The Janus Principle and Your Medical Practice

Janus-The Good Of Beginnings and Endings

Janus is the Roman god of doors and gateways but also the god of beginnings.  Interestingly, good beginnings are required for good endings.  The Temple of Janus had doors facing east and west, which allowed illumination of the temple at the beginning and the end of the day.  Most statues of Janus show him with two faces facing opposite directions.

The Janus principle in your medical practice is the idea of creating a favorable beginning of the doctor-patient interaction which culminates in a favorable ending.

How to get off to a good a good beginning?

It all starts with the first impression.  There’s a world of difference if the doctor enters the room and launches into medical questions versus the doctor who uses the first few seconds to talk about some non-medical topic such as the patient’s family, work, or last vacation.  This information can be obtained by keeping social progress notes on the written chart or on the first screen of the EMR.  Now the doctor demonstrates his interest in the patient and not an organ system, a diagnosis, or lab or X-ray report.  You can be sure that this registers in a positive way with your patient and well worth the few seconds it takes to demonstrate caring for the whole patient.

The Janus Close

Closing the office visit is the natural conclusion of every patient interaction.  Every patient visit needs to terminate with a successful close.  You will know you have closed successfully when the patient agrees to your advice, promises to take the medication, obtain the studies you suggest, or accept the surgical procedure you recommended.  Most patients leave without any physical evidence of their commitment to the doctor.  The close is intangible but you can recognize the signs of agreement or rejection very easily.

The Janus principle focuses less on rote formulas such as ending each visit with, “Is there anything else I can answer for you today?”  It does take into consideration the general tone and feel of the conversation with care and attention to begin well and to close well.  If it is done well, you have buy-in from the patient and a greater likelihood of enhanced compliance from the patient and improvement in patient outcomes.  You increase the buy-in if you learn to listen to what the patient says and pay attention to both verbal and non-verbal clues, which provide you with the feedback of the success of your close.

Doctors have the luxury of asking probing questions.  I am always amazed at the depth of questions that I am allowed to ask in areas that no other person could ask another individual.  After meeting a patient for the first time, I am able to ask about their personal life, their sex life, and their bowel habits.  No other professional could possibly accomplish this except a physician.  In order to be successful at asking probing, we must appear genuine and that we are caring and avoid making the patient defensive.  The best probing questions are open ended and not answered by mere yes and no questions.  It is a far better question to ask how the chief complaint is impacting the patient’s quality of life rather than is the pain mild, moderate or severe.

Next make sure to validate or acknowledge probing question that you ask.  This can be a head nod or use the echo technique of restating the last phrase of the patient’s response to your probing question.  For example, if I ask a man about his ability to engage in sexual intimacy with his partner and he responds that the problem is upsetting his partner.  I would counter with “How is this upsetting your partner?”  This clearly lets the patient know you have heard his response and you are paying attention to the discussion.

Psychologists point out that 70% of the population respond better to suggestions than to warnings.  Nearly 80% of patients’ buy ins are made emotionally and then they use logic to defend their behaviors.  You might approach the close by asking the patient what they feel about the lifestyle changes you might be suggesting they make.  If the patient agrees to the plan of action, you can ask for agreed upon goals.  Perhaps you can ask the patient to join the YMCA or a local gym and commit to an exercise program with the goal of losing two pounds in the next month or before their next visit.

This brings the Janus close to a successful conclusion.  You use the probing questions, provided the patient with motivation, and then receive their commitment and buy-in resulting in improved compliance.

Bottom Line:  We have less time to spend with patients because of the greater volume of patients that most of us are going to be seeing in the near future.  We will have to be experts at communication in order connect with our patients which begins with great openings and positive clsings. The Janus close starts with a good beginning and then has a happy ending.

Want to Elevate Your Communication? Pick Up The Phone

According to a survey from Accountemps, a temporary personnel service based in Menlo Park, California, nearly half of all business people dislike talking to someone calling on a speakerphone. Doctors and your patients are no different from businesspeople. The complaints range from poor voice quality to lack of privacy. If you still want to talk and free up your hands to sign letters, sort files, or even doodle, get a phone with a headset. Headsets do not distort the speaker’s voice in you will never hear the complaint that you sound like you are speaking from a well, as is the situation when using the speaker function on your landline. In addition, your staff will appreciate headsets that allow them to answer the phone and maintain correct posture. It is better for your neck and back to avoid holding the telephone handset between your shoulder and your ear.

 

Bottom line: we need to do everything that we can to enhance our communication when talking to our patients and our colleagues. You create an aura of being focused and in the moment when you lift up the telephone and speak through the handset rather than the speaker.

