Opening Case Study
Rhonda calmly told her family that she was ready to face her breast cancer surgery and the treatment that would follow. She had taken pride in being an empowered patient. She had done extensive research on the Internet, had contacted support groups to network with former patients, and asked acquaintances in the healthcare field to give her advice on treatment options and providers. Rhonda had finally decided on a treatment center less than an hour from her home, where she was told that she would be working with one of the best surgeons in the country.
Once Rhonda met her surgeon, Dr. Braghieri, she felt somewhat less empowered. While she knew that his credentials were impressive, his bedside manner was not what she had hoped for. When she first met him, he quickly shook her hands and then sat down to go over her chart, barely making eye contact with her. He asked her a few questions but often cut her off mid-sentence to ask her another one. After their first conversation, he reviewed what he called her ‘presenting symptoms,’ repeated her diagnosis, and went through his recommended course of treatment.
“Let me know what you decide and we’ll get started right away,” he said as he stood and prepared to leave the room. He shook her hand again and was gone.
Keep in Mind: Have you ever been in a situation with a healthcare provider or professional in which you were uncomfortable with his/her bedside manner? What was it about their behavior that was off-putting to you? Did you talk to other patients about your impressions? And were they similar to yours? Patients may vary in terms of how they prefer to communicate with the healthcare professionals they work with, and these expectations have a direct impact on their satisfaction with ongoing communications.
After Rhonda completed her surgery, which was successful, she talked with Monie, one of the oncology nurses at her treatment center, to begin planning for her upcoming chemotherapy.
“Let me start by telling you one thing right now,” Rhonda said to Monie. “I didn’t expect much of a bedside manner from Dr. Braghieri and that’s what I got. Not much of a bedside manner. I felt like he was a robot and I was some kind of machine he was repairing. I had really checked him out beforehand and I decided he was the best. And I still think he is. I wouldn’t have chosen anyone else. But I have to say that I am going to seeing more of my oncologist than I am the surgeon, and I am hoping Dr. Mitchell is a whole lot more patient-friendly than Dr. Braghieri was. Even with all of the research I’ve done on my condition, I feel like I’m in another country and I don’t have a tour guide. I’m going to be around here a lot while I go through chemo and I am going to need to work with people who I can talk to while I’m coming here.”
Keep in Mind: As a nurse, you might be asked to comment on a physician, or to indicate whether you agree or disagree with what a patient says. Most likely, you would want to try to make sure that each newly-diagnosed patient has initial experiences that promote positive communications as they adjust to their condition and its treatment. Are there any discomforts that would arise?
Monie had heard complaints about Dr. Braghieri before, though, like Rhonda, she considered him to be an excellent surgeon and had recommended him to friends who had been diagnosed with breast cancer. She listened as Rhonda talked but didn’t offer any comments.
Rhonda was determined to have a different experience with chemotherapy. While she had carefully chosen her surgeon, she had read and heard positive comments about all of the oncologists on the staff, and this had been a factor in choosing it. However, in spite of the positive reputation, she intended to demand that she work with someone with whom she would be able to communicate.
“Can you tell me anything about the oncologist who has been assigned to my case?” Rhonda asked.
Monie was accustomed to being asked this question, and she gave Rhonda the answer she gave to other patients with similar concerns. “We work as a team here, Rhonda,” she said. “You will have one oncologist assigned to your case, but you will also work closely with the nurses and other professionals that are part of our healthcare team. I’ll be working with you throughout your treatment, and will be overseeing your treatment plan. You can think of me as the go-to person. But let me reassure you that all of the oncologists on staff communicate well with patients.”
Rhonda considered her words and replied: “We’ll see how it goes. I’ll let you know if I am unhappy.”
Keep in Mind: How would you respond to Rhonda’s concerns? Given the unique needs of newly-diagnosed patients, how would you establish communications with her? How would you describe your role in terms of learning to communicate effectively while she is being treated so that she can get her needs met and have an experience that promotes healing?
Introduction
“I don’t understand.”
Hand in hand with the emotions that newly-diagnosed are the expectations that they have for their relationships with their healthcare providers. Often, these expectations are rooted in misperceptions, unrealistic expectations, and memories of bad experiences from the past. While communications may seem relatively secondary to the role of competent and thorough medical care, the primary concern of the healthcare team, addressing communications with patients by developing a professional relationship that encourages patients to ask questions, report symptoms, and express concerns. This, in turn, helps to assure that healthcare professionals are aware of what’s going on with patients and that their time is used as efficiently as possible.
Newly-diagnosed patients are in the process of learning to read their own bodies, to know how they should and should not be feeling, when to report a symptom or problem and when they don’t need to, and the language to use in talking about their conditions. Their healthcare team can help them to do this effectively by using the ‘teachable moments’ – the opportunities that arise along the way in which patients can be offered guidance and instruction – to build effective communications.
Keep in Mind: What has your initial exposure to the healthcare establishment been like? In what ways have you felt comfortable in adjusting to hospital/clinic protocol? Working with physicians and other healthcare professionals? In what ways have you had to venture outside of your comfort zone? Imagine being a newly-diagnosed patient who suddenly finds him/herself in this environment, negotiating the system to have his/her needs met. What do you think the major challenges would be?
The Starting Point: Help Patients Express Their Needs and Concerns
For most newly-diagnosed patients, the experience of communicating with healthcare professionals is new to them. Their interactions to date have most likely been minimal, limited to occasional illnesses or medical examinations. They are unfamiliar with the optimal manner in which to communicate to assure that their needs are met. Furthermore, newly-diagnosed patients are generally unsure as to what they can reasonably expect from a communications perspective – what they need to express and how they should express it. Patients who have been treated in the past may already developed a relationship with their healthcare team, though a new diagnosis may introduce new challenges to the relationship as needs and expectations change. Those who have been treated in the past, but by another team, may bring expectations to the new team that are unrealistic given the current diagnosis, or they may bring ‘baggage’ from negative experiences that, in turn, introduce unwarranted complications.
Healthcare professionals can greatly contribute to creating positive communications with their newly-diagnosed patients by taking the first step toward relationship building, based on the following steps:
Create Rapport
Developing rapport with a newly-diagnosed patient begins before the first word is spoken. Healthcare professionals can begin this process in two ways. The first is to be mindful of the emotions that newly-diagnosed patients may be feeling and watch for emotional cues that can guide initial interactions. A patient’s body language can reveal how open they are to interacting with healthcare professionals, as well as feelings they may be experiencing such as fear, anger, and disappointment (described in Chapter Two).
The second way to establish rapport is for the healthcare professional to be conscious of his/her own body language. An caring and welcoming attitude can be demonstrated through, smiling, maintaining eye contact, and assuming an open posture (open arms, not folded across the chest). This needs to be genuine – if the healthcare professional is not a caring person, the patient will sense this immediately. On the other hand, a hurried, distracted attitude on the part of the healthcare professional can serve to confirm the newly-diagnosed patient’s fears that the healthcare professional views them as another case and not as an individual.
