What Brings You In Today?

The 50-year old was here to do battle with her nemesis: diabetes. She hoped she had done enough to keep it at bay.

“I was staying away from the stuff that’s going to raise my sugar levels up,” says the woman we’re calling Barbara to protect her privacy. “Potatoes, they’re evil. And bread. And bacon.”

Barbara was also hoping to get some helpful advice—and a bit of encouragement—from her new doctor, Sumeera Baig. This was their first meeting, and Barbara was anxious. Baig had recently joined R-Health, a primary care practice, hoping to do more of what motivated her to go into medicine in the first place: face-to-face time with her patients.

The two began with the basics. Medications, smoking, drinking, exercise. The rapport was good. Then they moved on to Barbara’s medical history. Baig asked about a sensitive previous pregnancy. “We started talking like we were in a counseling session. I trust her—she’s a doctor—but to really trust her, to discuss that kind of personal information, we went there,” Barbara said.

Minutes later, Baig stumbled, after asking Barbara a seemingly straightforward question about her dad’s medical history. “She got very quiet,” Baig said. Barbara then told her doctor that she didn’t have much of a relationship with him and didn’t know anything about his medical history.

“At that moment, I could tell she wasn’t quite…sitting in front of me answering questions like a patient anymore,” recalled Baig. Sensing Barbara’s shift, the doctor gave her patient as much privacy as she could in an 8-by-12 exam room, busying herself with computer work.

Barbara didn’t say anything else out loud. But her mind flooded with memories. There had been sexual abuse and shame and domestic violence and trauma. Perhaps the most painful thought of all was not about what had been, but about what could have been. “What woman I would be if it was different.” Barbara remembered thinking at the time. “I don’t know if it could or not, but I think about it.”

In asking for some simple details—“Tell me about your father”—Baig had unwittingly hijacked the appointment. How she handled the next few seconds could either bring Barbara back into the moment—or push her away, possibly for good.

Baig stayed quiet for a few seconds before breaking the silence.

“OK, what I’m going to write in your chart is that [your father is] deceased, and you don’t know his medical history.” Baig said she saw Barbara exhale. “I think she was afraid I might write something in there that maybe she didn’t want.”

Baig had recognized Barbara’s comfort zone and respected it. And that was big for Barbara. “She didn’t make me feel like she was judgmental. She was just a regular person.” 

Baig could have written more down, but she didn’t. Because it wasn’t necessary, and it wouldn’t have done Barbara any good. “She made me feel like she was asking me these questions to make me a better me,” Barbara said.

Barbara now understood she could trust Baig. And that made it easier for Barbara to return to the real reason for her visit. “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,” she said. The two closed out by discussing Barbara’s progress and tips for staying on track with food and exercise goals.

A year later, Barbara was still doing well. “She’s not anywhere close to needing [diabetes] medication,” Baig said, “and that’s all her. The hula hooping, the mud runs, the exercise.”

Barbara acknowledged that staying healthy will always be hard for her, but having a doctor she can trust makes it a little easier.

“I’m behind. Way behind,” sighed Nurse Practitioner Kathy Trow. That might as well be the slogan of doctors and nurses across America.

In just 17 minutes—the average length of a primary care visit—doctors and nurses are expected to establish rapport with a patient, suss out all of their health concerns and questions, conduct physical exams, and work with the patient to create a plan they understand and leave feeling good about. And that doesn’t include entering all of that information into the electronic medical record.

Oftentimes, some of the two dozen patients Trow sees in a day are not even hers. Having to pick up other clinicians’ patients only exacerbates her chronic time crunch. Kathy estimates building rapport on the fly gobbles up about 10 of the 15 minutes she gets.

Earlier this year, she agreed to participate in a new training her employer, Clinical Care Associates at Penn Medicine, offered in the hopes it could improve her communication skills and make her more efficient. She decided it was worth doing, even though it made her anxious.

“I’ve never done this before. I’m nervous about how terrible they’ll say I do with patients. I just hope she doesn’t give me too hard of a time,” Trow said on the day of training, seated inside a stuffy conference room. Just for the day, that conference room had been converted into a mock exam room—at least in the participants’ minds. 

