Family Medicine Vital Signs

By Bob Chestnut, MD

In patient-provider interactions, the provider holds almost all the cards. The provider is on her home turf. She has years of medical training and experience and ultimately holds decision power in pursuing further diagnostic tests or prescribing therapeutic interventions. In contrast, the patient is placed in a small exam room. He is essentially cornered. He has limited access to high quality medical information and has not been able to devote years to developing his medical knowledge. He is also likely in acute distress. He has high interest in finding answers and/or relief, but has relatively low power to make an intervention for himself beyond placing himself in the care of a medical provider. The power imbalance is clear.

Although, many of the aforementioned obstacles are not easily changed – in one appointment a provider cannot impart a full fund of medical knowledge to a patient – there are many other behaviors a provider can adopt to address the power deficit. The goal of these behaviors is to surrender unnecessary elements of the power imbalance in order to establish trust and empower the patient. Here are some of these behaviors:

Agenda setting: Propose a plan to the patient about what you hope to cover during your appointment. Ask for their agreement with your proposed agenda. Ask them what is the most important thing to address today.

Inclusive dialogue and validating statements: Talk about the treatment plan as “our” treatment plan. Show that you are human too, and that you know what stress and pain are like by telling your patient “That sounds so painful,” or “Geez, anyone would be in crisis after something like that.”

Eye level: Position yourself at eye level to your patient, or lower. Sit down. In some instances it may be appropriate to have the patient sit on the exam table, essentially looking down toward the provider. As the provider you are sending the message, “Please, take the high ground”.

Share the screen: When using a computer, position yourself and the screen in a way that the patient can see it as well. Verbalize this. Tell your patient “I like to share the screen with my patients. It’s your medical record, anyways.”

Physician’s touch: Ask permission to perform physical exam on patient. Placing a hand on your patient’s shoulder while listening to his heart goes a long way in demonstrating mutual human warmth and acceptance.

Share your tools: You may wear a stethoscope for the majority of the time you are awake. Your patient has likely never handled a real one or heard his own heartbeat. After listening to his heart, give him a turn. Let him share in the physical exam experience.

Share your medical knowledge: Give your patient as much as you can during your time together. Explain what you are doing; briefly explain why you ask the questions that you ask, teach as you examine, and explain your medical decision-making. Include both what and why.

Sit next to your patient: Just as you positioned yourself optimally at or below eye level, reposition yourself for optimum empowerment and trust when developing a plan. Physically align yourself with the patient, standing or sitting next to them, directing their attention to a written or typed plan. Ask “Does this plan sound okay?” and “I would normally see a patient back for this kind of thing in X amount of weeks, does that sound okay?”

Of course there are many other behaviors that a provider can explore to further empower her patients and become more adept at quickly establishing trust. Most providers had to develop frank assertiveness during training, so it may be difficult to set aside previously gained skills in order to focus on patient empowerment through new provider-patient interaction behaviors. The skills above are learned behaviors, that require time, reflection and practice. However, as you develop these skills, you and your patient will mutually benefit.

Bob Chestnut, MD is a second year family medicine resident in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.