Ep38: Making a Connection

An empathic connection and good communication between physician and patient can promote better outcomes. In this episode of Pomegranate Health, U.S. physician A/Prof Danielle Ofri discusses where breakdowns in doctor-patient communication occur—often in the first 10 or 20 seconds of a consultation. Dr Ofri, author of What Patients Say, What Doctors Hear, suggests ways for physicians to listen better, to be understood and promote adherence.

Some media also report a 'crisis of compassion' in healthcare. Burnout of staff is a major contributor, and palliative care physician Dr Shamsul Shah describes how to mitigate it by convening groups to reflect on the emotional challenges of the job. She recently published an evaluation of Schwartz Center Rounds® (case-based reflections) run at Auckland City Hospital in the College's Internal Medicine Journal.

Guests
A/Professor Danielle Ofri MD PhD (Bellevue Hospital, New York; New York University School of Medicine)
Dr Shamsul Shah FRACP (Auckland City Hospital)

Production
Written and produced by Mic Cavazzini. Music courtesy of Blue Dot Sessions ('Periodicals'), Sergey Cheremisinov ('Old Ally', 'Tavern'), and Loch Lomond ('A String- Instrumental'). Image property of RACP. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP members Philip Gaughwin, Michael Herd, Andrea Knox, Paul Jauncey, Rebecca Grainger, Joseph Lee, Rachel Williams, Mahesh Dhakal, and Katrina Gibson.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

Transcript

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SPEAKER_00 0:00

Welcome to Pomegranate Health, a podcast for physicians of the RACP.

SPEAKER_03 0:08

I guess as doctors, we're trained to fix things, fix problems. And often in my patients, I can't fix what's what they're going through. And one of the questions I love asking people sometimes is, you know, there was one thing I could do for you today, what would that be? Because sometimes it might be, actually, I really want a decent coffee. And and so that's what I'll do. I'll go down and buy my decent coffee. So it's not always about the medicines. Sometimes it can be so simple.

SPEAKER_00 0:42

You just heard from Dr. Shamsul Shah, a palliative care physician at Auckland City Hospital. In this episode, she'll talk about empathic reflection in healthcare professionals, in a climate where some media report of a crisis in compassion. But first we'll start with communication skills, which are of course critical to building a trusting relationship with patients. To learn more about becoming a better listener and communicator, I called U.S. Physician Associate Professor Daniel O'Frey, author of a book titled What Patients Say, What Doctors Hear.

SPEAKER_05 1:13

My name is Danielle O'Frey, and I'm an attending physician at Bellevue Hospital in New York City, which is the oldest public hospital in the United States of America. I'm also a faculty member at the New York University School of Medicine.

SPEAKER_00 1:28

Wonderful. So let's go into how you describe how the experience of hospital for patients can be Byzantine and surreal. And studies variously show that 40 to 80% of the information that's thrown at patients is is typically retained. But tell us about that particularly alarming survey of patients discharged from the Connecticut hospital that showed this really starkly.

SPEAKER_05 2:02

And only 18% knew their primary doctor's name. Which it seems amazing to me because we're there every day. But in fact, most of them know their nurse's name.

SPEAKER_00 2:13

And and and what does that tell you about what's lacking in the patient-doctor interaction?

SPEAKER_05 2:19

Well, it lets us know that the ability to remember is not just information that's given to you, but how it comes through. So typically doctors stand at a distance from the patient's bed, usually arms crossed, talking, you know, maybe with a whole group in white coats. Whereas nurses tend to be close by, they're usually touching the patient, taking the blood pressure and cleaning them and changing them and helping change the bed. The doctors are delivering the medical care, the nurses are taking care of them. And that is perceived so differently. When I introduce myself now, I r try to be very slow and clear with my name, and I describe who I am. My name is Dr. O'Frey. I am the attending physician here. And then at the end of the visit, I say it again. I hand them my card. Here's how to reach me. So an extra emphasis on that. And the other thing we we do with information is asking the patients to repeat it back. And you have to be careful not to sound condescending like this is a test, but you know, something like, you know, well, we've gone over a lot. Can you tell me what you understand so far about your illness?

