JAMA study highlights 5 key links to strengthen Doctor - Patient relationship.

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The patient-physician relationship has been facing many challenges over the past years and continues to. We've been hearing claims from patients that they don't feel listened to by their doctors, and these have been backed by some researches. Recently on Twitter, under the hashtag, #patientsarenotfaking , over 70000 such cases were reported by users. Although the appointment times have increased but this increase is mainly focused on EMR - Electronic Media Recording and not the patient herself. 

In their enterprising Special Communication in this issue of JAMA, Zulman and colleagues have talked about this gap between patient and physician and the effects it has. Studies and experiences show that a good communication and connection with patients improve diagnosis, adherence to prescribed regimens, and give other significant outcomes.

A study conducted in 2009 included 583 physician-reported errors, Schiff et al and found that diagnostic errors occurred mostly in the examination room, many relating to an inadequate history.

The study by Zulman et al in this issue of JAMA, authors have proposed 5 specific "practices" that may promote healthy engagements and meaningfully empathetic connections between physicians and patients. For this they have observed the practices of those physicians who were known to excel in maintaining such connections and also studied the practices followed in other industries where communication is the key to achieve targets. 
A list of 13 behaviours has been thereafter prepared by the authors.

These 13 behaviours were then judged by a panel of experts, on 3 criteria: effect on the patient experience, effect on the clinician experience, and implementation feasibility. Each behavior was rated using a 9-point Likert scale, and those that were rated in the top quarter in all 3 domains were carried forward. The remaining 8 practices were compressed to the final 5 recommended behaviours, which are:

  1. Preparationwith intention :- Familiarize yourself with the patient you are about to meet. Create a ritual to focus your attention before a visit. Healthy pre treatment interaction will be a boon for future relationship with the patient.
  2. Listening intently and completely :- Sit down , make patient feel comfortable, lean forward and position yourself appropriately to listen what the patient is saying. Don't interrupt in between , your patient is the most valuable source of information for you. Your future course of action depends upon the clear first hand history provided by him. 
  3. Agreeing on what matters most:- find out what your patient cares about , and incorporate these priorities in the agenda of your next visit to the patient. It will include what your patient's health goals are , now and in the near future and draft your plan accordingly.
  4. Connecting with the patient’s story:- Consider the circumstances that influence your patient's health. Acknowledge your patient's efforts and celebrate success. Ask yourself how you can contribute to your patient's journey.
  5. Exploring emotional cues:- Tune in , notice , name and validate your patient's emotions to become a trusted partner. Patient's emotions are his fundamental rights , the more you will give weightage to it, the more strong your bond with your patient will become.

In adding this list to the huge literature on physican-patient relationship, the purpose according to authors is to present some easy to remember and implement practices. They also recommend maintaing a "prechart" of each patient, or at least review his history before examination. There onwards, attentive listening without interrupting the patients is to be adopted, also focusing on encouraging the patient to realize what's most important to her. It has been shown that visits were shorter when internists and surgeons responded empathically to their patients’ emotional cues. That's why, the physicians have also been recommended tending to the "patients' story" or the circumstances that led her there. These practices, as propounded by authors, are believed to nurture a strong engagement abd thereby benefiting both the patient and the physician.

Forcing practitioners to adopt these practices might not produce results on large scale owing to some fundamental barriers. The most prominent of these is the compulsive EMR. A recent study found that EMR design and use were leading factors associated with clinician stress and burnout, thus making care difficult. 

Throughout the article by Zulman et al, concerns for time are brought up repeatedly. Recommended practices were reached to after keeping in mind this factor. No time gap between visits, and also moving between rooms won't allow physician to give thought or consideration. Thus, structural changes are needed the most. 

Third, patients with chronic pain, those with medically unexplained symptoms, those with multiple chronic illnesses, or those who have experienced a medication or surgical error or other challenging conditions would pose more difficulty for doctor to implement the 5 specific practices, compared to those with straightforward requirements.

The sense of alienation felt by patients adds to the frustration of the physician. Also, understanding and connection with patients is thought to be a powerful diagnostic as well as therapeutic tool. What is clear is that these practices can do a larger good while posing no preceptible harm. The repackaging of these already well known 5 practices in this manner by Zulman et al is undoubtedly an important service, but what's more needed is a system that may support and value the physican-patient relationship.

 

Their is undoubtedly an urgent need to lay emphasis on the factors that will enhance the dialogue and trust values between a patient and a physician. The 5 key takeaways will definitely if executed in daily practise sessions will go a long way in strengthening the bonds between patient and doctors.



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