Create an Open Dialogue
From the initial contact onward, healthcare professionals can promote communications by encouraging openness from the patient. This begins with encouraging the patient to express any thoughts or feelings, and ask any questions, that he/she might have. Patients are watching for the reactions they receive from their healthcare professionals, especially during the initial encounters. Ways in which the healthcare team can promote openness includes:
- Listening without interrupting, unless additional detail is needed
- Not showing alarm at symptoms that a patient expresses
- Not using eye rolling or other negative body language
- Not judging or scolding when a patient demonstrates a lack of understanding or compliance
Figure 6-__
Photo or illustration of a healthcare professional rolling their eyes or another negative body language
If newly-diagnosed patients perceives that the healthcare professional is open to anything and everything they choose to bring up – within the boundaries of the professional relationship (discussed below) – then they will benefit by having a professional who is focused on their well-being and specific needs, and healthcare providers will benefit from receiving honest information that they can, in turn, use in making decisions and recommendations.
Establish Boundaries
Establishing boundaries is always a complicated issue for healthcare professionals. However, without boundaries, not only are professional ethics at risk, but professionals are at risk for burn out. Setting boundaries with newly-diagnosed patients can be a sensitive issue. Newly-diagnosed patients may not be able to talk to their families or friends about their diagnosis and how it is affecting them, and may look to the healthcare professional as not only a medical resource, but also as a sounding board and a support system. Because of this connection, the professional may feel an additional sense of commitment, if not obligation, to the patient which may gradually extend beyond the generally accepted parameters of relationships between healthcare professional and patients. As caring individuals, healthcare professionals want to be there for their patients, and this may include not only being available during office hours but, in some cases, being available beyond office hours. Furthermore, healthcare professionals sometimes find themselves providing emotional support that begins to feel more like psychotherapy, which can be both emotionally draining as well as present ethical issues as well as liability around qualifications to practice. None of this is acceptable professional behavior and is, in fact, detrimental to the patient.
Crossing boundaries also presents issues for newly-diagnosed patients. When the healthcare professional takes on too much responsibility, the patient is less likely to develop emotional coping skills, or create a support system of family and friends that will be necessary as they move forward beyond their treatment. And if the healthcare professional is offering emotional support and advice that is not optimal for the situation, and the patient exhibits complicated emotional reactions, such as extreme depression, the patient is at risk for not receiving needed treatment by a mental health professional.
While boundaries have been briefly alluded to in previous chapters, the following are guidelines to consider for establishing boundaries with newly-diagnosed patients.
Gently establish boundaries at the beginning of the relationship so that patients are aware from the beginning what they can and cannot expect on an interpersonal and professional level. Additionally, most practice settings have established guidelines, both formal and informal, regarding patient-healthcare professional interactions, that both patients and professionals are expected to follow.
Keep in Mind: Have you ever been in a situation in which you allowed communications to move in a certain direction and then decided that boundaries were being crossed and tried to change the way in which you were communicating with that person? Clearly defined communications boundaries, if established at the beginning of a relationship, can help in avoiding uncomfortable issues later on.
Figure 6-__
Photo of a patient talking with a patient.
Examples of Boundary-Establishing Statements
The following are positive statements that can be used with patients to introduce boundaries:
- “I’m only here on certain days, but there are other nurses in the office who could also talk to you after you meet with the doctor.”
- “I’m willing to listen and tell you about resources other patients have used when they were dealing with similar concerns, but I’m not qualified to give you that kind of advice.”
- “I just can’t give you my cellphone number. You might really need to talk to me and I would be worried that I wouldn’t be available. Let’s talk about some other emergency support options.”
- “I am not the best person for you to have this conversation with, but I think it is important for you to talk to a qualified mental health professional. Can I help you to find someone who could help you with this?”
- “I know you have family and friends who would want to be available to you during this time. Is it time to reach out and get them more involved?”
- “Can I suggest that you get connected with a support group in the area? It would be a way for you to meet other patients who could share their experiences.”
- “The practice has established guidelines regarding relationships between patients and members of the team. These guidelines protect both of us and help us stay focused on your health. That would be considered a violation. But I can give you a couple of other options.”
Keep in Mind: What are your hot buttons in terms of the areas in which you most need to establish boundaries with newly-diagnosed patients? For example, do you see yourself at times getting too involved in solving their problems? Or, do you see yourself at risk for making yourself too available to patients and not taking enough time to recharge when you are away from your job? The challenges that newly-diagnosed patients face can at times cause their healthcare professionals to feel helpless. These are issues to consider as you form relationships.
Keep in Mind: Have you ever visited a foreign country and wondered how you should behave to have your needs met but also avoid offending anyone? Newly-diagnosed patients often feel the same way.
How Newly-Diagnosed Patients Experience the Healthcare System
When newly-diagnosed patients begin to engage with the healthcare establishment, what they experience is not unlike what it is like for a tourist to visit a foreign country. The residents speak a language that is different from the tourists – even if the same language is being spoken, certain words have a different meaning, while local expressions may be completely confusing. The style of dress in the foreign country is most likely different from what a tourist may be accustomed to, and he or she may consequently be unsure as to whether any significance is attached to the various outfits that people are wearing. Etiquette is most likely very different in this unfamiliar country, with people behaving in ways that are either completely unfamiliar or, most likely, would be interpreted differently back in the home country. The food may be cooked with spices that don’t initially taste good or, on the other hand, may seem bland or tasteless. Newly-diagnosed patients often describe their experiences in hospitals, clinics, or doctor’s offices in similar terms.
Figure 6-__
A humorous illustration of someone dressed like a tourist, surrounded by people dressed as healthcare professionals.
“Those guys have their own language.”
Healthcare professionals have to learn to speak in ‘shorthand’ with each other. They simply don’t have time to articulate every word, nor do they need to. Abbreviations like ‘SOB’ for ‘short of breath’ is quick and to the point, and helps to avoid miscommunication. Discussing what symptoms a patient is ‘presenting’ – as if the patient were offering a gift – is part of the medical language that professionals use with each other. Technical terminology like ‘neutrapenic’ and ‘adjuvant’ are clear to professionals but also examples of ‘insider talk’ that is not understandable to outsiders.
Newly-diagnosed patients, however, can feel confused and intimidated when healthcare professionals use unfamiliar abbreviations, expressions and technical terminology during conversations. This can contribute to emotions like fear, when misunderstood words and phrases cause undue alarm, and anger, when medical terminology contributes to a feeling of alienation. The result is that patients can feel frustrated and even more out of control. Indeed, learning the language of the healthcare establishment is one of the challenges that patients face as they face their condition and its treatment.
The process of adjusting to a new diagnosis, for patients, requires that they learn the language of this new world of healthcare that they are entering into. Healthcare providers and professionals can greatly assist this process by watching for signs that the patient may or may not understand what they are saying, and checking in with patients to ascertain that the terminology is being understood.
