CHAPTER 4

Skill Set Two: Skills That Build Trust

One afternoon, a young woman came to my (Matthew Russell’s) outpatient practice with signs of an upper respiratory infection: runny nose, mild fever, cough, and scratchy throat. After examining her, I confirmed the diagnosis and started talking with her about over-the-counter medications that could provide some relief. The young woman didn’t take kindly to my suggestions. No matter what I offered—even recommendations such as gargling with salt water—she frowned. At one point, she was looking at me so doubtfully that I began to wonder if I had a poppy seed or piece of spinach in my teeth. I finally asked her, “Am I missing something?”

She replied, “Well, I have AIDS.”

This patient had visited our practice before, and I hadn’t seen anything in her chart about an HIV infection. I hastily stammered, “Oh, my God, I’m so sorry. I did not know this.” I frantically scanned her problem list on the electronic health record again but found nothing. “It’s not on your problem list,” I told her.

“Well, don’t I?” she asked.

Now I was completely baffled. I asked her a few more questions before I was able to put the pieces together. Before coming in, my patient had done a web search on her symptoms. Apparently, one of the top items that came up was the signs and symptoms of acute HIV infection. With this in mind, I explored for any potential risks or exposures and found none.

I reassured the patient that she was not infected with HIV but was dealing with a simple viral infection from the common cold. I also encouraged her to avoid using search engines as diagnostic tools. As you can imagine, she left the visit much relieved.

What would have happened if this same patient was stony-faced without body language that clued me in to the fact that there was something I was missing? What if I wasn’t tuned in enough to read her body language? She easily could have left my office still convinced she had an acute HIV infection!

In medical school, I was taught the importance of finding the patient’s “hidden concern.” As a student, I thought of it as a needle in the haystack—a rare unicorn that only the most accomplished diagnostician could discover. After my interaction with the young woman in my practice, I realized that the hidden concern was not a rare breed but in fact something that could accompany even the simplest symptoms and interactions.

When we are able to build strong relationships with our patients, we can support them effectively through life-threatening illnesses, prolonged illnesses, and acute emergencies. At times our relationships are brief (e.g., in the emergency department), while others may span many years (e.g., in primary care). This chapter describes concrete skills to help clinicians give as much attention to patients’ perspectives and emotions as we do to the biomedical details. This approach suggests that clinicians use these relationship-centered skills before even beginning to explore symptom details, diagnosis, or treatment options.

Relationship-Centered Skills: “Don’t Just Do Something, Stand There!”

To engage in relationship-centered communication, we must first acknowledge and embrace the personhood of each participant. When we use these skills, we are able to provide a richer experience for the patient and the clinician: the skills enhance rather than interfere with the scientific approach to illness. Healthcare interactions are often filled with complex concepts and strong emotions—a breeding ground for relationship challenges. When we make a point to establish a resilient relationship prior to encountering these challenges, it allows us to more effectively navigate through them.

To get a better understanding of what this looks like, let’s go back in time to my bright-eyed, bushy-tailed early days in medical school. The first instructor in my patient communication course was a family physician who had a knack for breaking down complicated concepts so they were easy for both students and patients to understand. We joked that she could tell us all to go to hell and we’d look forward to the trip. Years later, I realize that what she was so wonderful at doing was connecting with people. She was able to be fully present and attentive to what was being said. It wasn’t just nodding and eye contact. There was genuine interest and facilitative questions that helped to flesh out each story in more detail. By the time we would get to a physical exam, both the patient and the student observers would feel at ease and confident about her level of competence.

So, what is this special magic that some clinicians have and the rest of us struggle to obtain? If we are to be “scored” on our ability to communicate, we want to get an A. As overachieving clinicians, we all want to be at the top of the class! But for many of us, relationship-centered communication is not something that comes naturally. We may ask ourselves if we will ever be able to gain the skill sets to communicate competently or if we’re doomed to interactions that focus more on technology than the humanness of our patients.

In this chapter we describe four specific skills that help develop robust and trusting human connections. They may feel counterintuitive at first, but these sturdy bonds can actually increase the effectiveness of data gathering and treatment planning.

