Dan Gorenstein: On most of our shows, we make sense out of some of the most complicated policy questions in health care.

Bapu Jena: Like, would we really all be healthier if we had Medicare for all?

DG: But the reality is, our health care system isn’t just the sum of all of our policies. It has a ton to do with people too. At its core, it’s about one pair: the patient and the provider.

BJ: Getting the right diagnosis or treatment can often hinge on what happens in conversations with our nurses and doctors.

DG: Today, health care leaders are investing more time and more money trying to improve how doctors and nurses communicate with their patients. But as we all know, relationships are hard and that means no easy fixes. I’m health care reporter Dan Gorenstein.

BJ: And I’m Bapu Jena, a Harvard physician and economist.

DG: From the Annenberg Studio at the University of Pennsylvania, welcome to Tradeoffs.

Today four stories about doctors and nurses very intentionally trying to build more trusting relationships with their patients.

BJ: And what the research says and doesn’t say about the impact those connections can have on our health. Our first story, “We Went There,” starts near Trenton, New Jersey.

DG: And a note to listeners: It does include mentions of abuse that some may find upsetting.

[Clinic waiting room chatter]

Barbara: I am a fabulously 50 single Black woman in the state of New Jersey.

DG: About a year back, a woman we’ll call Barbara sat down, anxious for a physical with her new doctor, Sumeera Baig.

Sumeera Baig: She comes in. She’s got a dazzling smile. She’s athletic. She really has a very energetic and vibrant presence.

DG: Barbara was there to come up with a better plan to control her pre-diabetes from becoming full blown diabetes.

Barbara: And staying away from the stuff that’s going to raise my sugar levels up. Potatoes. They’re evil. Bread. Bacon.

DG: Sumeera was new to the physician practice R-Health, headquartered outside Philadelphia.

Baig: We just started going through history first past medical problems, smoking…

DG: Barbara felt comfortable answering Sumeera, including when a sensitive previous pregnancy question came up.

Barbara: We started talking like we were in a counseling session, letting down my wall. Because she’s a new doctor, I trust her. She’s a doctor. But to really trust her to discuss that kind of personal information, we went there.

DG: So far, so good. Sumeera moved on to family medical history.

Baig: Tell me about your mom.

Barbara: If we have any high blood pressure. 

Baig: She’s like, yeah, she’s got high blood pressure.

Barbara: Cholesterol.

Baig: She’s got cholesterol.

Barbara: Diabetes, cancers.

Baig: There was no hesitation. And then I moved on to, “Okay, tell me about your dad.” And she got very quiet.

Barbara: I know his name, his skin color, his height.

Baig: She just kind of looked at me and she said, “I didn’t have a relationship with him, so I don’t know his medical history.”

Barbara: I knew where he lived. I knew my grandparents, God bless them, before they died.

Baig: At that moment, I could tell she wasn’t quite with me, you know, sitting in front of me answering my questions like a patient anymore.

DG: Memories and emotions flooded Barbara.

Barbara: I didn’t know any of his health things except for he had a bad temper. I knew that’s where I got it from.

DG: Sensing Barbara’s shift, Sumeera gave her patient as much privacy as she could in an 8×12 exam room.

Baig: Sometimes I’ll do, like, busy work, you know? Let me just fix a few things here.

DG: She didn’t say anything out loud. But in that moment, this is where Barbara went when she went quiet.

Barbara: I have been through some sexual abuse and some other things that I’m not proud of. And a lot of it, you know, forgive me to say this because I’ve forgiven him, but a lot of it I blamed it on not having my father in my life: being in an abusive relationship — a bad one where I got a broken finger for life — black eyes, bruised ribs, just feeling like no matter what I was never good enough. Where my life could have been if it was different. What woman I would be if it was different. I don’t know if it could or not, but I think about it.

DG: The simple, benign question…

Baig: Tell me about your dad.