Figure 6-__
Illustration of a healthcare professional towering over a patient, with a speech bubble filled with medical terms and the patient cowering in fear
Example
What not to say:
“Hi Mrs. Smith. I’m looking at the physician’s orders here and I see that you came in today presenting some difficulties with Activities of Daily Living. Your complete blood count shows that you are anemic, so has prescribed growth factors.”
Encouraging empowered patients:
“Hi Mrs. Smith. The doctor says that you are anemic. Do you know what that means? You told the doctor that you were really tired and having some trouble concentrating and getting things done around the house. You blood test shows that you have some anemia, which would explain why you are feeling this way. We are going to give you a treatment for anemia that should get you feeling better in a few weeks or less. Before we talk about the treatment, do you have any questions about anemia?”
Figure 6-__
An illustration of a patient shivering in fear.
“I am never sure if I should ask a question or not.”
Newly-diagnosed patients often struggle with understanding who has the ‘power’ in their relationships with their healthcare professionals. One of the areas in which the power relationship is most evident is the concerns that patients have around asking questions. Generally, they want to communicate in a way that promotes positive communications, and doesn’t result in healthcare professionals avoiding contact with them, feeling disrespected, or otherwise not giving them their full attention and consideration. These concerns are essentially about power and superstitious thinking – as newly-diagnosed patients adjust to their condition, they want to make sure that they ‘stay on the right foot’ with their healthcare providers.
Older patients, who usually have a more traditional approach to their health care, are more likely than younger patients to perceive themselves as having less, or no, power, and their healthcare providers to have all of the power. Younger patients tend to be more assertive, as do Fighters. Superstitious thinking plays a role here as well. Newly-diagnosed patients often express the concern, directly or indirectly, that they will damage the relationship and, by extension, their treatment and recovery, if they question recommendations. They often have a fear that they may ‘jinx’ the effectiveness and/or somehow alienate their healthcare provider.
By encouraging patients to ask questions, healthcare providers can ease the power concerns for newly-diagnosed patients and enhance communications. Patients who ask questions are more likely to be complaint because they will understand their condition and its treatment, and be more likely to accept their healthcare-provider’s recommendations. Physicians may have limited time to answer patient questions. And patients may feel especially hesitant to ask questions of their healthcare provider, for the reasons described above. Consequently, healthcare professionals are more likely to be asked questions by patients and to build the relationship through their responses.
Examples
What not to do:
“I’m going to go through the list of prescriptions with you to review how you should take each one, and when you should take it. This information is also provided on the prescription bottle.”
Encouraging empowered patients:
“I see that you have some different prescriptions to take. This might feel like a lot to keep track of at first, so I will go through them with you, one at a time. Before I start, I want to see if you have any questions. And as we go through the list, also feel free to jump in if you have a question.”
“I am always worried I might offend somebody.”
As discussed previously, newly-diagnosed patients experience the healthcare establishment as an alien culture. Not only is the language foreign to them, but so are the customs. For example, the application of HIPAA rules may require that a patient not approach the reception desk if another patient is already being helped, as a means of protecting patient confidentiality. Therefore, if the receptionist requests that the patient step aside until the first patient is served (and on a busy day this may not be conveyed by the receptionist in the friendliest of terms), the patient being dismissed may feel as if he/she has made an egregious error or feel embarrassed. Clinics or hospital units that serve a large number of patients often have customs and rules that can further contribute to the confusion that a newly-diagnosed patient is feeling. Having to report to the billing office, for example, may leave patients confused if forms and policies are not carefully explained or if they are not treated in a humane manner. This treatment is something that the healthcare professionals who subsequently treat them have no control over, yet may have to listen to patient complaints or provide support for patients who feel additional fears and concerns after this interaction. Hospitalized patients, who have to rely on the schedules and procedures of this environment feel the culture shock even more acutely.
Newly-diagnosed patients are placed at a disadvantage when presented with the culture of the healthcare establishment. The confusion as to what is appropriate while they learn the system can be overwhelming. While patients in Fight reaction learn to adjust, those in Flight or Freeze feel even more overwhelmed and powerless. Patients often react to the strangeness of this environment the way in which they behave when visiting a foreign country. They tread carefully, motivated out a desire to do the right thing to get what they need, and to avoid ‘offending’ the natives. This results in tentative behavior, additional fear and frustration, and disempowerment. Patients will often hold in their frustration, rather than expressing it, out of a desire to ‘choose their battles.’ Their caregivers may advocate on their behalf, or they may adopt the same tentative attitude.
Healthcare professionals are not necessarily in the position to modify policies and procedures of the organizations they work for. However, they can help by being sensitive to how patients are feeling, and introducing behaviors that will encourage patients to be more assertive. Increasing patients’ comfort level in this new environment encourages them to be more open, which reduces stress and makes communication more effective.
Example
What not to say:
“You can’t stand here.”
Encouraging empowered patients:
“We have procedures here that we need to follow. It doesn’t always feel like it, but they really protect you and other patients. We have to ask patients to come to the desk one-at-a-time to protect confidentiality. Don’t worry, new patients don’t know about that.”
Figure 6-__
An illustration of a patient obviously confused.
“I’m not sure what they want me to tell them about.”
Newly-diagnosed patients are in the early process of getting familiar with their conditions. Part of this process is learning to understand what symptoms are associated with the condition and its treatment – including symptoms that result from the condition or the treatment as well as symptoms that they have not experienced but that the healthcare team is watching for. Patients, out of a need to try to work, if not also ‘please,’ their healthcare providers, may try to anticipate what they should be reporting on. They learn these cues from listening to what their healthcare providers ask them about and, based on these questions, form assumptions in their minds regarding what is important.
While this may streamline the communications process, patients may inadvertently avoid reporting symptoms that are also important but, in their minds, are of less interest. Or, they may avoid reporting on the symptoms that they perceived as important to their healthcare providers out of a desire to appear as well as possible and out of a desire to have their providers feel as if they are doing a good job. Conversely, some patients may over-report symptoms as a means of maintaining involvement with their healthcare provider or to hasten the treatment process by signaling that more medication is needed.
Clearly it is impossible for healthcare providers to anticipate how their newly-diagnosed patients are going to interpret the questions they ask them. However, some of the second-guessing that often occurs can be avoided by making it clear that, while specific questions are being asked, providers are interested in anything that seems to be out of the ordinary.
Example
What not to say:
“How is your appetite? Sleeping okay? How is your energy level? Alright, sounds like everything is fine.”
Encouraging empowered patients:
“As you adjust to your condition and its treatment, there are some symptoms that I am going to be especially concerned about. But let’s start by asking you to tell me how you have been feeling over the past week. And then I’ll ask you some more specific questions.”
Figure 6-__
A humorous illustration of a patient sitting in a lounge chair, feet up, receiving a manicure.
“I don’t want to be high maintenance.”