These four trust-building skills are:

1.   Ask open-ended questions and listen actively.

2.   Elicit the patient’s ideas and expectations.

3.   Respond with empathy.

4.   Transition to further data gathering.

In this book, we emphasize the value of using these four skills to build trust before we get technical. We may think of symptom elaboration, data gathering, diagnosis, and so on as our real work. Instead, following this approach allows patients to gain trust in us and in our abilities first, which enables us to get more accurate details when we begin gathering information. We achieve optimal results when we continue to respond to all of our client’s concerns throughout an encounter with empathy.

FIRST SKILL: ASK OPEN-ENDED QUESTIONS AND LISTEN ACTIVELY

A concerned mother enters an office carrying a one-year-old who is awake but lethargic. “My son won’t eat. He’s very listless. This scrape has not healed for many days. He is very ill.” Coming to the rescue, the clinician thinks: I’ll decide who is ill here! This take-charge attitude can instantly alienate the mother and set her even more on edge. She may feel more worried because she doesn’t know if the clinician will value her knowledge of her son and the details of the past few days.

In early training, we learned the basics of asking patients open-ended questions to hear their medical stories. Some of us may have even learned additional nonverbal techniques such as making good eye contact and leaning in to show interest. But as healthcare has become busier, time with the patient shorter, and use of a computer continuous, these interpersonal skills can easily fall by the wayside. Now, most clinicians worry that asking open-ended questions, eliciting patients’ perspectives, and responding with empathy will take too much time. When our progress slows, we risk decreased productivity and harassment from “the institution,” for not accomplishing our “real” clinical objectives. When we are face-to-face with our patients and they are in the midst of a long explanation of their clinical histories, many of us are thinking: Just the facts, please! I need to click these boxes and solve your problems in the 10 minutes we’ve been allotted.

And if there is a strong emotion, difficult news, or questions to be answered? Many of us don’t even want to go there—we feel we don’t have time to deal with it. Life is busy for everyone, and people seldom disrupt their lives to visit a clinician for nothing. Even those coming in for a routine follow-up usually have questions, concerns, or symptoms that are confusing, disquieting, or even frightening. As a result, patients want to feel confident that the clinician is emotionally invested in their problems. They want respect, attentiveness, and the freedom to express themselves. Patients are also looking for reassurance of the clinician’s technical expertise. They need relationships where they can express their ideas about what might be going on, their feelings and concerns about possible outcomes, and their expectations for the clinical encounter that day. Every patient has feelings that range from worry about the seriousness and treatability of the problem to concern about whether the clinician will show caring, kindness, and respect. They hope to be free from worry about clinicians’ potentially negative responses such as discounting, criticism, belittling, and rejection.

Let’s go back to the example of the mother with the one-year-old. Instead of taking charge immediately, why is it important to begin with an open-ended question? First, open-ended questions leave control with the patient, who can decide what to say next about the situation. Imagine how the encounter might unfold if this clinician uses the four trust-building skills listed earlier (page 37). First, he or she would elicit and set the agenda to begin with the child’s trouble feeding (see Chapter 3). Then the clinician would simply say, “Please tell me all about your son’s eating.” The open-ended request gives the mother an opportunity to offer details about her son’s symptoms or to share her distress. Either way, the clinician offers an invitation for the patient to place trust in the relationship. In addition, open-ended questions signal that the clinician will seek active participation from the patient throughout the encounter. Now it is the patient’s turn to choose what to focus on.

Let’s say that the mom not only talks about her son’s symptoms, saying, “He won’t even drink water,” but also shares her distress and ideas. “My husband is even more worried than I am … a friend’s child who started this way had pneumonia. Do you think it’s pneumonia? Do you think he’ll need antibiotics, or maybe surgery?” These types of responses about symptoms, ideas, feelings, and questions are typical responses to an open-ended question. In these types of interactions, the patient feels in control. While clinicians may fear that patients will launch into long, time-consuming responses, data affirm that patients seldom speak for more than 90 seconds when an invitation is extended.