DG: Had unlocked pain and shame for Barbara. The question unwittingly hijacked the whole appointment, Barbara’s own goal to get healthier. It wasn’t anybody’s fault — just the risk that comes with the doctor patient relationship. How Sumeera fills the quiet could get the conversation back on track, or could alienate Barbara jeopardizing this new relationship before it has gotten off the ground.

Bapu Jena: We’ll hear how things unfolded later in the show. 

I got to say, Dan, as a doctor, this story just shows how precarious these relationships can be and how easy it is to lose your way. And what’s really crazy, I’m thinking about my med school days, we got almost no training on this stuff — like how to deal with tricky patient encounters or even the simple ones.

DG: But that’s changing, right? As evidence mounts that these relationships actually matter, in response, med schools and hospitals are trying lots of different training and coaching approaches.

BJ: A popular one is so-called standardized patient sessions. That’s where doctors and nurses role play with an actor posing as a patient.

DG: Here in Philadelphia, the gigantic physician group Clinical Care Associates at Penn Medicine has even begun using standardized patients to help practicing providers hone their people skills.

BJ: We’re actually going to sit in on one of those sessions in our second story, “Fake Patients.”

Jeff Milstein: Probably what we’ll do is we could have the standardized patients sit here and then Kathy sit there.

DG: And it starts here in a standardized training with Kathy Trow, who works with the physician practice at Penn. Kathy treats about two dozen patients a day as a nurse practitioner, meaning she can provide patient care for many conditions without direct supervision from a doctor. And she’s agreed to let us sit in on her mock patient session.

How are you feeling? 

Kathy Trow: Good. I guess I’m just nervous in general. I’ve never done this before.

Milstein: We can do. I’ll go in and get myself set.

DG: This is Dr. Jeff Milstein, the doc who’s pushing the 300 physician and nurse practice at Penn to ramp up trainings like this. He works closely with Kathy on her patients. 

Milstein: And then you could just sort of pretend this is an exam room, basically. 

Trow: Okay.

DG: What’s your hope out of today?

Trow: Well, maybe I’ll learn something. You know, you never really think about this. You never really think of, I don’t know, somebody giving you feedback on the way you communicate with people. I just hope she doesn’t give me too hard of a time. 

Hello. 

Standardized Patient: Hi. 

Trow: Hi, I’m Kathy. I’m the practitioner. Good to see you today.

DG: Before the session starts, a quick word about Kathy: The 47-year-old with closely cropped blonde hair has a problem most doctors and nurses have.

Trow: I’m irritated because now I’m behind. Way behind.

DG: That was Kathy grumpy and on the move in clinic the first time we met her back in the spring. Not enough time ever. 

Trow: Oh, Lord.

DG: It’s exacerbated by the fact that on any given day, she may also pick up other clinicians’ patients. She estimates building rapport on the fly gobbles up about 10 of the 15 minutes she’s got.

Trow: I have to go in there and build a trust with them. I have to do that first before I start telling them what to do or they’re never going to listen to me.

Hi, I’m Kathy, I’m the nurse practitioner. Good to see you today.

DG: As the practice patient, Lorna walks in, Kathy goes right into clinic mode.

Trow: So what brings you in today? Are you here for a sick visit?

Standardized Patient: I am, I’ve been having a sore throat. It hurts me really bad. And I need some antibiotics.

Trow: Okay. Your birth date?

Standardized Patient: It’s 10/19/53. 

Trow: Okay, great. 

Standardized Patient: My old doctor, Dr. Reynolds, would just give me the antibiotics, and I would be set after about 48 hours. So if you just give me that, I can get out and get back to work.

DG: Writing that script would be the expedient thing for Kathy to do, but the clinical guidelines don’t call for it. So she tries to steer Lorna to another solution.

Trow: I’d recommend giving it a few more days, and you could always call us in a couple of days if it’s not better and I’ll call something in for you. 

Standardized Patient: I’ll tell you: Dr. Reynolds would just, you know, this is hard because he was my doctor for a long time, and then he passed away. And, you know, I feel like I’m starting over again, and I feel like I have to defend myself.