With some exceptions, the majority of newly-diagnosed patients want to perceive themselves as ‘good’ patients. They want their healthcare team to see them as compliant, following their treatment guidelines and reporting in for check-ups, or additional treatment, as necessary. For many patients, part of the internal bargain they have made with the healthcare team is that they will not take too much of their time and not raise any unnecessary alarms. They assume that if they are well-behaved, they will also be offered the best care possible because their healthcare professionals will be more likely to enjoy working with them and will, subsequently, reward them with additional attention and concern. As discussed previously, patients may exhibit superstitious thinking in this area, such as the belief that a positive relationship will result in a better prognosis because they will somehow be rewarded for their good behavior.
In a busy medical practice, the physicians may inadvertently, or intentionally, convey to patients that their time is highly limited and offer basic guidelines regarding any exceptions to the standard appointment schedule. The other healthcare professionals on the team, including the nursing staff, may be operating under the same guidelines. However, newly-diagnosed patients, until they have established a routine with their healthcare providers, may over-interpret these guidelines as implying that contact is discouraged. Out of a concern for being overly demanding or ‘high maintenance,’ patients may consequently avoid reporting symptoms or discomfort they may be feeling, as well as exaggerate any progress they may be making in their treatment so as to make themselves a more attractive patient.
Example
What not to say:
“I see that you’re not a complainer. That certainly makes my job a lot easier.”
Encouraging empowered patients:
“I know this is all new to you and you are still learning what to expect from your treatment. You can really help us if you let us know what’s going on with you as you adjust to your medications.”
“She looks really worried about me.”
As newly-diagnosed form relationships with the healthcare professionals who are treating them, they not only seek out verbal cues as to the perceptions and expectations of those who are caring for them, but they scrutinize body language as well. Watching body language is both a conscious and an unconscious process. On the conscious level, they will watch for signs of concern, such as when healthcare professionals frown or fold their arms across their chests, and may consequently assume that something is not going well in their treatment. On the other hand, newly-diagnosed patients will also seek out signs that the treatment is going well, if not completed, and may over-interpret a smile or a ‘thumbs up.’ More subtle body language cues, such as looking away when speaking to the patient, or a hand gesture that implies something is being brushed aside, may have meaning to a patient even if they are not able to articulate it.
As discussed in previous chapters, body language is an integral aspect of communications. In fact, it has been said that only 7% of communications is based on the actual words spoken and 9% is non-verbal, much of it based on body language (REFERENCE). As such, to attempt either to suppress body language, or to over-control it, is likely to be perceived as forced or unnatural on both a conscious and unconscious level. This can, in turn, result in discomfort on the part of the patient and contribute to a lack of trust. However, it can be useful for healthcare professionals to remain aware that their newly-diagnosed patients are scrutinizing them for visual cues, both positive and negative, and that these cues will likely be over-interpreted. This awareness can, for example, help to avoid inadvertently appearing to be overly concerned when merely focusing attention on the patient or reacting to an unrelated concern.
Additionally, healthcare professionals can benefit from observing their newly-diagnosed patients’ reactions to body language and other verbal cues and, when it appears that a patient may be misjudging their body language, to take a moment to ‘check in’ and clarify the patients perceptions and their own intentions.
Example
What not to say:
Demonstrate body language that is mismatched with the situation, e.g. sitting with a patient to discuss their initial experiences with a new medication and frowning in concentration.
Encouraging empowered patients:
“I want to carefully go over how you are feeling with this new medication. I’m going to be very focused while you talk because I want to learn as much as possible from you.” (The healthcare professional would also need to demonstrate active listening here.)
Figure 6-__
A patient making demands, with an angry expression
“I expect to be treated like a customer here!”
We live in an era of greater assertiveness on the part of patients. While this assertiveness can be of benefit to communications between patients and healthcare professionals, as patients ask more questions and participate more actively in their treatment, this assertiveness can sometimes come across in a manner that is less than productive. For example, patients’ assertiveness may be expressed in a demanding or accusatory manner.
For newly-diagnosed patients, inappropriately expressed assertiveness may arise from more than one cause. They may be reacting out of the fear factor, and demanding behavior may be an expression of panic or a cry for help – unrecognized or suppressed fear may be expressed as anger. Newly-diagnosed patients may also be expressing their lack of experience with the healthcare establishment when their assertiveness comes across as distrust – they may be operating under the impression that, if they are not aggressive, they will be ignored. Additionally, past experiences in other healthcare settings, as a caregiver or patient, may influence current behavior – newly-diagnosed patients may initially generalize, and assume that they need to behave in a demanding manner in all healthcare settings. Furthermore, newly-diagnosed patients may simply misunderstand the current emphasis on patient empowerment to imply that their needs will not be met without a ‘battle.’ Attention in the media regarding the difficulties that patients have sometimes faced certainly contribute to this misperception that healthcare professionals should automatically be distrusted. Unfortunately, newly-diagnosed patients who often have a lack of experience in dealing with healthcare professionals, are susceptible to negative imagery and react accordingly.
When exposed to – or confronted by – newly-diagnosed patients who are behaving in an aggressive manner (loud, pushy, demanding), the starting point for healthcare professionals is to recognize their own initial reactions. It is only human nature to respond emotionally to aggressive or otherwise unpleasant behavior, with reactions that include retreating from or avoiding the patient, responding in kind with similarly aggressive behavior, or some type of withholding or passive-aggressive behavior such as verbally agreeing to a demand but not following through. However, responding emotionally will most likely result in further demonstrations of unpleasant behavior on the part of the patient, and potentially, the healthcare professional.
Instead, it can be helpful for healthcare professionals to ‘take a pause’ and evaluate their own initial emotional reactions to aggressive or demanding patients. This might be as simple simply reminding oneself that the newly-diagnosed patients is under a lot of pressure and expressing their fears or lack of experience in an inappropriate manner, or using a relaxation technique like deep breathing to provide an opportunity to reflect on their responses and deflect the patient’s negative attitude. Verbal responses focused on acknowledging the patient’s needs and concerns can in turn signal to the patient that he/she is being understood which, in turn, reduces the patient’s need to behave aggressively. Reflective listening, described in Chapter __, is useful in these situations.
Example
What not to say:
“I have a lot of patients making demands on my time. Giving me orders is not going to get you very far around here. So calm down.”
Encouraging empowered patients:
“I know this is all new to you. You’re getting to know us, and we’re getting to know you. We’re doing everything we can to make sure you get everything we need. Let’s try to be patient with each other while we get a routine in place.”
Compassion, and Being Sensitive to the Role of Helplessness
An underlying them explored in previous chapters has been the role of helplessness. Virtually all newly-diagnosed patients deal with a sense of helplessness around their condition, for many it is the first time in their lives that they have not felt in control of their own daily lives as well as, at varying levels, their destinies. Some patients accept that they are not totally in control, and learn to live with their conditions as they are unwelcome but unavoidable houseguests who might stay for a short period, or indefinitely, but will only leave on their own volition. At the other extreme are newly-diagnosed patients who are overwhelmed by their sense of helplessness, or simply refuse to recognize it, or give into it completely. In any event, helplessness is that elephant in the room that, as described in Chapter Three, cannot be ignored or talked around indefinitely.
