When Stanford physicians Donna Zulman, MD, and Abraham Verghese, MD, set out more than two years ago to lead a team in finding ways to heal a growing fracture in doctor-patient relationships, they knew the task would be complicated.
In recent surveys, clinicians have reported that the current climate of medicine -- with limits on the amount of time they can spend with patients during appointments, an explosion of biomedical knowledge and increased demands to update and review electronic health records -- translates into less time for meaningful interactions with patients.
That, Stanford researchers contend in a paper to be published Jan. 7 in JAMA, isn't good for patients -- or for clinicians who are feeling increasingly disconnected from the reasons they got into medicine.
The goal of their research, which began 2½ years ago, was to identify evidence-based measures that clinicians can take to be fully engaged with patients and understand their perspectives, life circumstances and priorities. Ultimately, researchers wanted to generate a brief list of highly effective practices that clinicians could easily incorporate into their interactions with patients, Zulman said.
In their paper, researchers describe five evidence-based recommendations:
- Prepare with intention: Familiarize yourself with the patient you are about to meet; create a ritual to focus your attention before a visit.
- Listen intently and completely: Sit down, lean forward and position yourself to listen; don't interrupt; your patient is your most valuable source of information.
- Agree on what matters most: Find out what your patient cares about and incorporate these priorities into the visit agenda.
- Connect with the patient's story: Consider the circumstances that influence your patient's health; acknowledge your patient's efforts, and celebrate successes.
- Explore emotional cues: Tune in, notice, name and validate your patient's emotions to become a trusted partner.
The research was conducted in conjunction with Presence, an interdisciplinary center at Stanford that promotes the art and science of human connection in medicine. The objective of the research project was to revise the critical moment when physicians and patients meet, shifting the emphasis from institutional procedure to an interaction focused on meaningful human interaction.
"We were looking for practices that would improve the experience of patients and lead to better care for them, but would also improve the experience of clinicians and help them to rediscover the joy of medicine," said Zulman, an assistant professor of medicine and the director of Stanford Presence 5, one of several Presence initiatives.
"As physicians, we are privileged to work with people in their most vulnerable moments," she said. "And in today's climate, particularly in primary care, it's easy to lose sight of that with all of the administrative demands, time pressures and technology distractions."
Zulman, a health services researcher at Stanford and the Veterans Affairs Health Care System, is the lead author of the paper. Verghese, an advocate for the importance of bedside medicine and physical exams, is senior author of the paper, which includes links to podcast interviews with him and Zulman.
Identifying strategies
The Presence 5 practices, as they are known, were identified through a systematic review of 73 studies of interpersonal interventions published between January 1997 and August 2017, as well as through observations of clinician-patient encounters, and interviews with clinicians and patients at Stanford internal medicine and family medicine clinics, the Ravenswood Family Health Center in East Palo Alto and the Veterans Affairs Palo Alto Health Care System. The team also interviewed professionals outside the field of medicine to learn about cross-cutting themes related to clinician presence and human connection.
The published studies were analyzed to measure how interventions improved health outcomes, costs and patient and physician experiences. The interviews and observations provided insights into best practices at the clinical level.
The information researchers gleaned from the studies, interviews and observations generated 31 ideas for practices physicians could implement, which were reviewed, rated and culled to five with input from a group of experts: physicians, researchers, a patient advocate, a caregiver advocate and health care leaders.
Zulman said the team's next step is to evaluate how using the five practices affects the experiences of patients and clinicians, with new research being conducted at Stanford primary care clinics, the MayView Community Health Center in Mountain View and the San Jose VA Clinic, which is part of the VA Palo Alto Health Care System.
Researchers are holding workshops to share their findings, as well as developing a curriculum for training medical students and residents. The team is also working to validate their findings with international collaborators and to determine whether the practices can be adapted for different clinical settings and models.
"The Presence 5 practices resonate because they speak to something that is timeless and central to medicine," said Verghese, the Linda R. Meier and John F. Lane Provostial Professor and director of the Presence Center. "Patients want us to be more present. And we as physicians want to be more present with our patients, because without that contact, our professional life loses much of its meaning."
Systematic change is needed
Zulman said the researchers see the Presence 5 measures as just one step to address frustrations with modern-day medicine.
"While we might not be able to change the system overnight, our study suggests there are some concrete, evidence-based strategies that we, as physicians, can use that will help preserve and foster the connections that are most healing for patients and for us as physicians," she said.
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Formative components of the study were led by co-authors Cati Brown-Johnson, PhD, a social science researcher; Marie Haverfield, PhD, a former postdoctoral scholar who is now an assistant professor at San Jose State University; and postdoctoral scholar Rachel Schwartz, PhD. Other Stanford co-authors of the paper Jonathan Shaw, MD, clinical associate professor of medicine; former research assistant Aaron Tierney; project managers and social science researchers Dani Zionts, MScPH, and Nadia Safaeinili, MPH; research coordinator Meredith Fischer; Sonoo Thadaney Israni, MBA, executive director of the Presence Center; and Steven Asch, MD, professor of medicine.
Stanford Presence 5 is supported by the Gordon and Betty Moore Foundation.
The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://med.stanford.edu/school.html. The medical school is part of Stanford Medicine, which includes Stanford Health Care and Stanford Children's Health. For information about all three, please visit http://med.stanford.edu.
Print media contact: Patricia Hannon at (650) 725-3244 (phannon@stanford.edu)
Broadcast media contact: Margarita Gallardo at (650) 723-7897 (mjgallardo@stanford.edu)
Journal
JAMA