Kathy Trow: I’m sorry. I know it’s hard changing providers.

Standardized Patient: God, it just seems like such a big fat mess when, you know, we just met today and I’m telling you what I know works and, you know, it’s just really frustrating.

Trow: Can we meet in the middle? What would you like to do? Can we meet somewhere in the middle?

DG: After a couple more minutes of back and forth, the two hammer out a deal. Lorna will try cough medicine first, and Kathy agrees to send Lorna home with a prescription for antibiotics as plan B.

Standardized Patient: Okay, exhale.

Kathy Trow: Okay. 

Standardized Patient: So relax: This is our little feedback portion.

DG: Jeff and Lorna hand out high marks to Kathy for proposing the compromise at the end of the five minute mock session, but they tell her the start needed some work. Let’s hear that again and listen for Kathy’s responses to her patient.

Trow: So what brings you in today? Are you here for a sick visit?

Patient Lorna: I am. I’ve been having a sore throat. It hurts me really bad and I need some antibiotics.

Kathy Trow: Okay. Your birthdate.

Patient Lorna:  It’s 10/19/53. 63. I’m sorry. My head is like, oof. 

Trow: That’s okay. So how long have you had the symptoms?  

DG: Jeff tells Kathy it sounded like she was trying to hustle through the appointment, feeling the tick tock. He points out that by asking more open ended questions, Kathy could have given Lorna more room to say whatever it was she needed to say.

Jeff Milstein: I’ve found that it’s actually kind of counterintuitive, but it takes less time to do less questioning up front.

DG: In other words, people tend to get right to the point if you ask them, why are you here?

Trow: I hear all that, but I feel like I’m in such a rush sometimes. Like with the easy stuff, I try to be quick because if I let them keep talking I’ll never get out of the room. I know that’s terrible to say, but sometimes I feel like, okay, this has to be quick because I have another 20 patients to see.

DG: Jeff hears concerns like Kathy’s all the time, so he spent the last couple of years educating docs and nurses about the evidence.

Milstein: The study shows that if you allow a patient to just speak without interruption, that they really talk for around 40 seconds and the most they talk is about 90 seconds.

DG: Kathy nods along as Jeff talks. She tells him she’ll try it, but she says it’s not going to give her what she really wants: more time to meet with a patient.

BJ: So, Dan, let’s bring in Dr. Calvin Chou, a professor at the University of California, San Francisco. He’s one of the nation’s leading experts on improving relationships between patients and their doctors and nurses. We asked him to put Kathy’s story into context for us. 

Calvin Chou: I love that story.

DG: Calvin says even though Lorna was fake, Kathy’s story couldn’t be more real.

Chou: I think it’s emblematic of the most common struggles that providers have.

BJ: Speaking from both my experience and Kathy’s, two of those big struggles are time and stress. The frustration of seeing 15 Lornas in a row is real.

DG: One reason for the stress: Hospitals are trying to have it both ways. On the one hand, they’re asking doctors and nurses to get through as many patients as they can in a day, with the average primary care visit just 17 minutes.

BJ: On the other hand, because hospital pay has become tied to patient satisfaction, they’re asking doctors and nurses to care more about connecting with patients. Through trainings like the one Kathy just got, hospitals are hoping to equip doctors and nurses with techniques to both manage time and build empathy.

DG: Calvin says not long ago, this work wouldn’t have found much traction.

Chou: When I first started as a supervising doctor, I would kind of feel like I was a lone voice shouting into the forest, that no one would hear me that interacting with patients was really, really important. Once upon a time, people would have rolled their eyes a little bit more.

DG: Now, 94% of medical schools use standardized patients, and other forms of training are also on the rise.

BJ: This means increased scrutiny and pressure on researchers to show that these investments actually get results.

DG: So far, the evidence suggests that efforts like these can improve empathy and possibly leave patients more satisfied. What’s less clear is whether these trainings actually translate into better health for people. Calvin believes that one way or the other, we’ve got to figure out what works.