More Communication Means Less Litigation

Doctors, hospitals, insurance companies, and malpractice carriers have known for years that there is a direct correlation between patient satisfaction\patient complaints and law suits.  (American Journal of Medicine 118:1126,2005)    Physicians have always prided themselves as being good communicators but surveys show that we often overestimate our ability to communicate effectively with our patients.   A well-publicized study reports that the average doctor interrupts a patient after 16 seconds during the interview process.  So what can we do to improve our communication skills and lower our risk of law suits?

1. Prepare for your visit with the patient.  Before entering the room look at the chart or the EMR and know one or two facts about a new patient.  This can be their referring physician, their employment, or where they live.  The same applies to an existing patient.  Don’t initiate the conversation talking about their medical problem.  Regardless of your patient volume and how far behind in the schedule you are, start the conversation with some topic that is not associated with their health issues.  This clearly sends a message that you care more about them than their blood pressure, their shortness of breadth, or their dysuria.

2. Sit down and don’t stand while speaking to a patient.  Make every effort to be eyeball to eyeball with the patient.  Never have a meaningful discussion when you standing and the patient is sitting or worse if the patient is lying down on the exam table.

3. If possible, don’t have any barriers between you and the patient.  If possible be on the same side of the desk or exam table as your patient.  You don’t want any barriers, either psychological or physical, to be between you and the patient.

4. Lean slightly forward when you speak to the patient.  Patients are going to notice your body language before you even open your mouth.  Leaning forward in your chair demonstrates a sincere interest in the patient.

5. Lock eyes with the patient.  People normally make eye contact 70-80 percent of the time.  If you fall below average, you come across as shifty or lacking confidence.  People who make less eye contact often aren’t’ aware of it, so ask a colleague to critique your eye contact.

6. Smile. Keeping a neutral face may feel natural, but the other person might perceive your expression as negative.  People are looking for signs of approval and the lack of a smile may even seem threatening and can make a patient become defensive.

7. Don’t spend all of your time looking at the chart or the computer.

8. Don’t turn your back on the patient.  This is disrespectful and a barrier to good communication.  Avoid placing your wall mounted computers  in the corner of the exam room that put the doctor’s back to the patient.  This is certainly one advantage for mobile tablet PCs rather than fixed machines in the exam room.

9. Minimize interruptions.  Nothing can derail your communication with your patient than to be interrupted during the visit.  It is very hard to get the train of thought moving in the right direction when you take a phone call, leave the room, or allow the staff to open the door to have you sign a prescription or an order.  Set guidelines for interruptions.  Examples include the emergency department, the intensive care unit, or the operating room.  If another physician calls, instruct your staff to say, “The doctor is with a patient and if it is an emergency, I can interrupt him\her.  If not, I can arrange for him to call you when he is between patients which will be in 10 to 15 minutes.”  Most physicians calling another physician will respect this policy and allow you to call back.

10. Always ask the patient if their questions have been answered and if there is anything else that can be done to make their visit complete.

11. If possible walk the patient from the exam room to the check out counter or have a nurse accompany the patient to the check out counter.  This assures that the patient will take care of the bill and make their next appointment.

Bottom Line:  Improving communication with your patients means making the patient feel that he or she is the most important thing for that physician that day.  Doing this will not only make you feel good and be a source of gratification, but will also reduce your liability and reduce your risk of law suits.

The Scent of a Woman-How To Talk To Female Patients

As medical students it was naturally intuitive for us to appreciate the difference of taking a history from a prepubescent child than from an adult.  As urologists, I know the difference in a discussion between a patient with newly diagnosed prostate cancer and one with a recurrentUTI.  But how many of us are cognizant of potential gender based variances of communication? After all, there must be a difference if has been stated,  “that men are from Mars and women are from Venus”.  So how does one speak to these so-called Venutians?

Women influence nearly 85% of healthcare decisions. (Women primarily responsible for family health needs. AORN June 1, 2003).  It is well documented that women exert great influence on the healthcare decisions not only for themselves but also for their men, be it husband or son. With the heightened verbal and non-verbal communication skills of women, you may find either the sharpest critic or the greatest “word of mouth” advocates for your practice depending on her clinical experience with you and your practice.   Therefore, a dedicated effort to assure a positive experience through enhanced verbal and physical communication skills may provide rich dividends.   A collateral benefit is that patients steered to your practice by another patient based on experiential accolades may have a higher initial baseline trust and thus require less convincing for open interaction, diagnostic studies, or proposed treatments.

Today, the patient is much more sophisticated, more medically educated, and is looking for more explanations from her physician.  Consequently, it is time for physicians to reassess their approach to providing medical care to women and contemplate a change of strategy for communicating with this segment of the physician’s practice.  

The History: Making the Connection

Physicians will often state that they treat men and women exactly the same.  Let the truth be told that if you are communicating with women just like you do with men, you may fail to connect with many of the women in your practice.  So what are the differences? For the most part, men and women may not think, verbally or non-verbally communicate, or emote the same way. 

