It’s not an easy task. You don’t know the patient from a hole in the wall. Yet you’ve got to question, poke, prod, empathize, explain and gain their trust in the blink of an eye. There are three critical communication practices that will help you establish the trust you want and need to provide your hospital patients with great care and a high quality experience.
1. Beware the bystander effect. Be the boss and say so.
A recent Perspective piece in the New England Journal of Medicine addressed the bystander effect - the human tendency to be less likely to offer help in emergency situations when other people are present - and the increasing evidence of this phenomenon to occur during care in the inpatient setting. The authors describe a patient who posed a clinical conundrum and subsequently encountered over 40 physicians during an eleven day stay in the intensive care unit. The uncertainty over the patient’s diagnosis and the number of physicians involved led to provider passivity and directionless care.
Unfortunately, as physician care teams balloon in size, even under routine conditions - a couple of ER docs, two or three hospitalists and a couple of specialists would be a common, if not conservative cast of providers - it’s easy for everyone to focus on their piece of the patient’s puzzle and forget that someone has to be the captain of the ship. And patients are acutely aware of this lack of accountability as we overtly pawn off decisions and explanations on our colleagues without reassuring patients that we are all part of a single team and that there is a clear leader.
It is a critical step for any attending physician, particularly for hospitalists who are most often the attending physician for both medical and subspecialty patients to explain your role as captain of the ship. Stating this plainly - “I’m the physician in charge of your care while you’re here” - is a powerful way to initiate the process of building trust as you vocalize your commitment to looking out for your patient’s well-being.
2. Let everyone know we work together. Convey continuity during transitions.
One of the biggest obstacles to patient safety, quality and good experiences in the inpatient setting is that of continuity of care, which I’ll define as “a patient experiencing care as clear and coordinated over time.” The reality of inpatient care is that multiple providers across different disciplines will manage patients during the course of a hospitalization. This lack of provider continuity has been shown to negatively impact patients’ experiences. A 2011 meta-analysis of studies evaluating patients’ perceptions of continuity of care found that, “when [provider continuity] was absent, patients expressed dissatisfaction, feelings of helplessness and isolation, as well as confusion by receiving different treatment and medical advice.”
Thus, it is critical that we share with patients, particularly at transitions of care, our efforts to maintain continuity of care despite the fact that provider continuity is lacking. You can accomplish this by always informing patients that:
You have reviewed their chart and that you are familiar with their diagnosis/reason for hospitalization
You have spoken to the referring physician (PCP, ER doc, specialist or hospitalist) or your colleague for whom you are assuming care
Taking a moment to share this information with patients will show that you are committed to the continuity of their care and will also allow you to give context to questions you ask that might otherwise seem repetitious or suggest you are unfamiliar with their care. These efforts will allow you to build on the trust gained by the providers before you .
3. Talk about the team like you know them. Refer to colleagues by name.
You hear it all day long in the hospital:
“That’s a question for the hospitalist.”
“I’m going to ask nephrology what they think of that.”
“Let’s wait and see what ortho has to say.”
When we refer to colleagues in the abstract, it’s not very reassuring for patients. It suggests that we don’t have a relationship with those individuals, which certainly doesn’t support the notion that we are a team. Additionally, we often use abbreviations or terms that patients simply don't understand (nephrology, “ID”, “ortho”, etc.). Of course, there will be times - such as when calling a consult - when you may not yet know which of your colleagues will be seeing the patient. And I would argue that you should share the name of that individual after you determine who it will be. This gives you an opportunity to manage up your colleague and will likely prove reassuring to patients since we all like to know who and what to expect whenever possible.
Our ability to establish and maintain trust with patients during a hospitalization is crucial to the patient experience and likely reflects the degree to which we are committed to patient-centered care in a broader sense. Additionally, the implementation of critical communication practices such as those listed above stands to improve provider satisfaction as patients respond to the high quality of communication and consideration being shown to them by their providers.