Helplessness often finds its way into conversations between patients and healthcare professionals, either directly or indirectly. Patients do not respond well to being confronted about their helplessness, or told that it is irrational. Furthermore, treating patients for mental health issues is not within the healthcare professional’s scope of responsibility. However, patients do respond to professionals who exhibit a sense of compassion. Compassion can be described as an attitude of concern and acceptance of the ways in which patients react to their diagnoses, even when these reactions add at least temporary complications to interactions with healthcare professionals. An accepting attitude benefits both the patient and the healthcare professional by neutralizing the stress and frustration that difficult patients can present, and helping to assure that the healthcare professional’s reactions do not, in turn, further complicate interactions. Compassion can be exhibited through:
- Demonstrating active listening
- Maintaining a calm, patient demeanor when patients express their emotions or are resistant or defensive
- Encouraging patients to express their hesitations or concerns
- Offering referrals for counseling or support groups if patients are open to these options
Figure 6-__
A diagram with a wheel, with compassion in the center, surrounded by spokes separating the words: Active listening, Calm demeanor, Encouraging, Offering referrals
Keep in Mind: What kinds of experiences have you had in dealing with physicians, both as a patient and as a healthcare professional? In what ways have you seen physicians be especially helpful? In what ways has communication been less positive? Newly-diagnosed patients enter into the treatment relationship with similar experiences which, in turn, affect their current expectations regarding how their physicians should, and should not, communicate.
Handling Problem Situations Between the Physician and the Patient
Situations sometimes arise between newly-diagnosed patients and their treating physicians that can result in tension and frustration for both parties. While there any number of causes, newly-diagnosed patients present unique challenges to their treating physicians, and members of the nursing staff, as well as other members of the healthcare team may find themselves in the position of listening ear for both the patient and the physician and mediator in problem resolution. Realistically, their efforts will be directly primarily toward newly-diagnosed patients, assisting them in understanding the perspective of the treating physician and coaching them to better understand the physician’s recommendations and how to remain compliant, as well as the best way to interact with the physician on an ongoing basis.
Some of the issues that arise, and optimal ways for non-physician healthcare professionals to handle them, are discussed below.
“The doctor doesn’t listen to me.”
Physicians are constantly under time pressure, and cannot always spend as much time as newly-diagnosed patients might feel they need in answering their questions or providing emotional support. Some physicians are more comfortable with this level of patient interaction than others; practice setting guidelines regarding the allocation of time for each patient also plays a key role. Nevertheless, newly-diagnosed patients often require additional ‘hand-holding’ when they are initially coping with the news of their diagnosis, treatment decisions, and adjusting to their treatment. Physicians may explain the constraints they work under, and their professional boundaries, to their patients who, in turn, may not fully understand or accept these constraints and boundaries. Or, they may not explain them at all. Either way, newly-diagnosed patients may feel confused or frustrated by what they perceive is an unwillingness on the part of their physician to give them the attention they need. Other communications issues may arise that result in patients feeling that they are not being listened to. For example, the treating physician may feel that he/she has fully answered a patient’s question or addressed a complaint, yet the patient hasn’t fully understood the answer or doesn’t accept it.
While over time patients learn what they can and cannot expect from their physicians, the initial adjustment to the constraints of their relationship can be problematic.
Members of the healthcare team – and often, receptionists – may hear complaints from patients expressed in terms of frustrations around what they perceive is the physician’s unwillingness to listen to them, expressed indirectly, through subtle hints that their complaints are not always being heard, or directly, through open-criticism of their physician. In turn, physicians may complain to the nursing staff that a patient is difficult to deal with and/or may request that a nurse provide additional ‘face time’ with a patient. Again, practice guidelines in terms of the relative roles of physicians, nurses, and other healthcare professionals may also guide these interactions.
Newly-diagnosed patients can benefit from reassurance that the physician is indeed watching over their case and that they are being treated based on best practice guidelines relevant to their condition. Patients in Fight reaction may request additional information regarding standard treatment approaches, or directed toward Web-based or printed information that will further answer their questions. It may be helpful to briefly explain the treating physician’s personal style so that the newly-diagnosed patient has a perspective on his/her ‘bedside manner,’ which may in turn replace ‘second-guessing’ the physician with a more realistic perspective. What is of course to be avoided is implying agreement with the patient that the physician is somehow remiss or otherwise criticizing the physician, or volunteer to be the ‘go between’ with the physician. Newly-diagnosed patients can also benefit from coaching in terms of how to record symptoms and complaints and present them in a way that is an efficient use of the physician’s time.
Example
What not to say
“The doctor is too busy to listen to you again. He’s already answered this question before.”
OR
“You’re right. She’s not a very good listener.”
Encouraging empowered patients:
“You said you don’t feel much better yet and you’re beginning to wonder if the medication is working at all. Let’s go through some information I have on what to expect when your treatment begins.”
Figure 6-__
An illustration of a patient and a physician, both of them with angry expressions
“The doctor keeps getting angry at me.”
Physicians are human like everyone else. Sometimes they become impatient when patients don’t seem to listen to them, or when they have assurances from patients that they will be compliant with treatment and they discover that they aren’t. Newly-diagnosed patients, on the other hand, are often highly sensitive to any negative reactions on the part of their physicians, and may draw irrational conclusions. These reactions include the fear that their physician will become frustrated with them and not treat them to the utmost of their abilities or decide not to work with them at all. Newly-diagnosed patients, because of the impact of their illness on their daily lives, may also feel entitled to what they feel should be infinite patience and consideration on the part of their treating physician, and will consequently overreact to any indications that this is not the case.
Members of the healthcare team can assist both the physician and the patient when these conflicts occur by asking the patient to clarify what it was that, in the patient’s eyes, caused the physician to express frustration or anger. He or she can subsequently provide perspective around the conflict, in terms of explaining what may have caused this reaction from the physician, as well as help the patient to understand how to avoid these conflicts.
Example
What not to say:
“The doctor gets in a bad mood. And if you aren’t doing what she tells you to do, you’re going to receive the brunt of it.”
The patient friendly approach:
“From what you described, it sounds like the doctor was hoping that you would have your diet in place, and be monitoring your blood sugar regularly, and as you said, you aren’t quite on track with that. Let’s talk about what help we can get for you in putting a routine in place that is going to help you to get feeling better.”
“I don’t agree with the doctor about this.”