Chou: The number of patient interviews that an average doctor does in his or her career is 200,000 to 500,000. Doctors just need to get better at doing the thing that they do most often.

MIDROLL

Bapu Jena: Okay, Dan, we’re half way through — two stories down. So far, we’ve heard how important communication can be during a visit affecting time and trust. Our next story, “Great Expectations,” focuses on the impact a provider’s words can have well after a patient leaves her appointment.

Lauren Howe: A lot of my work is inspired by research on the placebo effect, which shows that your beliefs and your expectations can become kind of self-fulfilling and transform something like, say, a sugar pill into a potent pain reliever.

DG: That’s Stanford social psychologist Lauren Howe. The question she set out to answer: Can that same power of expectation change how patients experience side effects? To test her hypothesis, she designed an experiment around what happens when you expose people with nut allergies to small doses of nuts.

Howe: The thing that is really difficult about this treatment is that while you’re taking these kind of doses of your allergen, you might have some symptoms of an allergic reaction.

DG: Skin rash, scratchy throat, an EpiPen injection if it’s really serious. Now, this treatment can actually reduce the severity of a person’s reaction. But some people with these side effects assume the treatment isn’t working, get frustrated or scared, and quit. Lauren saw that as a missed opportunity to get healthier. Her hunch: Change patients’ perceptions of those reactions, and more people are going to stick with it.

Natalie Levinson: So my name is Natalie Levinson. I am 10 years old, and yeah.

DG: Lauren and the team recruited Natalie and 49 other kids to join their trial, explaining that this would be a chance to see if they could eat a few peanuts without getting sick. Of course, Lauren really wanted to test whether doctors could frame the side effects in a way so kids like Natalie and parents like Natalie’s mom Jessika Welcome would see the therapy through even if they hit road bumps.

Jessika Welcome: It’s incredibly scary to give your child something that you have protected them from their entire life.

DG: On the trial’s first day, all 50 kids received a small dose of nut powder, maybe an eighth of a teaspoon.

Levinson: Like, I was nervous that I would faint. I was nervous that I would die. I was nervous that my throat would close up. That was the main thing. I don’t like stuff in my throat.

DG: Doctors told half the kids, including Natalie, “If you feel symptoms, it’s your body getting stronger, like an athlete in training.” They told the other kids any symptoms they felt were just an unfortunate side effect. The few times Natalie experienced discomfort, Jessika leaned into that positive message that they’d heard.

Welcome: I’m not someone who’s particularly trusting of the medical profession, but there was something about the way that they did the work where I didn’t even question what they were telling us. Like when they said, this is like muscle soreness, you’re going to become stronger because of this, I was just like, okay, that’s good to know.

Levinson: I felt a lot more comfortable eating, and I was a little bit more, like, I felt braver than I did before the study.

DG: Parents and kids in the “you’re getting stronger” cohort reported less anxiety. They also called the patient support team a lot less than the other group.

Howe: As the treatment progressed, patients who had gotten that positive message were actually less likely to show symptoms.

DG: It worked for Natalie. Her diet has expanded to include nuts, and now, she can answer a question that’s been gnawing at her forever.

Levinson: I always wanted to eat a Twix because everybody said it was their favorite candy, and so I couldn’t eat it, and I would always wonder what a Twix would taste like. And now I’ve eaten a Twix and I have to say that I still like Kit Kats better.

DG: A quick caveat: The study is based on self-reported information from just 50 kids.

BJ: But it’s backed up by a growing body of evidence that the expectations doctors and nurses set for patients can make a difference, including for people with chronic pain.

DG: It’s important to remember, though, anything that powerful can also be problematic and lead to things like excessive, even harmful care. This research on framing speaks to just how influential doctors and nurses can be in the health care that we get or don’t get.

BJ: So far we’ve heard a lot about the power of words, but what about the things we don’t even say? Could the unconscious sentiments and stereotypes inside a doctor’s mind actually affect the way we care for different patients? A growing field of research has put a name and some numbers to that phenomenon. It’s called implicit bias, and it’s the focus of our last story, “Common Ground.”