For those of us who have been trained to lead with multiple clinically appropriate questions, this relationship-based strategy represents a paradigm shift. It’s easy to talk about it, but to accomplish this change successfully requires sustained effort. In this strategy, we actively listen to our patients, regardless of the subject matter. When our patients pause, we then explicitly show that we heard what the patient said. Verbal skills that demonstrate active listening include continuers (“uh-huh,” “go on,” “I see”), echoing statements (using the patient’s words), short requests (“tell me more”), and short summarizing statements. Active listening is one way we can affirm that we heard what the patient said. This simple act allows the patient to relax into the relationship, laying the groundwork for the trust that must develop for successful care.

SECOND SKILL: ELICIT THE PATIENT’S IDEAS AND EXPECTATIONS

As soon as some details of the initial story emerge, we must continue to explore our patient’s ideas and expectations. Sometimes, as above, the ideas and expectations have already arisen. Other times, we will need to ask explicitly: “What ideas do you have about what is going on?” “What were you hoping might happen as a result of your visit here?”

Again, clinicians worry about opening Pandora’s box with these questions. On the contrary, there are two good reasons to ask them up front. First, this inquiry and your empathic response represent more tools to develop trust. Patients appreciate the opportunity to reveal more about their concerns, and usually only briefly add information that gives us a much deeper understanding of where they are coming from. This information can be very useful in expanding your own reasoning process and in framing your treatment plan (see Chapter 5).

Second, knowing the patient’s expectations for the visit (if there are any) makes the end of the visit easier for the clinician. The patient-clinician relationship cannot be a poker game in which the patient reveals his or her cards only at the end. If the mother in the ill-child case does not state her expectation for a chest x-ray, for example, the clinician may complete the evaluation and recommend fluids and acetaminophen for a common cold. If the mother then asks, “What about a chest x-ray?” the clinician, thinking the visit has concluded, now has to backtrack and spend time dissuading the mother from her expectation, and, in doing so, likely will communicate annoyance at the disruption. Asking expectation questions up front is mutually beneficial: patients can express their ideas and expectations explicitly, and clinicians obtain a fuller picture—one that facilitates better treatment.

THIRD SKILL: RESPOND WITH EMPATHY

Asking the right questions is not enough. In order to continue building trust and strengthen the relationship, we can go further by recognizing the emotions that patients express and responding to those emotional cues. Of course, it is also important to reassure patients that we will attend explicitly and carefully to the clinical data in a few moments.

No matter how rational and reasoned we can be when our minds are clear, human beings are ruled by emotions. Patients almost always have emotions accompanying their symptoms, illnesses, ideas, and expectations. So, recognizing emotion by attending to nonverbal expressions of empathy and statements of feeling in the patient’s narrative is the first step to helping and healing. Clinicians can also either ask directly about the patient’s emotions and/or make hypotheses about those emotions and check those hypotheses with the patient.

Once elicited, by working hard to detect when patients reveal emotions, clinicians must respond to them with an empathic statement or a knowing gesture, posture, or facial expression. Failing to communicate empathy at those moments has the effect of erecting a communication barrier. Patients describe that barrier as “the clinician did not listen to me,” and this may be the crucial reason for excessive tests, missed diagnoses, inappropriate treatments, poor adherence to recommendations, and low scores on clinician evaluations by patients.^{1, 2, 3, 4}

At a basic level, empathy refers to trying to imagine another person’s emotional state. We can never know precisely what it feels like to be another person, but our willingness to imagine it matters strongly in clinical settings. It helps us feel a sense of partnership with patients when facing the challenges of their experiences. On the other hand, merely feeling empathy for someone’s distress can weigh us down even further—the concept of “mirror neurons” suggests that when we see someone in pain, the area in our own brain that feels emotional pain is activated.⁵ Instead of succumbing to this potential weight, however, making empathic responses allows us to feel with the patient, to show caring concern, and to offer help.⁶

Let’s return to the example of the mother with the ill child. When she first voices her concern, a very simple empathic response such as, “I see you are very worried,” or “What you described would concern any parent,” would demonstrate attention to her distress in the moment. The empathic statement helps to build the beginnings of a relationship. The mother remains the expert on her child instead of feeling dismissed and left to cope with more stress.