SPEAKER_00 3:19

Yeah. You refer to a study that some of our New Zealand fellows will probably have already heard about, 2013 paper by Sonia Morgan of the University of Otago, where GP consultations were uh videotaped, and both the doctor and the patient were interviewed afterwards. And even when they both came out saying they were satisfied by the interaction, there were problems.

SPEAKER_05 3:42

This is a a very emblematic case study in which there is a physical finding of alarm, and in this case it was a mole that looked of concern, was bleeding a bit. And and for the doctor, seeing an unusual skin lesion that either bleeds or is has some of the red flag signs, the alarm bell goes off right away. Now for the patient, ended up not going to the appointment because the sense of alarm wasn't automatic for them. They just heard, okay, you have this thing, you should probably go get a biopsy and yeah, no, maybe I'll do it. And we doctors, what is so automatic and distinctive for us, we don't recognize it's not the same for a patient. We haven't seen it from the patient's perspective. And so it wasn't conveyed that this is at the red alarm level and needs to be taken, you know, action immediately.

SPEAKER_00 4:28

Aaron Powell So is is there something in the emotiveness of the language that as doctors you sort of filter that down? There's almost a risk of being too cool and clinical and losing the emotional affect that will really lodge in people's minds.

SPEAKER_05 4:44

Aaron Powell I think that's absolutely true. I think we doctors um we tend to use clinical jargon and it's very automatic. We'll say, you know, uh a patient has an MI, which stands for myocardial infarction or a heart attack, and and that wouldn't trigger the same response in the patient as it would for a fellow clinician. In this case with the mole, a patient may have many moles and people have birthmarks all their life.

SPEAKER_00 5:07

And uh what about the the approach to interviewing, getting the patient history? You write about how doctors aren't always that able to let the patient tell their story.

SPEAKER_05 5:18

Well, we typically we start an interview with, you know, oh, what can I help you with today? What brings you here today? And the patient will say, well, you know, I have this pain over here. And then we doctors, we jump in right away, you know, on average, maybe 10 seconds, and we jump in with legitimate questions. Oh, when did the pain start? When did it stop? What makes it better, what makes it worse, um, because we want to find the origin of this pain. But of course, the patient may have had a second thing to say, like, I think I might have had a stroke last week, but we'll never get to that because we do we dive right in, and it's really this dogged detective instinct that in essence backfires because we interrupt the patient and they may never get back to the most important thing. And so you can see the genesis of medical error right there in those first ten seconds, and we doctors divert the dialogue in the area that we want to go.

SPEAKER_00 6:07

I I found quite amusing in the book your insistence on testing this out on yourself with a stopwatch.

unknown 6:12

Trevor Burrus, Jr.

SPEAKER_05 6:12

You know, I wondered how how long would patients actually talk if I let them speak. And so I found one study that actually looked at that, a Swiss study where they let the patients talk and till they naturally stopped and checked the stopwatch. And on average it was 92 seconds. You know, not the tsunami that we all were fearing, but but you know the Swiss reserve, precise, diplomatic, they don't necessarily have the gaff or loquaciousness that maybe Americans have. So I tried it out myself. And what's interesting, the first patient, you know, talked maybe 30 some odd seconds, wasn't too bad, but he was pretty healthy. And the second patient also less than a minute. But then came my patient, Josefina Garza, which is not, of course, her real name, a patient with a host of aches and pains, anxiety, depression, irritable bowel. She has an elderly mother to take care of and an unsupportive boss. And I thought, boy, we'll be here forever. But you know, I made a promise to let every patient talk. So I said, How can I help you? And turned on the stopwatch. And she said, Every single thing hurts, from my nose to my toes, and she reeled off every symptom. You know, her tongue was burning and she had pains up and down her elbows. And every time I said anything else, there always was. Finally, she came to the end. When I checked the stopwatch, it was about four minutes and ten seconds, right? Not four hours. And what I noticed about her is when she finished, I had a list of things she was concerned about. And then once we had a list, we could tackle it. And I found that our visits thereafter went much more quickly. So when I talked to my students and interns about how to be efficient, and we're a very, very busy clinic, I talked to them about the counterintuitive strategy of letting the patients talk uninterrupted. It's a real investment in good communication and of course decreasing medical error.