Sickness causes stress and genders respond differently to the challenge. Men are challenged by changes in their health or a divergence from the status quo and wish for a rapid and successful return to baseline (most men may have two different states of health: 1) a perfect state of health or 2) they have problem). This will be expressed through their fight or flight response; a vector delineated pathway.   In their “fight or flight mode” men are often dealmakers who are trading their time and resources in exchange for a return to their perception of their baseline health.  Women may be more concerned controlling the pathway of their health and well-being through social interaction. Women, through their allying process, are hoping to build a relationship to optimize their current and future medical situation and guide its course.

Women, on the other hand, may view their health and its potential fluid state as part of their natural life experiences and will want to partner with their physician in order to optimize their situation and the longitudinal experience with their healthcare provider.  It is very important to have some period of quiet reflection or “yielding the floor” to the patient during the verbal portion of the consultation. Partnering early and using non-patronizing language is of very great value; the key is to foster a long-term focus, and the results are important primarily in context of the entire experience. 

Because of the potentially more complex multifaceted nature of a female patient, it may be of value to ask her “How may I be of service or a help to you?” during the history phase of the consultation. Though some may view this as pandering gallantry, the patient will be able to clearly verbalize her expectations (is the nature of the visit a second medical opinion, a desire for a medical therapy, or a surgical intervention).   By asking this question at this opportune point of initiation, you have the ability to set clear boundaries with achievable expectations that will hopefully limit heartbreak and bitterness from a non-rewarding course of care or a less than optimal outcome.

The physical exam

The physician is the final arbiter of who will be present in the room during the physical exam besides the patient.  That being said, if you are male physician with a female patient, regardless of comfort level or situation, no physical exam should be completed without a female chaperone in the room.

After the exam has been completed, the doctor or the nurse should inform the patient that they are welcome to bring into the consultation room anyone that they wish to complete the visit. All consultations or discussion with the patient about her diagnosis or tests or any surgical procedure should not take place with the woman disrobed.  If a doctor is speaking to a woman who is undressed, (or worse, undressed and in the dorsal lithotomy position), the actual or perceived vulnerability of the patient will often hinder the growth of the relationship and her ability to communicate in both a verbal and non-verbal fashion.

Disposition

Most female patients will have already formulated a working diagnosis of their problem at the time of consultation, which may be of extra ordinary value in challenging cases.  For example, when facing a patient with pelvic pain or functional disorders, the doctor may ask the patient “What do you think is wrong with you?”  Patients have an exponential level of body understanding and are truly able to pinpoint the problem as a functional or anatomic disorder and thus aid in the diagnosis and be helpful to the physician in the management of the patient.

If you find that you are not connecting with the patient, or if she has quizzical expression that indicates a lack of understanding, you might want to say, “Was my explanation clear?  If not, what aspect of my discussion would you like me to review again?”  It is usually a good sign if a patient asks questions.  Use this as an opportunity to clarify any misunderstanding.  The more questions presented, the more engaged she is and indicates that she is interested and trusts the physician. Women will often ask more questions than a man and don’t want to feel like they are irritating the doctor with their questions; remember she may be bridge building at this crucial time.   

 Signs that you are making the connection

It is very important when interacting and communicating with a female patient that you are in tune to both her verbal and non- verbal cues.  This is especially important at the end of the consultation.  It is a positive sign that if at the end of the consultation the woman has a smile on her face, or if she nods in agreement and, most importantly, if she initiates any kind of physical touch such as hand shake, a pat on the physician’s shoulder.  In some cases, a female patient may opt to hug her physician if she is very comfortable with their relationship. Women traditionally keep less personal space between themselves when comfortable than men but will readily withdraw if their space is invaded. This should be kept in mind if you note that your female patient is backward leaning away from you when you move forward to make a point; your presentation may be too imposing and poses a subliminal threat.  Any interaction with your female patient that ends with a warm smile and positive physical communication means that the relationship has been successfully been established and that she will do her best to be a good patient. The ultimate sign of connecting with your patient is anybody contact such as a handshake or hug. It is imperative that the doctor allows the patient to initiate any non-examination based contact. An unsolicited embrace at the end of a consultation (especially one that has included a disrobed physical examination) may be subliminally construed as an unwanted incursion into personal space.  In the absence of touch, direct eye contact combined with a warm facial expression of acceptance and close physical proximity indicates a favorable physician-patient relationship.

 Bottom Line: 

For most women, a visit to the doctor isn’t just a purchase of a diagnosis followed by a payment for the service.  Women may desire more of a professional relationship with the doctor and to be part of the decision making process.  They want to hear the options and want to participate with the physician in making the medical decision.