Patients and their treating physicians are not always going to agree with each other. Sometimes newly-diagnosed patients are resistant to treatments they feel are extreme or unwarranted. Denial of the condition may play a role here or, because the patient doesn’t experience any specific symptoms, he/she may not quite accept that treatment is even needed. Patients who feel they have educated themselves about their condition may feel that they have opinions on alternative treatments that their physician should be respecting and taking into consideration. Personality conflicts between physicians and patients may arise, such that the patient is combative or distrustful of any recommendation. Patients in Fight reaction are most likely to disagree openly with their physicians. However, patients in Flight who are emotionally overwhelmed may simply overreact to any suggestion from the physician and, as a result, become argumentative. Patients in Freeze may use an argument as a means of avoiding discussing an important treatment decision.
Newly-diagnosed patients may look to other healthcare professionals as sounding boards when they have a disagreement with the physician. They do this out of a need to ventilate and feel supported, especially if this disagreement results in feelings of helplessness or fear. During the course of these discussions, they may also look to healthcare professionals to intervene with the physician, or otherwise advocate for them. This situation can be uncomfortable for the healthcare professional, and if not handled appropriately, can contribute to the conflict the patient is having with the physician.
The key to these discussions is to remain both objective and uninvolved, while also being supportive in a way that serves to reduce conflict and enhance the patient’s trust of the physician. Often, what newly-diagnosed patients need most is a listening ear, and reassurance that the physician is experienced in working with their condition and is providing the best care possible. It can also be helpful to make suggestions to the patient in terms of how to present their concerns to the physician in a way that is collaborative and not confrontational. Reminding newly-diagnosed patients that adjusting to a new medical treatment can be an uncomfortable and frustrating process, and that part of this process is learning to trust the physician, can also help to relieve frustration.
Example
What not to say:
“The doctor is the expert here, not the patient. You need to trust her if you are going to work together.”
OR
“The doctor is not always right. Speak up and let him know what you want.”
Encouraging empowered patients:
“I know it’s not easy to begin treatment for a new condition. A big part of the process is not only learning about your treatment but also learning to trust your doctor. Always feel free to ask us questions. This will help you to better understand your treatment and the doctor’s reasons for recommending it.”
Figure 6-__
An illustration showing a nurse with titles that include teacher, leader, enforcer, and ‘good cop’
Communicating With Newly-Diagnosed Patients Around Compliance Issues
It is often the responsibility of healthcare professionals to help patients to maintain ongoing compliance with the physicians’ treatment regimen. For newly-diagnosed patients, this role can include being a teacher, a cheerleader, enforcer, and otherwise playing ‘the good cop’ to the physician’s ‘bad cop.’ This can be frustrating when patients are resistant to being compliant, generally out of feelings of fear and a sense of helplessness. In turn, healthcare professionals may question their role, and the level of their responsibility in keeping patients compliant, and boundary issues occur with patients who regress into what can feel like a child-like reliance on their healthcare professionals. Effective communication – proactively and in reactions to issues that arise – is crucial to helping patients to understand their responsibility in maintaining compliance.
Common compliance issues that arise are discussed below.
Figure 6-__
A photo of a patient and a nurse working together.
“I thought you were going to take care of me.”
The helplessness that newly-diagnosed patients experience may evidenced through avoidance of taking responsibility for maintaining compliance. For example, a newly-diagnosed patient may, out of misunderstanding, expect to be called to be reminded of the need to call and schedule a test that the physician has ordered. Because this process is new, patients may assume that that the physician’s office will handle the scheduling. When learning that this is not the arrangement, patients may express their frustration directly, e.g. “I thought this was supposed to your job,” or more indirectly, e.g. “You told me you were going to be watching over me.”
While the expectation of this level of ongoing ‘hand holding’ may initially feel like an attitude of entitlement on the part of the patient, it may also reflect the patient’s sense of fear and helplessness. In other words, newly-diagnosed patients can feel so overwhelmed by their condition and the new responsibilities that it presents that they doubt their ability to handle these new demands. Furthermore, the fear factor can interfere with a patient’s ability to listen effectively and to process, and then respond to, the demands that accompanies their condition. These demands may include keeping prescriptions filled, taking their medication on schedule, reporting for ongoing labs, maintain lifestyle management recommendations, among others.
While direct and indirect demands and expectations can be frustrating for healthcare professionals, maintaining a non-defensive attitude when patients express the expectation that compliance is the responsibility of the healthcare provider and not the patient. The patient may simply need additional specific guidelines as well as encouragement to become more responsible and empowered. Placing these responsibilities back in the hands of the patient can help patients to realize that they can manage the demands of their condition. The boundary issues may arise between newly-diagnosed patients and healthcare professionals is often evident in the ways in which patients express their expectations of the nursing team in regard to remaining compliant with their treatment.
Example
What not to say:
“Scheduling labs are your responsibility, not mine. We can’t monitor this for every patient. It has to be your job.”
Encouraging empowered patients:
“I know there is a lot to keep track of here. Why don’t we go over the list together, and make sure you know everything you need to do and, for the things that we don’t handle, who to call. If we break this all down into the individual pieces, and get them into a schedule, it will be a lot less overwhelming for you.”
“I don’t understand what you are telling me to do.”
A medical condition invariably results in change, and it is human nature to resist change if at all possible. Newly-diagnosed patients express this resistance in a variety of ways, one of which is expressed through avoiding compliance with treatment recommendations by pleading lack of understanding. Out of resistance, patients may use ‘selective listening’ in which they essentially hear what they want to hear – what is convenient and less disruptive – as well as in keeping with what helps them to feel like their condition is less ‘serious.’ The result of selective listening is that the patient attempts, consciously and unconsciously, to create their own treatment plan, and to ‘plead ignorance’ when feeling confronted with evidence that key requirements are being overlooked.
Emotions can play a role here as well. As discussed previously, patients may be so overwhelmed by fear and other emotions that they have difficulty processing and acting on the recommendations of their healthcare providers. Newly-diagnosed patients can be distracted by their emotional reactions, at least temporarily, and simply not be able to pay attention to what they are being told.
Healthcare professionals can help patients who are using selective listening by adopting an attitude of patience. If patients feel that they the healthcare professional is attempting to scold them, or to dictate to them what they should be doing, they may become even defensive and even more resistance. Instead, it is advisable to explore with patients what they understand about how they are expected to be in compliance with their treatment, and why, and what they are not understanding. Offering additional clarification, as well as assistance on how they can become compliant, can help to reduce resistance.
Example
What not to say:
“I thought I had made it clear to you that you needed to take your medication one in the morning and once in the evening. It’s not going to help you if you don’t use it correctly.”
Encouraging empowered patients:
“It’s really important to follow the treatment plan that your doctor set up. Why don’t we go over your treatment plan again. You can ask any questions that you might have, and I’ll clarify some of the details that slipped through the cracks.”
Figure 6-__
An illustration of a nurse talking to a doctor, with the patient listening at the door
“Can’t you talk to the doctor about this?”