SPEAKER_00 7:56

So that sort of fear of letting the patient go on and on. It's also framed in the phrase, sometimes applied to patients as being poor historians. There's this real burden on the patient to be as concise and articulate as possible. Um is that really fair?

SPEAKER_05 8:14

That that phrase always cracks me up. The patient, my interns will come and say, Oh, my, you know, the history's not so good because the patient was a poor historian. And always say, Oh, would they make a better architect or social worker? And the idea is that the burden is on them to tell the best story, as opposed to the burden being on us or shared by us as being good listeners. And there's really interesting research on the quality of the listener directly affects the quality of the storytelling. There's a wonderful study out of Canada in which they paired uh college students, one would tell a story or a real life near-miss, almost, you know, killed by the train kind of story, and the other person wouldn't listen. But while the their friend was telling a story, they had to press a button every time their friend used a word starting with the letter T. And they, of course, nodded and said a huh in the right spots, but they equally missed the you know the punchline of the story. And what was intriguing was the effect on the storyteller. Because as the person is telling a story and they sort of catch their listener isn't with them, well then they circle back and they tell the you know plot again, and eventually the story falls apart and Peter's out. The T-word counters were confusing because they looked like they were paying attention, but they weren't actually hearing what was being said. And I believe that's us, the doctors. We kind of look like we're paying attention, but we're busy typing into a computer, and so that alone already detracts from the ability to look at the patient, see how their face is responding to the questions, catch the the body language, and so we're not actually hearing what the patient says.

SPEAKER_00 9:47

As you've said, the the key complaint might be the second or the third thing that the patient uh gets to if you let them talk uninterrupted. And there's a a study you mentioned in the book of over 2,000 primary care visits across Europe, where in one out of six consultations some psychosocial aspect to the illness emerged. Umestic violence is one that is behind the story in many GP and emergency consultations. Uh what about in the in the specialist visit?

SPEAKER_05 10:14

Aaron Powell Well, I don't have uh the data to necessarily back that up. But it is the same patients who go from the GP to the specialist. So their domestic violence doesn't go away when they get to the gastroenterologist. It just may not come up because now they feel they're focusing on one small issue. And certainly for patients whose symptoms are unexplainable by you know standard medical workup, and if we ask, we will find out about that. In the same way, and in our clinic, we started a big push toward asking about depression. Not that these psychosocial issues cause the problems, the problems are clearly real, but they certainly exacerbate them. So if someone's having a peptic ulcer, uh, we may give them the right treatment, but if they're being abused at home, that ulcer is unlikely to get better until we address that and their safety.

SPEAKER_00 11:26

Empathy is the ability to take someone else's perspective, to feel their pain. Compassion requires the additional step of seeking to alleviate suffering. Auckland psychologist Dr. Tony Fernando gives the example of a doctor rushing to an important meeting who sees a pregnant woman crying in the waiting room. Whether or not they stop to offer support depends on a number of personal and situational factors. For example, the doctor's own well-being, the pressures of the workplace, and relationships with other staff in the institution. In the British Journal of General Practice, he writes that viewing compassion via the lens of compassion fatigue has tended to imply a finite reservoir of caring resource. There is, however, no proof that compassion runs out. Another barrier to compassionate care is a failure to reflect on one's own state of mind and how this affects the course of the consultation. Psychoanalyst Michael Balant explored this in the late 1950s and started the practice of group therapy sessions that would allow physicians to talk about emotionally challenging episodes. He would facilitate the discussion with comments such as, How does this patient make us feel? Or, If I were the patient, I would probably be feeling abandoned. Today there are various less formal incarnations of these so-called valent groups. One example are the Schwartz rounds, established in memory of US healthcare lawyer Kenneth Schwartz, who was diagnosed with lung cancer at the age of 40. Over his 11-month decline in 1995, he wrote about the elements of care that made the biggest difference. In his words, how the smallest acts of kindness made the unbearable bearable. There are hundreds of healthcare facilities in North America and the UK that organise Schwartz centre rounds, usually on a monthly basis. Shamsul Shah has helped bring this practice to New Zealand, and last year had an evaluation of the 12-month project published in the Internal Medicine Journal.

