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Would it be easier if I went home and skyped you?

When I am sick or worried I need you to look at me. I know you need to maintain my records doctor but while you are doing that it isn’t helping me to tell my story. Wasn’t that the point of me being here? Would it be easier if we both looked in the same place through a screen?

The non-verbal behaviour of doctors themselves is easily overlooked in communication research. Many instruments for measuring qualities such as patient centredness are designed to be applied to audio rather than video tapes, and questionnaires for patients may not be sufficiently detailed to seek their views on this area. However, an increasing body of work over the last 20 years has demonstrated the relationship between doctors’ non-verbal communication (in the form of eye-contact, head nods and gestures, position and tone of voice) with the following outcomes: patient satisfaction, patient understanding, physician detection of emotional distress, and physician malpractice claim history. Although more work needs to be done, there is now significant evidence that doctors need to pay considerable attention to their own non-verbal behavior. Silverman and Kinnersley

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Small details matter

It’s a small detail. If you are accompanying someone down a corridor as a healthcare professional- don’t stride ahead. Ideally walk alongside the person or let them lead the way if they know where you are headed. If they are wheeling a buggy and carrying a bag offer to help by wheeling the buggy.  Just try it. You might like how they respond. Apart from that you can learn so much about the person even before the consultation begins:

So instead of a doctor assessing a patient’s blood pressure, body mass index, chronic conditions, hospitalization and smoking history and use of mobility aids to estimate survival, a lab assistant could simply time the patient walking a few meters and predict just as accurately the person’s likelihood of living five or 10 more years—as well as a median life expectancy. Scientific American

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You can’t fix what you don’t know

Georgia has been waiting to see you for over an hour. She has been ignoring the pain in her side for days. Initially she hoped it would just go away. There is too much else to deal with. Josh her partner lost his job last week. Her mother had a stroke 3 weeks ago. Her dad is barely coping with caring for his disabled wife. The children are going to a new school this year and Emily (9) is having trouble settling into the new class. Meanwhile Georgia was hoping for a promotion at the office. With Josh out of work they need the money and it looks like she might now need to spend her weekends helping dad to manage at home. The pain in her side has got steadily worse and now it’s disturbing her at night. She mentioned it to her friend who forced her to make this appointment. Georgia doesn’t know her doctor well. She just wants this nightmare to end. She imagines this might be a urine infection but surely that wouldn’t last this long? She doesn’t want to think about the other possibilities. She especially doesn’t want to think about the lump she found in her right breast last month. She hasn’t told Josh she was coming to the clinic today and gave a vague impression that she needed to come to this end of town to collect something for work. She doesn’t want Josh to worry even though she thinks he might have noticed her holding her side while making the children’s lunch last night. Please let it be a urine infection so that a course of antibiotics will fix it. Georgia isn’t ready to handle any more bad news. A quick visit and a prescription is all she expects.

In 2 national, nonprobability online surveys of 4510 US adults, most participants reported withholding at least 1 of 7 types of medically relevant information, especially when they disagreed with the clinician’s recommendations or misunderstood the clinician’s instructions. The most commonly reported reasons for not disclosing information included not wanting to be judged or hear how harmful their behavior is. Levy et al

The outcome doctor is up to you but it all hinges on you being able to get the picture. Georgia isn’t sure she is going to tell you any of this even though she desperately needs someone to make it alright. Will you notice? Are you set up to receive the signals?

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Do you take the shortest route to add value?

Every thriving business adds value. If it didn’t it would not exist. Healthcare shares many points of difference with any other service but none is more remarkable than the  ability to forge connections via the physical examination. It meets our fundamental need when we are ill.

Treatment that uses direct touch can have a depth and potency that can have a great therapeutic impact, which provides some explanation for why so many people are seeking out their own “professional touchers” or are filling the waiting rooms of physicians, waiting for the doctor to find the cause of the pain and make them better. In the process, they are touched. When the patient is assured that the work of the professional toucher is free from infringement, that sexual contact is clearly out of bounds, and that the patient can say “no” to any intervention the body-work practitioner proposes, then the patient can have the experience of trust and physical touch in the context of a controlled respectful relationship. Sharon K Farber

If you are a healthcare professional in what proportion of cases don’t  you perform a physical exam? Why?