Healthcare professionals may feel like the patient is relating to them as they ‘good cop’ while the physician is the ‘bad cop.’ They may also feel as patients are relating to them as ‘mom’ while the physician is ‘dad.’ This perception is a result of numerous factors. One factor is the traditional roles that physicians have played in the healthcare establishment, as the authorities, while the other professionals were in a secondary, nurturing role. However, the constraints of the healthcare system is a factor as well, with physicians needing to focus on diagnosing and making treatment decisions, and other healthcare professionals managing day-to-day treatment planning and communication with patients.
Hence, other healthcare professionals may be viewed as the good cops, or in a maternal role, and the physicians as the bad cops, or in an authoritative, father role. Furthermore, patients may feel that physicians are too busy, or too important, for them to approach directly.
Figure 6-__
Illustration of doctor as bad cop and nurse as good cop
When physicians are viewed in this manner, the consequence is that members of the healthcare team are going to be approached as the go-between between the patient and the physician. Newly-diagnosed patients may request that the members of the healthcare team report side effects, for example, out of a concern that the doctor won’t want to discuss it, or will think less of them if they complain. They may also approach members of the healthcare team to request a change in their regimen, or for additional medications. While not aware of this dynamic, newly-diagnosed patients can essential infantilize themselves – behave in a manner more associated with children than adults – and other healthcare professionals may participate in this dynamic but also not realize it. Furthermore, being in this role, and the power associated with it, can be temporarily gratifying. However, healthcare professionals who offer to be go-betweens may find themselves over-extended with patients constantly conveying information and making requests that should be directed toward the physician. This can be time-consuming. Furthermore, it can cause friction with the physicians who may prefer to develop a relationship of trust with their newly-diagnosed patients.
Healthcare professionals can avoid this situation first and foremost by being aware that patients may be unconsciously setting up this dynamic. Asking a healthcare professional to ‘talk to the doctor’ is one sign, especially when it involves intervening in an issue that the newly-diagnosed patient needs to address directly with the issue as part of his/her process of coping with the diagnosis and learning to take an active role in treatment.
The starting point for healthcare professionals when faced with a newly-diagnosed patient who wants them to be a go-between with the physician is to maintain the goal of encouraging independence. This might include helping the patient to clarify what it is they feel they can’t communicate directly with the physician on, and why they feel they need the involvement of another professional. The patient may simply need some help in defining the need, e.g. to request a modification of the treatment regimen or to report additional symptoms, and encouragement to be his/her own advocate. However, it is important to keep in mind that individual physicians and practices have their own preferences and guidelines for the respective roles of physicians and other healthcare professionals in communicating with patients and, consequently, healthcare professionals may be required to be more, or less, involved in communicating on behalf of the patient.
Example
What not to say:
“Sure, I’ll put in a good word for you.”
Encouraging empowered patients:
“Going forward with your treatment, you’ll be seeing her on a fairly regular basis and I’m sure she will want to work closely with you. You mentioned that you heard about a treatment for some of the side effects you’re experiencing. Why don’t you bring this up with her during your appointment today? I’m sure she will want to talk with you directly about this.”
SIDEBAR: BODY LANGUAGE
Patients experiencing conflicts and other communications issues with members of the healthcare team may have body language that includes:
Shoulder-shrugging and head-shaking, in disbelief
Arms folded across chest
Avoiding eye contact
Patting/fondling hair, showing insecurity
Standing with hands on hips
SIDEBAR: SELF-TALK
Patients experiencing difficulties in communicating with healthcare professionals may use negative self-talk that includes:
Why should I even bother to tell them? They won’t listen.
She obviously doesn’t like me so I won’t ever get her to help me.
I am too stupid to understand what he’s talking about and I look like a fool when I ask questions.
They’re too busy to spend any time with me. I will have to figure things out on my own.
They seem to avoid my questions. I think there is a lot they aren’t telling me.
Suggested antidotes to negative self-talk around patient-healthcare communications includes:
The healthcare team is busy but that doesn’t mean they don’t have the time to answer my questions.
No question is stupid. If I need to know something, I can ask someone for the answer.
A healthcare professional may be focused on their work, it doesn’t mean they are mad at me.
The healthcare team needs to know about any symptoms or side effects I might be experiencing so that they can help me better.
Just because one healthcare professional seems disinterested, that doesn’t mean that others aren’t willing to help. Maybe I need to talk to the right person.
SIDEBAR: EDUCATIONAL MOMENT
While being aware of professional and personal boundaries, and any guidelines established in the practice, there are nevertheless a number of opportunities for newly-diagnosed patients and healthcare professionals to communicate in ways that promote both emotional and physical healing. When newly-diagnosed patients voice concerns or complaints about communications with healthcare professionals, this is a time to offer reassurance and guidance. For example, making a suggestion regarding the person on the team who can best answer a specific question, and encouraging patients to make their questions known, can help to avoid a communications breakdown.
FIGURE 6-__
A patient and a nurse talking together.
Rx: Talking with a Newly-Diagnosed Patient Who Has a Communications Issue
In the case example at the beginning of the chapter, the nurse, Monie, encountered a patient, Rhonda, who had had a negative experience in working with her surgeon. Rhonda was coming into the oncology clinic feeling defensive and frustrated from her experience, and was both expecting and fearing that her interactions with the healthcare professionals in oncology would be similar. Monie knew that it was important to reassure Rhonda that patient-professional relationships would be different going forward. She also wanted to set expectations with Rhonda.
Monie: From what you are telling me, you want to have an open line of communications with the team in oncology and you’re worried that you won’t find that here. And you’re especially worried that the doctors won’t be good communicators. Is that right?
Rhonda: Yes, exactly. I have to say that I am going to need some hand-holding along the way. This is traumatizing for me. And I am hoping you can do that. I don’t want to come here and be treated like a number.
Monie: I can understand why you would say this, Rhonda. Chemotherapy is a lot to go through and I want to reassure you that we don’t intend for you to go through it alone. We’ll be with you every step of the way. And I can also reassure that our doctors are totally sensitive to the needs of patients. That’s what we’re all about.
Rhonda: That’s really good to know.
Monie: Now, I am thinking that you must have some questions about how we’ll be working together. Why don’t I let you start by letting me know what’s on your mind, and we’ll talk about what you need. Then, I’ll fill in any gaps so that you have a clear picture of what to expect. Does that sound good?
Rhonda: Sure. One of things I am wondering about is how I should work with you. Are you the nurse I’ll be working with most closely?
Monie: Yes, I am the charge nurse on your case. I am here Monday through Friday, and you can feel free to call if you have questions or want to report anything to me. We also have a general email address for the department, and you can send email messages as well.
Rhonda: That sounds good. But I’m worried that something might come up in the evenings or on weekends. And what happens if you are off for a day? I was wondering if I could also have your cell phone number and email address.
Monie: We don’t use cell phones with patients. Instead, we have an answering service that is always available, so that if something comes up, they can get you assistance right away from whomever is on call. Don’t worry, we’ll make sure you get the help you need. Our email box is always monitored by someone in the office, so you will get an answer within a few hours or less during the day, or the next business day.