unknown 13:19

Dr.

SPEAKER_00 13:20

Shah describes the episode that drew her attention to this area.

SPEAKER_03 13:24

How I got interested in this is it was just before I was due to come out to New Zealand on a sabbatical, and my mum was diagnosed with avarian cancer. And it was just really interesting being on the other side, you know, being a daughter and a carer. And by the end of the six months, it was like the blinders had come off in a way for me. That somehow the system that I was trained in, I was really familiar with, wasn't always conducive to a patient's well-being or a carer's well-being. And yeah, I think we we forget how alienating it is, how isolated you feel. And you kind of lose a lot of your kind of liberties in a way. And I guess this was on the backdrop, certainly in the UK, where there was a big media onslaught about the lack of compassionate care, lack of dignity in hospitals and care homes and so on.

SPEAKER_00 14:21

Yeah, the there have been high-profile scandalous cases such as the was it the Staffordshire hospitals.

SPEAKER_03 14:26

Staffordshire Hospital, that's right. In the UK.

SPEAKER_00 14:28

Where patients were neglected without pain relief, or in Australia there's been scrutiny about aged care after, you know, it was found that incontinence pads aren't changed unless they're 75% wet. So those are, you know, those are moving dramatic in particular cases.

SPEAKER_03 14:44

Is there evidence for a system-wide lack of compassion and and therefore lack of trust and I mean when we talk about compassion, I think there are several layers to it. Uh I remember a really good quote, which is that a difficult person is nearly always a person in difficulty. And I and I also equate it to the sort of the oxygen mask in flights. They always say that you have to put your own oxygen mask on before you put it put it on for your loved one. And it's the same in in healthcare. You know, we don't do a normal job. It in a way, it's not normal to witness pain and suffering every single day. It kind of seeps under your skin in a way. Probably might be our helplessness, our sense of unfairness of what's happening. And we withdraw, and that's as I say, a normal human response when we witness pain and suffering. And it really came home recently where I was looking after a patient with really complex chronic pain. And I saw her on the Friday, and I made some changes to her medications thinking that we'll, you know, we'll get on top of this. And I got back on the Monday and I found out she had a terrible, terrible weekend. And and it was only after I reflected on it that I was obviously feeling quite guilty. I felt responsible. I was also feeling um a little bit hopeless in a way, because everything had pretty much been tried. I realized that you know I was carrying that in into the room that Monday morning, and and sure enough, she was feeling hopeless, she was feeling frustrated. And I guess we don't really talk about you know, transference and counter-transference. I think we talk a lot about it in mental health, but you know, it happens to us all.

SPEAKER_00 16:33

So, how in the middle of all of this, how did the structure of these Schwartz rounds fit in?

SPEAKER_03 16:38

Yeah, so how the format of these rounds are usually centred around a particular case that has been challenging for a team, and two or three members of that team agree to be panelists, and each person spends five minutes sharing their thoughts and feelings around that particular case. Then it's opened out to the audience where people start sharing their stories, their experiences, and they can be incredibly powerful.

SPEAKER_02 17:11

The story is quite simple. It was December 30th, and I received a page that there was a woman 35 or 36 weeks pregnant who'd had some bleeding at home, and that there was a concern that this woman had a serious abruption.

