presentations, treatments and outcomes you've learnt about are only part of the package. The first few years are a huge learning curve. The greatest part of which comes from patients themselves. The reality of illness is very different to the clinical facts that are taught in uni, and will be different for each patient you encounter. But each encounter is a fantastic chance to learn and expand your knowledge.

There will be patients (and family members) who are still uncooperative and fractious no matter how good your rapport building skills. It's the nature of the job. But don't judge all patients by those few. The majority of patients are looking to you to help them. They want to feel better. They want to trust you and they are willing to work with you to get well. They are looking for a partner to help them navigate the often difficult and scary path of illness. Let them know you care and that you genuinely understand and it can be a truly rewarding partnership.

Day I: Why do I write about my health.
Day 2: Find a quote and use it as inspiration.
Day 3: I don't know about this, but I'd like to.
Day 4: A chronic handbag
Day 5: Health Activist Soapbox 
Day 6: And I've done my back, because it's not like I had anything else going on.
Day 7: Setbacks. Vlog time.
Day 8: A letter to my health.
Day 9: No Blogging Day.
Day 10: Taking a little Time.
Day 11: Strength
Day 12: Chronically Blogging Australia
Day 13: Taboo
Day 14: Favourite Blogs
Day 15: No Blogging Day
Day 16: How to be Alone.
Day 17: No Blogging Day
Day 18: No Blogging Day

1 comment:

  1. building rapport is so important in our lives- every one has a story and every one has something we can all learn from. Thank you for sharing this greta message


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