DG: Back in 2016, Dr. Hannah Herman was spending a few hours a week working in a jail reentry program in Washington, DC. One Tuesday, she sat down with a social worker and a man who’d just been released. Hannah listened as the former inmate ran through his to-do list getting a Metro card, figuring out job training, hammering out a daily routine.

Hannah Herman: And as they’re kind of talking about the details of this, I’m in my head realizing he’s got details that he needs to figure out, just like I have details I need to figure out. And that was a big moment.

DG: Hannah is a doctor in training at Unity Health Care, a federally qualified health center. Many of their patients are low income. Many are immigrants. Many struggle with addiction, mental illness or both. Not Hannah’s world.

Herman: I grew up in suburbia, your basic suburbia. My dad is a physician. My mom is a nurse.

DG: Hannah knew that at Unity, she’d be working with very different people. That’s what she wanted. Unity as an employer, understands that lots of their doctors come from very different places than their patients. About four years ago, the clinic developed a program designed to help their staff identify any baggage that they brought to the job.

Andrea Anderson: We need to help the residents to not only figure out where their implicit or unconscious biases lie, but then what? You know, how do you work it out?

DG: Dr. Andrea Anderson runs Unity’s leadership and advocacy program. When you’re more aware of your own prejudices, you’re more likely to see the patient as a person, and that builds trust, she says, which can lead to better care.

Anderson: The patient is more likely to open up and say, “Actually, I wasn’t able to get that medicine because I couldn’t get to the store before it closed.” Whereas in another context, the patient might just say, “Oh yeah, I took it,” and the physician’s wondering like, well, how come they’re not getting better? Like, if there’s a cultural understanding, then there’s a better exchange and a better doctor-patient relationship.

DG: When it came to connecting with her patients and that kind of way. And Hannah felt she was doing alright. She worked hard to find common ground asking lots of get to know you questions.

Herman: How is their life going? Do they have kids? Are they married? What do they do for fun?

DG: And yet she had a blind spot. And it took that day in the jail reentry program to realize what it was.

Herman: They’re going through health insurance, Metro card, where he was living. It was all these complicated moving parts.

DG: It was in the midst of witnessing this most mundane of interactions that Hannah had her a-ha moment. This man was a lot like most everybody else she treated. He was just trying to put one foot in front of the other and live his life.

Herman: I had this moment of, “Oh, this is my bias.”

DG: Hannah’s mind filled with flashbacks to visits with other patients who’d been locked up. Appointments with these patients had been transactions. They needed medical care. She had medical expertise. End of story.

Herman: They’ve done this bad thing. So aren’t they maybe bad people? Well, you broke a law, maybe you deserve what you got.

DG: She realized she’d been delivering two levels of care. Maybe a slight difference to some people, a question skipped here, or less eye contact there, but Hannah knew it wasn’t the same.

Herman: Have I been treating this type of patient the same way I would want to be treated? And the answer was no. I was a little disappointed in myself that I had thought that I was above all that., that I was better than that and this was a moment where I realized I wasn’t.

DG: Hannah credits this training program for helping her see a part of herself that’s hard to admit. Now that she sees it, she says, she’s got to stay on top of it to be the same doctor for all her patients.

BJ: Hannah is not unique. As Aaron Carroll wrote in a recent New York Times Upshot column, dozens of studies show what you’d expect: Doctors are just like everyone else — biased. But how does that carry over into the clinic? 

To talk about this evidence, we’re bringing in Dr. Lisa Cooper from Johns Hopkins. Lisa has devoted much of her career to understanding why some groups of patients get better care than others.

Lisa Cooper: We found that physicians who had an implicit bias that favored whites over Blacks actually ended up sounding less friendly and less interested when they were engaging with their African-American patients. And their Black patients trusted them less and felt less respected by them.