SPEAKER_00 17:24

This is an example of a Schwartz center round recorded at Emerson Hospital in Massachusetts, USA. The first speaker is pediatrician Marianne Sutton. Then you'll hear registered nurse Kim Peterson and another audience member.

SPEAKER_02 17:36

They brought the mom to the operating room, did a stat C section, got the baby out as fast as possible, and out emerged a limp blue baby with apcards of zero who made n did not respond to pain, made no respiratory efforts. Um this baby has not had any oxygen for about an hour and a half.

SPEAKER_01 17:55

We really thought there was no hope here. The the baby, you know, this was going to be we're gonna come with a commodity at 15, and and we did our best. And then at 14 minutes I felt for the heart rate, and there it was. And all of a sudden, it's a whole different story, and you get really frightened. Well, you're excited because the heart rate's there and you've got a baby, but then you're worried about, you know, how much damage has been done and what's happened, and you know, was this the right choice to have done what we did?

SPEAKER_02 18:24

The role that we played in that is something that I think none of us feel comfortable. That 30 seconds ago we were gonna call this baby dead, and now we're calling him alive, and he has a name, and he's gonna because we gave him one more dose of epinephrine, and I just remember feeling that I knew how to do the mechanics of what I do, but I didn't understand what I was doing.

SPEAKER_04 18:54

I had the identical case, and the baby didn't die. It's been ten years. The baby does really nothing but rule. He's totally incapacitated. But the family thinks that the doctors in the hospitals were wonderful because we listened to them, did what they wanted us to do, and they do have a baby. And I guess I had to feel good that I fulfilled their wishes, but I don't feel good that I gave her such a devastating situation.

SPEAKER_01 19:21

As the day progressed and the baby got worse, it kind of gave me a feeling of we saved this baby for mom to hold a live, warm, heartbeating to say goodbye. So I knew what was going to happen and I knew what was down in the future. But I also knew that it was a better thing than having to say to a mom, being a nurse, your baby is dead. Would you like to hold it? And then trying so hard to make this cold blue baby look presentable and feel good.

SPEAKER_03 19:58

So suddenly we evaluate every round that we do. So suddenly our last evaluation where we did over 12 months showed that over 90% attendees rated that improve their knowledge in terms of how to care for patients and felt that they were able to work better with their colleagues as well. It's not that we don't have meeting, we have lots of meetings in hospitals, but most of them are around or based around problem solving. But there is no meeting that allows you to share your emotions about a situation. I I can only sp you know, I can certainly speak from my own experience. I find it an incredibly humbling experience. I remember an oncology colleague who I'd had some sort of challenging interactions, and I remember him talking about a patient who was diagnosed with breast cancer which was treatable, but chose not to have treatment, chose not to have chemotherapy, and how he struggled with that, and and and it made me yeah, influence my respect for him and understanding. It's recognizing that we all struggle in some way. Um none of us are immune to having those feelings.

SPEAKER_00 21:11

So the facilitators do they come from a particular school, do they have a particular training in this format, especially?

SPEAKER_03 21:19

The Schwart Centre themselves do provide facilitator training, which is um really important to keep it safe. Because it's not about providing solutions, and I think one of the things that people have said is that uh they found a really valuable knowing that there was no right or wrong, and that there's this huge grey in a lot of what we do. You know, we we really we are really hard on ourselves and we have high levels of perfectionism often, and I think that's something the Schwartz round helps is given a space where we can be honest about how we felt, whether we felt We failed, or whether we felt angry, or frustrated, or helpless, or whatever it might be. And anyone can come from a cleaner, administrative staff, management, doctors, nurses, and so on, clinical staff, anyone can come. We've had domestic staff as part of our panel alongside a senior leadership member as well. I think the round we had that time was around uh was titled, you know, Why I Come to Work. We have also done a round on Patient Experience Week where we had patients coming in and sharing their stories. So, I mean, that's the beauty is that you can have a real mix of people in that room. You know, Kenneth Schwartz, he talked about in his experience how when a person, a carer, shared something about themselves that made that personal connection with him, how that made him feel less lonely. And he talked about how those little things actually were more healing than the chemotherapy and radiotherapy that he was having. One of the practices I do, which I stole from Tony Fernando, which is before I go into the room, we have to gel our hands. So as I'm gelling my hands, I say a little sort of mantra in my head, which is, you know, may I be of benefit to this person, may I be of service to this person. And also recognising that I'm walking into a space, I guess a sacred space, and that's the person's space. Um, and it's not mine, and it's not the hospitals. That just gives you a sense of humility and groundedness.