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How do you prepare for work?

I don’t know him personally but I don’t imagine that Michael Phelps dives into a pool when he isn’t ready to race. Similarly Usain Bolt might look like he jumped off the viewing stands and popped himself on the starting blocks but in truth his mind and his body are ready to make him the fastest man on dry land. However when we arrive at work we might still be thinking about the argument at home, the traffic jam or the news. We might arrive a bit disheveled, a bit breathless or a tad tired. We might not hear the first few things we are told or notice more than we can take in at a glance of our first customer client or patient. However to perform at our peak we might consider what might get us in the zone so that our performance is not in question.

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Do you miss opportunities to forge a connection?

There are very few services in which the customer or client has physical contact with the service provider. Hairdressers and masseuse are the exception. These ‘therapists’ often relate hearing things that are seldom confided in others:

A questionnaire, specially designed to measure the mood change was filled in by 359 women at their arrival in different hair‐salons and after having received various hair care services. The results show that hair treatments increase all the positive dimensions of mood and decrease all the negative ones. Picot -Lemasson et al

Patients expect that some form of bedside evaluation will take place when they visit a physician. When physicians complete this evaluation in an expert manner, it can have a salutary effect. If done poorly or not at all, in contrast, it can undermine the physician–patient relationship. Studies suggest that the context, locale, and quality of the bedside evaluation are associated with neurobiological changes in the patient. Recognizing the importance of the bedside evaluation as a healing ritual and a powerful diagnostic tool when paired with judicious use of technology could be a stimulus for the recovery of an ebbing skill set among physicians. Verghese et al

If you are a healthcare professional and there are opportunities to forge a connection with your patient do you leverage that capacity? Does every person who sees you have some sort of examination? Why or why not?

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Does your equipment work?

Everyone has equipment in their office that they take for granted right? But are we sure that equipment works? The stethoscope is the most iconic of instruments used by healthcare professionals. Our research suggests that people are far more trusting of an individual wearing a stethoscope. But does that equipment always work? If you are in healthcare when did you last service your stethoscope? Is it possible that it might be unreliable?

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Is there such a thing as simple administrative task?

Jane was invited back to have a repeat colonoscopy ( examination of the bowel). Her specialist wasn’t happy that he had a clear view through her bowel last year and he couldn’t be completely reassuring. Meantime Jane had noticed a change in her bowel habit and was now worried.

So she made an appointment with her doctor who practiced several suburbs away. It is a vagary of the system that although the specialist invited her back she had to get a letter from her family doctor to accept the invitation. Her doctor didn’t ask whether she was worried about it or why she had made an appointment that particular day given that the specialists note to her was a month ago. He simply wrote:

This lady needs a repeat colonoscopy as per your previous records. Thank you for seeing her again.

Two minutes later she was handing her credit card to the receptionist and walking out of the building.

Lost opportunity. Is there such a thing as a simple administrative chore or what we choose to make of an opportunity presented to practice our art?

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You are a prop too

In any theatre where people interact- including your office- you are also a prop. Anyone who enters that room will react to you as much as they might respond to anything else in there. Your look, smell and sound will draw a reaction. You may not be able to change many of your attributes- but you can’t afford to be unaware of them.  How do you take this into account when you plan that interaction?

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Do you use aids to help you explain?

If your job involves explaining complicated ideas- and let’s face it nothing is simple in medicine- do you use models or aids of any kind?

if not, why not? If you do what do you use and how do you know they work? How do you explain sciatica, heart disease, asthma, cancer?

Physicians cannot control all the reasons for patients pursuing legal atonement but they are able to determine the quality of their connection with them, by improving their communication skills and techniques. Law-suits for medical negligence can be lowered or prevented by taking steps to keep patients content, thus making them more compliant to the treatment, adhering to the medical policies and procedures. Tevanov et al 

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