When I (William Clark) entered medicine, I wanted to relieve suffering by being a good detective, making diagnoses, and providing treatments. I always conveyed kindness and patience, but as my expertise developed, I could feel that something was missing. My patient relationships seldom went beyond the detective phase. Through my own curiosity and a lot of feedback—some of which was not easy to hear—I discovered that I could be a better clinician by learning and practicing skills that demonstrated clearly that I cared about the patient and his or her emotions, and not just about the disease. I came to realize that strong emotions are a natural human response when facing unknown and potentially life-changing circumstances. I understood that strong emotions caused by dramatic events in the patient’s life may be present in even the most routine clinical encounter (like the first patient in this chapter who thought she had AIDS). I became able to more often acknowledge patients’ feelings and respond with empathy, eventually internalizing this foundational aspect of effective healing relationships. I went beyond detecting to connecting.

Beloved ACH colleagues and I codified this idea and suggested effective and simple statements of empathy that we described in the mnemonic PEARLS: Partnering with the patient, naming the Emotion, Appreciating patients’ strengths or character (or “Apologizing” for the situation), voicing Respect (for courage, for persistence, etc.), Legitimizing understandable feelings, and offering ongoing Support to show empathy and attention to the human elements of the interaction.

These concepts are not unfamiliar or original to ACH, but collecting them into a teachable framework (PEARLS) was essential for my learning. Complex clinical situations or interactions that involved strong expressions of fear, anger, or sadness had previously left me at a loss for words, so I would ask the next clinical question. The mnemonic helped broaden my awareness of opportunities to respond more empathically. As I embraced PEARLS-type statements, I could feel the relationship-enhancing effects for myself and my patients. Responding with empathy in these moments also emerged as very helpful in my detective work of diagnosis and treatment. When we fail to elicit and respond to emotions, we are at great risk that patients will feel invisible, perceive us as unconcerned, cooperate only poorly with the rest of our work on their behalf, and report a less positive experience.

You can imagine how many of these statements might have a further connecting and trust-building effect with the ill child’s mother.

One further possibly surprising item: responding to emotional cues, for example, by using a PEARLS statement, saves time. Surgeons who incorporate even one statement spend 1.5 fewer minutes per outpatient visit than surgeons who don’t. Internists spend 2.5 fewer minutes in their outpatient visits.⁷ If you consider this, it starts to make sense. We mentioned that patients frequently have strong emotions connected to their symptoms. If the clinician neglects to address these emotions, patients will continue to state their emotional concern until either the clinician finally uses a PEARLS statement, or in the worst possible outcome, the patient gives up.⁸ We have repeatedly seen how deepening connections through PEARLS improves diagnosis, builds trust, and saves time.

FOURTH SKILL: TRANSITION TO FURTHER DATA GATHERING

Once the clinician provides space for concerns to be expressed and addressed with empathy, everyone is well prepared for a transition to gathering more clinical data and providing information about the illness process. A transition statement can be as simple as: “I’d like to ask you more detailed questions about what’s been going on, examine you (or your child), and make a plan. Does that sound OK to you?”

Typically, implementing the skills in this chapter requires only a couple of minutes. This exploration helps patients feel that we are on their side, strengthens the relationship, and allows space for patients to simultaneously share their worries and momentarily put them aside. The focus on relationship building as a prelude to clinical data collection makes tracking and responding simpler and more effective for both parties. With this activity, the clinician regulates the flow of information without becoming authoritarian or impersonal. Importantly, once we get the clinical details and move to making plans, we can return to previously stated ideas and expectations and further solidify the relationship by referring to them as we wrap up. Better relationships result in better care.

In subsequent chapters, we will show that incorporating elements of Skill Set Two can greatly benefit numerous conversations in the healthcare workplace. These are not just skills for patients, they’re skills for everyone.

Conclusion

The components of Skill Set Two are:

•   Ask open-ended questions and listen actively.

•   Elicit ideas and expectations.

•   Respond to emotional cues using PEARLS.

•   Transition to further data gathering

Skill Set Two involves delving into the patient’s perspective to elicit information about underlying worries, concerns, and sense-making. The one or two minutes spent in this way facilitate understanding of health literacy, beliefs surrounding illness, the role of the patient, and the role of the clinician. By eliciting these beliefs and perspectives early on, the clinician can avoid unnecessary detours, efficiently and effectively establish a diagnosis, compassionately comfort patients, and provide them with the appropriate knowledge, perspectives, and treatments.