SPEAKER_00 23:45

There are a few qualitative surveys of Schwartz center rounds conducted around the world, which echo the findings described by Dr. Shah. A longitudinal study in the UK has been quantifying improvements in psychological well-being using the GHQ 12 questionnaire, and preliminary data were published recently in the Health Services and Delivery Journal. These showed that incidence of psychiatric caseness decreased by half in staff who attended the rounds regularly over eight months, while there was virtually no change in the group that did not attend. Now we've talked a few times on Pomegranate Health about the challenge of adherence. Very generally, we know that about half of patients stop following therapies, and many explanations for this have been put forward. Cost of medications, health literacy, and difficulties in following multiple regimens. But physician empathy and communication are reported as critical drivers of adherence and even clinical outcomes in both the common cold as well as diabetes. A 2012 study in the journal Academic Medicine followed nearly 21,000 Italian patients with diabetes and noted their rates of acute metabolic complications. The treating physicians were profiled using a validated assessment tool for empathy, and they were stratified into three groups based on their scores. It turned out that patients of doctors classified as high in empathy had a 41% lower odds of disease complications than patients of lower empathy doctors, even after controlling for some variables relating to clinical competence. Danielle O'Frey explains just how communication style can affect the patient's engagement with the therapeutic strategy.

SPEAKER_05 25:17

Because we know that more than half the patients don't end up taking their medications as prescribed. And so we doctors just tend to berate our patients over and over. If you don't take that medication, you'll end up amputated blind in a wheelchair on dialysis. And that's very ineffective. Most patients already know that part. And I loved a study done at Georgetown where they videotape doctors and patients over the topic of diabetes and then interviewed the patients and doctors separately afterward. The doctors never ask the patients, why is it hard to take this medication? Because the answers could be, you know, it makes me nauseous, I lose my sex drive, I'm embarrassed to use a needle at work, it looks like a drug, you know, a paraphernalia. My family makes fun of me when I eat my brown rice instead of white rice like everyone else. All these various reasons that are completely different from what we expect when they miss an appointment and say, oh, that you know the patient didn't show up or the patient refused treatment. But there are reasons behind that. And so if we actually ask and listen to the answers, that's what patients really uh I respond to. I think it's the genuineness that really matters.

SPEAKER_00 26:24

And we hear a lot about how it's best for healthcare to be collaborative. But some patients do turn up who want to feel completely in your hands, they want to feel completely looked after by an expert, um, to not have to make very difficult decisions with complicated data. How do you strike the right balance?

SPEAKER_05 26:45

So for every patient, you want to get a sense of how much agency they want and where they want you to be uh in that spectrum. But you have to elicit that. You know, I had one patient uh who wrote about in another book who the issue is whether or not he should get um a pacemaker, a defibrillator and a pacemaker. And he really said, you know, you tell me what to do. And I remember feeling uncomfortable about that, but he really the burden of making the decision was too hard for him. So I talked with him and tried to elicit his values, and then I did my best based on on what I thought would be best for him. But he it would have been unfair for me to say, you know what, I will say nothing, it's all your decision, because then I'm I'm abandoning him.

SPEAKER_00 27:23

Aaron Ross Powell We've heard how empathetic consultations can you know avoid miscommunication and improve adherence, but it can also directly improve clinical outcomes via the placebo effect. Tell us about that Italian study with the IV drips published in the journal Pain.