DG: Back when Lisa first started her research, people told her she was crazy for even studying the topic, arguing that somehow health care was immune from prejudice and discrimination. But over the course of her career, evidence of the problem has piled up. One of the seminal works,an Institute of Medicine report, showed that African-American patients are less likely to get optimal care to treat cardiovascular disease, HIV and cancer.

BJ: And today, more hospital executives do accept that bias exists, but it’s in somebody else’s hospital.

Cooper: There’s still some skepticism around that. “It’s happening, but not in my backyard,” you know. This can’t be going on in like, large health systems that have top notch doctors and everything.

DG: One cause for that skepticism: Critics question the methods used to measure bias. But for the people who have come around, they’re now staring at another tough fact: We don’t really know how to address bias in medicine. The program at Unity Health, for example, has been running for four years, but there’s nothing definitive to show it works beyond anecdotes like Hannah’s. 

BJ: Of course, people are trying to prove these programs work, whether at battling bias or enhancing empathy. But Calvin says it’s tricky.

Calvin Chou: If you’re studying a medication and its effect on blood pressure, take the medication and see whether the blood pressure changes. If I’m studying the effect of communication on a patient’s ability to take medications, it’s not just me. It’s also the influences from their family members, from their friends, from other doctors they see. The communication field, in general, can’t show really, really robust outcomes in the same way that if you intervene with a medication, you can show the same outcomes.

DG: For some health care leaders, the problem is important enough that even when you can’t prove your program works, you’ve got to do something because something must be better than nothing. But others might argue that given finite resources, it makes more sense to focus on trainings with proven returns like reducing wasteful care. This is a common challenge in health policy: When a problem is clear, but the evidence to solve it isn’t, what do you do? Wait or wade in?

BJ: There are a few promising studies on the horizon. That includes a randomized controlled trial comparing three ways to improve doctor-patient communication and measure the impact on patient satisfaction.

DG: It’s only anecdotal, but here’s one thing I’ve learned covering health care for the last seven years. Most people, especially clinicians, get into this work because they like people and want to do right by them — people like Barbara, who’s dazzling while trying her damnedest to fend off the diabetes.

Barbara: Staying away from the stuff that’s going to raise my sugar levels up. Potatoes. They’re evil. Bread, bacon… [laughs]

DG: Barbara’s doctor, Sumeera Baig, left her old job at a major hospital in New Jersey and started working with R-Health because they give her more time with her patients. That’s part of why she could occupy herself with busy work when Barbara got quiet.

BJ: Let’s wrap up, Dan, by hearing how their story ends.

DG: Maybe the most important thing Dr. Sumeera Baig did was wait — ride out the uncomfortable silence.

Baig: I’m thinking there’s something that was not good about her relationship with her father. I think she was afraid I might write something. I could even see her shoulders relaxed when I said, “Okay, what I’m going to write in your chart is that he’s deceased and that you don’t know his medical history.” And she’s like, yeah, that’s good.

Barbara: She didn’t make me feel like she was judgmental, like, she wasn’t judging me.

DG: As minor a gesture as it may seem to Barbara, it spoke to the quality of her doctor.

Barbara: She was just a regular person. I know she’s a doctor, but she made me feel like she was asking me these questions so it can make me a better me.

DG: And suddenly, Barbara snapped back, focused on her diet and preventing the onset of diabetes. A year later, Barbara is doing alright.

Baig: She’s not anywhere near close to being put on medication, and that’s all her — the hula hooping, the, you know, mud runs, the exercise.

Barbara: To be honest, it’s always, it’s a struggle because I struggle with food. But I know that Dr. Baig she’s going to be on me. She’s going to make sure that I do what I say I’m doing. And if I’m not, she’s going to give me other suggestions to help me get back on track.

DG: Just what Barbara wants.

Barbara: I joke and say I’m fabulously 50, but I want to be able to be fabulously 60, fabulously 70. I need to be able to be the best me I can be.

DG: And to do that, it helps to have her doctor on her side. I’m Dan Gorenstein.

BJ: And I’m Bapu Jena.

DG: And this is Tradeoffs.