Chances are that the above scenario is rather unusual. In today’s busy practices, it is challenging to simultaneously have the adequate time, energy, and emotional capacity to have such successful patient encounters. Time restraints and overall burnout can impede practitioners from engaging with their patients more meaningfully, ultimately creating miscommunication, frustration, and even additional appointments to have issues resolved. Practitioners might find themselves focusing on the devices, their technical aspects, and fit problems rather than connecting with patients to understand more about how their problems are affecting their lives. When we focus on the device and not the overall situation at hand, we can easily miss valuable information.
In time-pressed situations, I found myself losing sight of the human aspect of the appointment and instead fixating on how to solve the problem as quickly as possible. However, when I did that, I frequently misread the situation: a painful tibial crest was actually a mismanagement of sock ply, an overall rejection of the prosthesis was for cosmetic and not fit reasons, or a bruised big toe was from using different shoes than what were brought in for the appointment. My focus on solving the problem blinded me to the actual problem.
Aside from actually allowing practitioners to get to the root of fit, function, and aesthetic concerns, why are communication and active listening so important in patient care? Per an article in Harvard Business Review, by listening actively, healthcare providers can build trust with their patients and communicate respect for self-knowledge. “It allows physicians to assume the role of the trusted intermediary who not only provides relevant medical knowledge but also translates it into options in line with patients’ own stated values and priorities.”1 By serving our patients in this way, we strengthen our relationships with them and create a safe space for them to share with us.
What does good active listening and communication look like in patient care? Active listening can be defined as “the highest and most effective level of listening…based on complete attention to what a person is saying, listening carefully while showing interest, and not interrupting.”2 Effective communication can be defined as “a critical component to the patient’s understanding of the informed consent process, participation in his or her care, understanding of all information provided to him or her, and ability to fulfill the responsibilities related to his or her care. In order for communication to be effective, the information provided must be complete, accurate, timely, unambiguous, and understood by the patient.”5 “Successful communication should: be uncomplicated, be specific, use some repetition, minimize jargon, [and] check patient understanding. In addition, communication should simultaneously employ a patient-centered approach and interpersonal interaction to promote patient satisfaction.”3 Taken together, these definitions require that we, as practitioners, stay fully present with our patient and ensure that we take the time to adequately explain the process and situation, while also ensuring that the message we are trying to communicate is being understood by the patient.
In my experience, staying curious and not jumping to conclusions about what a patient communicates are key. Asking for more information and guiding the conversation gently are much more effective than interrupting patients to only focus on the device in question. Asking about how the situation is impacting the patient, while also understanding the details of the situation, is just as important. We may be able to tease out more information about how this device fits into the patient’s daily life instead of solely thinking about how the socket trimlines don’t seem to be quite right. Understanding how these situations affect our patients also helps us comprehend how important these concerns are to our patients, allowing us to prioritize what needs to be addressed.
When we ask our patients for more information, there are ways that we can adjust our wording to encourage open and honest answers. We can also tweak our questions to help remove bias from our phrasing. Asking open-ended questions is a good start to encourage more open communication. Questions that do not lend themselves to a yes or no response can be considered open-ended. For example, instead of asking “Does your prosthesis fit well?” you can ask “How is your prosthesis fitting?” While only a slight adjustment to the wording, the second option provides patients more space to express themselves.
In addition to managing active listening and open communication with our patients, what are the things we need to talk about with them that go beyond fit and function of their devices? I always started my appointments with a general check-in to see how my patients’ days were going, how they were feeling about this phase of their recovery, and focused on their attitude first. Sometimes patients are so eager to talk about their concerns they want to skip this portion of the appointment, but I made sure to work it back in as one of our first items. I wanted to understand where my patient was coming from in that particular moment so I could meet them where they were. By slowing down the appointment I also made sure I could understand the context of the situation instead of too quickly zeroing in on what I perceived to be the problem.
I have uncovered many root causes by slowing down appointments in this way. By taking just a few minutes at the beginning of the appointment to set the stage for our time together, I could outline what we would work on and create a list of concerns up front. Having an in-depth conversation at the beginning helped to paint a more comprehensive picture of the patient’s situation and also helped to set expectations. By asking deeper questions about a patient concern to fully understand what was going on, I could figure out what the underlying cause was instead of only addressing symptoms. Checking in on the patient’s holistic state is also a great way to figure out how to pace the appointment. For example, in an initial evaluation for a new patient, assessing the patient’s mental and emotional state is crucial. If a patient is hesitant to share information, cannot look at the residual limb, or is otherwise showing guarded body language, it is worth pausing and asking directly how the patient is feeling. While we are not trained therapists, it is certainly within our scope of practice to make sure our patients are in the right place to proceed with the process. In this case, I would hit pause on the technical and physical evaluation segments of the appointment and talk about what kind of resources the patient had, and what we could offer. I regularly referred patients to the Amputee Coalition’s Certified Peer Visitor Program to connect them with someone who had been through a similar experience.