SPEAKER_05 27:39

Aaron Ross Powell Sure. Usually in terms of research trials, where you always want your new medication tested against the placebo, and that's absolutely rigorous, and you wouldn't have a clinical trial without that. But in clinical practice, we find the use of placebo a bit shady and maybe a little unethical. And this um trial was with patients who had chest tubes, very painful condition, which it's a tube in your chest, requires strong um morphine-like medications. And they uh had two groups of patients who got the same amount of morphine. One group got the morphine in a drip every four hours, and the other group, every four hours, the doctor came in and pulled up the syringe full of morphine, injected it. And those latter patients had twice the amount of pain relief compared to the other ones, with the same amount of morphine, twice as much. And it points out that the ritual around the care, everything around us, when the doctor comes in, talks to you, how are you, asks you, maybe examines you, you see them pulling up the medication, the syringe, the injection, all of that adds to the um analgesic effect, and that's a value. I had one patient tell me, I don't care if it's a dill pickle, if it makes my pain better, you know, I I want it.

SPEAKER_00 28:49

There was a quite a moving editorial by Dr. Abraham Vergese, which you probably come across in the BMJ in 2009, called In Praise of the Physical Examination. And he says, We propose that if the ritual is short-changed, if it's done in a cursory fashion, if its sacredness seems to be violated, then the formation of the doctor-patient bond does not take place. We believe the failure of that bond could account for a great deal of the dissatisfaction patients express and doctors feel about their encounter.

SPEAKER_05 29:20

I wholeheartedly agree with that. And I and I look at placebo and communication as tools in our bag. We have many tools in our bag, thankfully even more tools than we had a hundred years ago. And and that and I wouldn't ever want to be without my tools of MRIs and antibiotics and chemotherapy and heart transplants. Those are are wonderful and life-saving. But if I can double the pain relief with how I present, you know, the medication, why not give them both? There's no downside. But I I also look at the physical exam um as a as a refuge. You're now communicating only with words in touch, with no technology between you. And that is increasingly rare in medicine and in society at large. And once you're talking with nothing between you, a conversation of a different type is possible. And in countless times, it's only when I'm, for example, listening to a patient's lungs they remember, oh, the cough I was having. Or they feel comfortable enough to reveal the depression issues or sexual symptoms or domestic violence, things they didn't feel comfortable at the desk with the computer, because talking and touching is very intimate. It's not a romantic intimacy, but it's intimate nevertheless, and that changes the dynamics of the conversation.

SPEAKER_00 30:40

That was Danielle O'Frey sharing insights from her book, What Patients Say, What Doctors Hear. Thanks also to Shamsul Shah for joining in this episode of Pomegranate Health. Just to recap the main points they make. When introducing yourself to a patient, it's worth clarifying your role from all the different staff they see. When taking a history, try and let the patient speak uninterrupted, as they may reveal important details which are otherwise overlooked in a more hasty interrogation. And the more engaged you appear as a listener, the more coherent the history is likely to be. Use commonplace descriptors of disease in therapy, as these are retained better than unemotive technical jargon. To make sure you and the patient are on the same page, you can ask them to repeat back what they've understood. When it comes to adherence to therapy, there may be hidden personal or social reasons that get in the way. It's worth trying to understand the unique barriers each patient has. Some scenarios are emotionally challenging, and it can be helpful to reflect on your own reaction to a patient or their outcomes. Share your feelings with colleagues and the burden of so-called compassion fatigue. If you're thinking about establishing Schwartz rounds in your hospital or clinic, follow the link from our website. Thanks to the Schwartz Center for Compassionate Care for allowing use of the audio clip you heard earlier. Our web address is racp.edu.au forward slash podcast, and you'll find a transcript of this episode embedded with all the academic references mentioned. There are also links to some other interesting podcasts about communication and empathy. Click on my CPD to log credits for using these resources, and subscribe to every episode of Pomegranate Health via the mailing list or any podcasting app. I'm Mick Kavazzini. I hope to hear from you.