This story was first published in Emergency Physicians Monthly.
It’s more than just satisfaction scores.
Great customer service is critical to the success of any business or organization. We often think of highly successful businesses that have achieved the highest levels of customer service that then translated to unparalleled success in the marketplace. Think Southwest Airlines. You are surrounded by relentless great customer service when you fly Southwest. Translating customer service to patients can make physicians and nurses uncomfortable. They say we are caring for patients, not flying a plane, but they are the same thing. Think about the following syllogism:
Customer Service ->
Patient Service ->
Patient Care ->
Caring for the patient
Therefore, customer service is caring for and about the patient
If you study patient satisfaction frameworks and questionnaires, the framework and translation is the same as the four lines above.
In an emergency physician group where I work, we had patient satisfaction scores that were fair, often in the mid-80 percentile. It is an excellent group of highly skilled physicians and PAs. Two of my colleagues ran the simulation lab and did a lot of work in team-based communication and crew resource management. An offshoot of this led to conversation about not just our communication with our nursing colleagues, but about how to clarify and improve our communication with our patients.
We developed principles of making sure that the patient could articulate what we had said and to make sure they understood the plan of care. The structure looked like a lot of communication frameworks. The guiding principles were:
- Clarity of communication around the immediate plan of care
- An expectation of the time of the work up, and often a request for the patient to ask for you if you haven’t returned by a certain time
- Returning frequently to update the patient
- A careful review of the information gained from testing and treatment
- A plan to make sure the patient understood the communication
- And to ask if the patient had any further questions
Implementation of these communication principles led to a dramatic increase in the physician/provider patient score section, often with quarterly scores in the 99th percentile for similarly sized hospitals.
For a primary care physician that has cared for a patient for years and who is well known to the patient, the communication and connection might look different than one for an emergency physician who is having a one-time, chance meeting — often one the patient would rather not endure. This creates an urgent need for connection. This is true for other settings such as a first-time meeting with a hospital consultant or an office specialist.
As an emergency physician, there are several important points in this framework that help to create the most connection. This connection is critical because I really need and want the patient to know I care about them and am glad and honored that they are asking for my help. It is the calling that creates this connection. This first part looks like this for me:
- “Hello, Mr. Doe.” That is easy and obvious. Recognize the person in front of you. The next part, I find, is critical and creates a tremendous amount of connection. I articulate that I am sorry they are sick or injured and that I am glad they came to see me. And often you can say, “We are going to get you feeling better” or “We are going to work to figure this out.” So, I often say something like this: “I am so sorry you are feeling so sick and are here on a Saturday night. I am sure there are places you would rather be. We are going to get you feeling better and figure this out.”
- “Hello, I am Dr. Lynch, Michael Lynch.” (I say both to cover the frequent need for patient to know the first name of the doctor. Some people want to hear “Dr.” and are reassured by the title. Others are put-off by the hierarchy and distance of the title and the lack of a first name so I just do both and no one seems to mind. It avoids the awkward question, which does occur if you don’t do it, of “what is your first name?” If that happens, you have lost a little bit of connection with the patient that you made need to work to recover. So why not just avoid that issue?
Expectations
This is an important part of the communication, which involves, after you have done a history and physical exam. The tenet of under promise and over deliver applies heavily here. If you think a test will take an hour, tell the patient the test will take about an hour or a little more. And if you haven’t returned by that time to ask for the nursing team to get you. It is also a good reminder for you. If there are some initial screening tests that will help narrow the diagnosis or treatment options, then there is another expectations discussion and reset that follows the first one.
Reviewing the information that the patient came for — this is the critical relaying of the findings and your thoughts. It is important to make sure that the patient understands and, in ideal circumstances, can repeat/read back the information you relayed. There is a nuance that often occurs in this part of the patient communication that you have to be perceptive of the patient’s words, tone and body language, knowing that tone and body language convey more meaning than words.
If you are getting a sense that the patient doesn’t understand or is thinking about something more, this is the time to say the critical phrase “Is there anything else you are worried or thinking about?” As providers, we often are either chasing a bias, which is a whole other issue that warrants a separate article about missing the patient’s concern or cues. Remember, the patient is coming to see you because they are worried about something. If you don’t address or discover that, you are missing the reason for their visit. In addition, you are missing an important opportunity to think about something you may not have considered.
Sometimes, the question “Is there something else you are worried about?” can lead to a simple reassurance. “No, I don’t think this is a stroke, it is a peripheral neuropathy, but I am glad you asked.” Other times, it can lead to a diagnosis you weren’t considering. The patient can ask “Can this be a brain tumor?” that leads to a deeper discussion and imaging that you might not have performed in what appeared to be a benign headache.
The wife of a patient, a man in his mid-30s, who had microscopic hematuria, but a negative CAT scan, asked me “What else could be going on?” When I said that he likely just passed a kidney stone, I missed the opportunity to listen to her question. I was rushed. It was a busy evening in a full department and I didn’t reengage with the conversation. Probably to no one’s surprise, he returned two days later with an aortic dissection and was airlifted to another hospital.
Gratitude
Being grateful to and for the patient, has become an important part of my communication with my patients. Over 20 years, I frequently said thank you to patients. I was polite, clear and thoughtful. But the sincerity with gratitude was missing. I found this to be transformative. Saying “thank you for coming here and allowing us to take care of you” and meaning it while looking in the patient’s eyes creates a level of connection and gratitude that is so powerful and surprising. I do this faithfully now, and I can truthfully say that I have gotten a positive response, and a smile and a level of connection almost every time I do it. It is shockingly simple, but with real gratitude, it can lead to an interaction of caring for the patient that will surprise you the first time you do it. And every time thereafter.
Lastly, there are a few pearls of wisdom and commandments that I use and live by that help me connect with my patients more fully. Wisdom has been said to be “what you get right after you needed it.” I love that. It is so true and why we should listen to hard-earned wisdom whenever and wherever it comes from. (see the Anger bullet point below.) The first is discussed above, but because it is so important, I will list it again as the first bullet point:
- Worry – what is the patient (or the family member!) worried about that you haven’t addressed. If you have any concerns that you are connecting with them or are missing something, ask them “is there anything else that you are worried about?”
- Sitting – this is my personal obsession. Sitting down, on a stool preferably or a chair, at eye level with the patient, lets them know you are there for them and them only, not rushed, and are concerned about them. You can leave a cardiac resuscitation and walk into another room and connect quickly. It is also very centering for you.
- Everyone has a story – this is my go-to if I am having trouble empathizing with a patient. Some people are harder than others, and you also may be hitting them at a bad time (often true in health care). Remembering that this person has a life story that led them to this place and that this is someone’s child, mother, father, son, daughter, spouse or friend can carry you a long way to the empathy you need to care for them.
- Anger – this is simple and an immutable rule. Never get angry at a patient. When they are angry, absorb it. That is your job. When you get angry at a patient, you will almost never get them back, with that or any subsequent encounter. And you open yourself up for complaints and potential suits if there is any adverse outcome. Never get angry at a patient. I did it once as a young attending and the result was so complete that I never did it again 20 years and counting.
The prescription for excellent communication and unparalleled, genuine connection is to create truly excellent customer service by caring for the patient. Do that, and follow the outline of care above and lead with your heart and you will achieve, genuinely consistent high patient satisfaction scores. You won’t be working the system, but are a reflection of the deeply compassionate and thoughtful care you provided.