Rhonda: I’m really worried that I might have an emergency and need you.
Monie: I understand. That’s why we have a system in place to make sure you’re covered if anything comes up. It’s worked well for other patients when they needed something outside of office hours. It will be there for you.
Rhonda: Okay. Now, I am also concerned about what you want me to report on. If I have a bad day, do you want to know? Are there any kinds of symptoms you are going to be looking for? I have to tell you, this is all new to me and the only thing I know about chemotherapy is what I have seen in movies and on TV, and with a couple of friends. I didn’t see anything that made me feel very encouraged.
Monie: Rhonda, this is something that patients often say to me. And I can tell you that the process is unique to each patient. I am going to go over a list of symptoms that chemotherapy patients sometimes experience. I’ll also let you know which ones we are especially concerned about. But I am going to want to hear anything that you have to tell me. Don’t worry about whether it is going to be interesting to me or not. If it’s on your mind, let us know.
Rhonda: Do I tell you or the doctor?
Monie: That’s a good question. When something comes up, call the office and talk to me or one of the other nurses. We will enter this into your chart and pass it on to the doctor. If the doctor has any concerns, you will get a call from one of us. And you can also talk to the doctor about your questions or concerns at your appointment.
Rhonda: This helps a lot. At least I know that I’m going to working with people who are willing to listen to me.
FIGURE 6-__
Illustration of stair steps, as in other chapters, labeled according to the subheads below, including ‘Educate,’ ‘Remain Objective,’ ‘Clarify,’ ‘Set Expectations,’ ‘Assess Readiness,’ ‘Avoid jargon.’
Guidelines for Enhancing Patient-Healthcare Professional Communications
Here are some guidelines to use when helping patients to communicate with healthcare professionals:
Look for Educational Moments
Newly-diagnosed patients can only take in so much information, and they tend to tune out when information doesn’t seem immediately relevant or when they feel like someone is lecturing them. Healthcare professionals can accomplish more by being sensitive to educational moments that might arise along the way. In the example above, Monie listened to Rhonda and, as Rhonda expressed her concerns, Monie corrected misperceptions and provided alternative behaviors. These educational moments present themselves in situations that include when patients express concerns about how they are being treated by the healthcare professionals with whom they come into contact, when they make requests that may or may not be reasonable, or when compliance issues arise that are clearly the result of a misunderstanding. It is at these moments that the patient is focused on a problem and will, consequently, also be open to a solution.
Maintain a non-judgmental, non-defensive tone.
Newly-diagnosed patients unconsciously pick up on signs that their healthcare providers are judging them in some way, e.g. annoyed that the patient is being childish when expressing fear. Patients may assume that they will be judged, and may make assumptions in regard to body language that is not necessarily based on a judgment. Patients are also sensitive to any sign of defensiveness, e.g. when a healthcare professional appears to be caught off guard, or becomes argumentative, when a patient expresses an observation or an assumption. It’s important that healthcare professionals keep an open mind when working with patients on communications issues, and remember that newly-diagnosed patients may be expressing perceptions that are rooted in their own fears and helplessness, and not intended to be personal assessments of the healthcare professional. Monie listened to Rhonda’s complaints about her previous experiences with a surgeon with an open mind, and then steered the conversation toward how the two of them would work together in the future, rather than defending the way in which Rhonda had been treated previously, or implying that Rhonda needed to stop being so needy.
Clarify communications processes.
Patients want to know that they are being heard by healthcare professionals who are treating them, and that they are being watched over. Without information as to what processes are in place to make sure information is shared, it is human nature to fill in the gaps with assumptions. When communications processes aren’t made clear to newly-diagnosed patients, they essentially make up the rules on their own. This can cause discomfort, frustration, and stress for the patient as well as for the healthcare professional when patients make assumptions about how information is, or is not, being shared among the team. . While patients can’t process a lengthy discussion of protocol, they will benefit from guidance on communications processes as the opportunities arise. Monie explained to Rhonda that she should call the nursing staff if concerns arise, but also reassured her that this information would be passed on to the doctor who, in turn, would also call if necessary.
Set expectations and clarify boundaries.
Newly-diagnosed patients are focused on their own needs, and they often feel overwhelmed. Helplessness, fear, lack of information, the stress of change… these factors in combination may result in causing patients facing a medical condition to feel extremely vulnerable. Out of this vulnerability, they reach out to the healthcare professionals with whom them work most closely. Patients in flight reaction are especially likely to look to want to attach themselves in a way that may lead to over-dependence. Rhonda, in the example above, was exhibiting a desire to keep Monie as close as possible. Out of her own fear and helplessness, she was under the impression that she would not get through her medical treatments unless Monie was available to support her around the clock.
Monie used a supportive and empowering approach to helping Monie realize that she would have support but that a team of professionals would be available to provide this support. She set boundaries in terms of her own availability, being careful not to say anything that might make Rhonda feel unsupported or abandoned. She also helped to empower Rhonda but implying that Rhonda herself would be taking responsibility for making her needs known while working within the patient-professional communication system established by the oncology practice.
Begin communications based on the patient’s readiness.
Effective communications with patients is not based on a ‘one size fits all’ model. As discussed previously, newly-diagnosed patients bring their own level of readiness to the relationship with healthcare professionals when they begin their treatment, based on their unique emotional reactions, past experiences or perceptions of their condition, and expectations about what their treatment will be like. Therefore, reciting a set of guidelines and instructions, and expecting newly-diagnosed patients to adapt and respond accordingly, will most likely not be effective. Instead, it recommended that the healthcare professional begin the conversation by gaining an understanding of the patient’s expectations for communication.
Throughout the conversation with Rhonda, Monie encouraged her to be open about her concerns and to ask any questions that were on her mind. Monie made it clear that she wanted to address any concerns that Rhonda might have. She began by suggesting that the conversation begin with Rhonda voicing her concerns and questions, and then she addressed these issues. This saved time for Monie because she addressed what was on Rhonda’s mind first. Also, once Rhonda had her initial concerns addressed, Monie was able to assess Rhonda’s expectations and gauge the discussion to addressing these expectations.
Avoid jargon.
Newly-diagnosed patients are faced with a whole new vocabulary of medical terms, and this is both overwhelming and confusing. When healthcare professionals use terms they don’t understand, they feel as if they are not being acknowledged. As a result, patients can become defensive and suspicious, and/or jump to irrational conclusions. It’s important for healthcare professionals to constantly ‘check in’ with patients to make sure they understand terminology.
Summary
Newly-diagnosed patients take cues from healthcare professionals in terms of the optimal way to communicate. This provides an opportunity to guide patients in communicating in a way that will enhance the relationship, helping to assure that patients report symptoms and side effects, as well as compliance challenges, that arise. Guiding patients in effective communications also contributes toward assuring that the time spent with them is used effectively, and that boundaries are not crossed.