In terms of connecting patients with the appropriate resources, our long-term relationships with our patients allow us to be the contact point with other healthcare specialties. Interdisciplinary care is key for our patients’ success, and we can encourage our patients to continue seeing their physicians and therapists. Keeping our patients connected with their healthcare support system can prevent larger problems in the future and gives our patients a community that helps them succeed. I frequently referred my patients back to their physical and occupational therapists and physicians to manage concerns that came up that were outside my scope of practice. Not only does this help the patient achieve more, but also builds relationships with these healthcare professionals.
Another important aspect of communication to keep in mind is non-verbal communication. Patients are actively monitoring whether their providers are listening to them. Non-verbal communication comes into play more heavily when it contradicts verbal communication. This mismatch raises flags for patients and the non-verbal communication tends to take over as the dominant message.4 While it is important for us as providers to note our patients’ non-verbal communication, we must also manage our own body language to ensure that we are being authentic and matching our words. Elements such as “use of eye contact, body position and posture, movement, facial expression, and use of voice can all influence the success of the consultation.”4 Simply being cognizant that these are factors our patients are actively assessing can cue practitioners to adjust their body language and align their words with their non-verbal communication.
Additional challenges are the prevalent use of computers and the higher demands of documentation. While computers are valuable note-taking devices, they reduce eye contact with the patient and even serve as a physical barrier between the provider and patient. A negative effect was noted in a study when the starting position of the provider’s lower body was not angled toward the patient, even if occasional eye contact was provided, accompanied by the turning of the upper body.4 At physicians’ offices I have been to as a patient, the physical barrier of the computer between me and the physician has always been palpable and off-putting. While I understand the need for thorough documentation and the checkboxes required for a visit, there are few times when I feel I have been heard. I harnessed that experience and changed my patient interactions. Instead of reviewing the patient’s history in the room, I began reading it before I went into the room to minimize screen time with the patient. I also switched to paper and pen for note-taking, being careful to process the information and then write down what was relevant, instead of writing down each word said. This deliberate note-taking allowed me to maintain more eye contact and be more present with the patient.
So, where do we go from here as practitioners who are pressed for time but want to provide high-quality care? If our main obstacles are a lack of time, emotional energy, mental energy, and attention, how can we overcome those?
Given the reimbursement system and billing practices of today, it is not as simple as making patient appointments longer. Ideally, assistants and fitters can be employed to offload some of the technical work from practitioners. If hiring assistants is not possible, consider where else you might make the appointment more efficient. Are you able to prep question lists ahead of time or review the patient’s history before the appointment? I found that taking photos helped to reduce time spent in the room instead of trying to verbally describe the patient’s anatomy. I also spend five minutes after each appointment to write down any other salient details given the interaction as a whole, as I have the entire appointment as context. These five minutes served to compartmentalize each appointment and ease the transition between patients. While it did not necessarily save time during each interaction, the overall time spent per patient on documentation was reduced significantly since I no longer struggled to recall details and was better able to keep the interactions separate.
In terms of mental energy and attention, I found that if I had too many tasks to manage that day, I would start thinking of my to-do list instead of focusing on the patient in front of me. This was not only stressful to run through items I could not tackle at the moment, but also detracted from helping the person in front of me. I would make a note on a running list as these worries came up instead of letting them dominate my mental space, which helped to improve focus on the present. Before the next appointment I would make sure those to-do lists found a consolidated home and handled them during any free time or at the end of the day. I also realized during my clinical practice days that the best way to re-energize myself was to spend time with my family, friends, and colleagues. I particularly enjoyed sharing with colleagues because the experience of clinical practice is hard to describe to those outside of it. I always found these conversations rejuvenating. They provided a sense of comradery and community that made each day more enjoyable. Focusing on our collective wins, supporting one another through tough days, and creating an atmosphere of levity and teamwork generated positive energy.
While the obstacles to communicating well and listening actively are apparent, there are small steps and adjustments that can be made to improve the appointment on both the practitioner and patient side. Staying present in the moment and suspending judgment may initially seem like big asks of oneself, but a conscious effort to implement these elements can reduce the overall time spent on each case.
Nina Bondre, CPO, is the clinical educator for Cascade Orthopedic Supply, headquartered in Chico, California. She can be contacted at [email protected] and welcomes your thoughts on this topic.
References
- Awdish, R., and L. Berry. 2017. Making time to really listen to your patients. Harvard Business Review. https://hbr.org/2017/10/making-time-to-really-listen-to-your-patients
- Jahromi, V., S. Tabatabaee, Z. Abdar, and M. Rajabi. 2016. Active listening: The key of successful communication in hospital managers. Electronic Physician 8(3): 2123-28.
- King, A., and R. Hoppe. 2013. Best practice for patient-centered communication: A narrative review. Journal of Graduate Medical Education 5(3):385–93.
- Silverman, J., and P. Kinnersley. 2010. Doctors’ non-verbal behaviour in consultations: look at the patient before you look at the computer. British Journal of General Practice 60(571):76–8.
- Wilson-Stronks, A., K. Lee, C. Cordero, A. Kopp, and E. Galvez. 2008. One size does not fit all: Meeting the health care needs of diverse populations.
