Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

Zulman DM, Haverfield MC, Shaw JG, et al.
JAMA. 2020;323(1):70–81.
doi:10.1001/jama.2019.19003

Key Points

Question  What are the most promising practices to foster physician presence and connection with patients?

Findings  This mixed-methods study identified 5 practices that may enhance physician presence and meaningful connection with patients in the clinical encounter: (1) prepare with intention; (2) listen intently and completely; (3) agree on what matters most; (4) connect with the patient’s story; and (5) explore emotional cues.

Meaning  For busy clinicians with multiple demands and distractions, 5 recommended practices have the potential to facilitate meaningful interactions with patients.

Abstract
Importance  Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

Objective  To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

Evidence Review  Preliminary practices were derived through a systematic literature review (fromJanuary 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (−4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Finalrecommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

Findings  The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions).

Conclusions and Relevance  This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

The research is here.

How AI is transforming the NHS

Ian Sample
The Guardian
Originally posted July 4, 2018

Here is an excerpt:

With artificial intelligence (AI), the painstaking task can be completed in minutes. For the past six months, Jena has used a Microsoft system called InnerEye to mark up scans automatically for prostate cancer patients. Men make up a third of the 2,500 cancer patients his department treats every year. When a scan is done, the images are anonymised, encrypted and sent to the InnerEye program. It outlines the prostate on each image, creates a 3D model, and sends the information back. For prostate cancer, the entire organ is irradiated.

The software learned how to mark up organs and tumours by training on scores of images from past patients that had been seen by experienced consultants. It already saves time for prostate cancer treatment. Brain tumours are next on the list.

Automating the process does more than save time. Because InnerEye trains on images marked up by leading experts, it should perform as well as a top consultant every time. The upshot is that treatment is delivered faster and more precisely. “We know that how well we do the contouring has an impact on the quality of the treatment,” Jena says. “The difference between good and less good treatment is how well we hit the tumour and how well we avoid the healthy tissues.”

The article is here.

Dealing with Racist Patients

Kimani Paul-Emile, Alexander K. Smith, Bernard Lo, and Alicia Fernández
N Engl J Med 2016; 374:708-711

Here is an excerpt:

Beyond these general legal rules, when patients reject physicians on the basis of their race or ethnic background, there is little guidance for hospitals and physicians regarding ways of effectively balancing patients’ interests, medical personnel’s employment rights, and the duty to treat. We believe that sound decision making in this context will turn on five ethical and practical factors: the patient’s medical condition, his or her decision-making capacity, options for responding to the request, reasons for the request, and effect on the physician (see flow chart). It’s helpful for physicians to consider these factors as they engage in negotiation, persuasion, and (in some cases) accommodation within the practical realities of providing effective care for all patients.

The patient’s medical condition and the clinical setting should drive decision making. In an emergency situation with a patient whose condition is unstable, the physician should first treat and stabilize the patient. Reassignment requests based on bigotry may be attributable to delirium, dementia, or psychosis, and patients’ preferences may change if reversible disorders are identified and treated. Patients with significantly impaired cognition are generally not held to be ethically responsible.

The article is here.

Over half of doctors have symptoms of burn-out: survey

Lynn Desjardins
Radio Canada International
Originally published August 28, 2017

A recent survey suggests that 54 per cent of Canadian doctors have symptoms of burn-out and it’s a problem that physicians themselves don’t like to talk about. This was a topic much discussed at the annual meeting of the Canadian Medical Association which represents more than 80,000 doctors.

‘Very frustrating and annoying’ interventions required

“First and foremost, it’s about the inability that physicians have sometimes to get what the patient actually needs in a timely way,” says Dr. Granger Avery, immediate past president of the Canadian Medical Association.

“So, that’s whether looking for a consultation, following up on an operation, whether it’s transferring a patient from one level of service to another, these things often require the doctor to make repeated phone calls, repeated interventions to get what should be a relatively simple piece of work done. So, that’s very frustrating and annoying for a physician who’s been brought up and trained and focused on helping people, not doing that administrative work.”

The article and the podcast are here.