They were partaking in a standardized patient session, where doctors and nurses role play one-on-one with an actor posing as a patient. Such trainings have become increasingly popular as hospitals acknowledge the importance of communication skills, both for boosting their bottom lines—which are now tied in part to patient satisfaction scores—and for battling burnout, a serious epidemic among clinicians.

To make Trow’s anxiety worse, Dr. Jeffrey Millstein, a supervising physician who is championing this training initiative at Penn Medicine, attended the session and was observing her every move. But Trow went straight into clinic mode as she knocked on the door and walked in to meet her “patient,” Lorna. Their visit started like this:

Kathy: Hi, I’m Kathy…are you here for a sick visit?

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

Kathy: OK. Your birth date?

Lorna: 10/19/53 I mean ’63. Sorry my head is just…[groans]

Kathy: Any chills? Body aches?

Lorna: Not really…

Kathy: And what’s your past medical history?

Lorna: I’m totally fine except I get a sore throat a couple of times a year. 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.

Writing that prescription would have been the expedient thing for Trow to do. But the clinical guidelines don’t call for it. Although some of her practice partners are what one might call more generous prescribers, that’s not how Trow rolls. She tried to steer Lorna toward another solution.

Kathy: Well, I’d recommend giving it a few more days. And you can always call us in a couple days if it’s not better. 

Lorna: I don’t have time for sick days. I have to be able to work.

Kathy: I’d like you to try some over-the-counter things first…I’ll give you a prescription cough medicine and you can try that for a few days.

Lorna: It’s hard because [Dr. Reynolds was] my doctor for a long time, and he passed away and, you know, I feel like I’m starting over again and having to defend myself. 

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

Lorna: I’m telling you what I know works. It’s just really frustrating.

Kathy tried her best to show empathy, but she also sensed she was at an impasse and running out of time. She tried another tack.

Kathy: Well, can we meet in the middle? How about if I give you the cough medicine [and] nasal spray, and I’ll write you an antibiotic, [but] don’t take it right away. Give it a couple more days and if you’re still not feeling well, then you can start the antibiotic. Does that sound reasonable?

Lorna: Yes.

Kathy: Okay, we’ll do that.

With a compromise snatched from the jaws of defeat, the 5-minute mock visit ended. Kathy exhaled.

Millstein and Lorna, the fake patient, complimented Trow for getting to the outcome that she did, but they had some feedback about how she got there. Millstein told Trow it sounded like was trying to hustle through the appointment, especially at the beginning when she was barging through her list of questions.

“I hear all that,” said Kathy, “but I’m in such a rush [that] sometimes with the easy stuff I try to be quick. I know that’s terrible to say, but sometimes I feel like, ‘OK, this has to be quick because I have another 20 patients to see.’”

The irony, Millstein told Trow, is that by trying to go fast, she might actually be going slower. He cited research showing that asking fewer questions and keeping them more open-ended can actually save time in a visit. He said the same is true of taking a little time to show empathy and acknowledge patients’ emotional cues and concerns.

Millstein isn’t naïve, though. He conceded, “There definitely are operational factors. Communication can make time more efficient [and] more meaningful, but it doesn’t add hours to the day.”

Trow agreed to try asking more open-ended questions, but she’s skeptical. What she’d really like are some of those extra hours in a day. 

The placebo effect is known for the surprisingly powerful pull it can have on patients, including those battling crippling pain and depression. It’s also had a big impact on Stanford social psychologist 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 self-fulfilling and transform something like, say, a sugar pill into a potent pain reliever,” Howe said.

The question she set out to answer recently: Can that same power of expectation change how patients experience side effects? To test her hypothesis, she designed an experiment using a treatment that exposes people with nut allergies to small doses of nuts.

“The thing that is really difficult about this treatment,” Howe said, referring to an approach used by allergy specialists known as oral immunotherapy, “is that while you’re taking these doses of your allergen, you might have some symptoms of an allergic reaction.” 

Although this treatment can ultimately reduce the severity of a person’s allergy, some people never finish it. The side effects—itching, rashes, and sometimes worse—and the anxiety and frustration they cause can be too much for some to bear. 

It was in those lost cases that Howe saw opportunity. If she could change patients’ perceptions of the reactions the treatment causes, she figured more people would stick with it, despite any bumps in the road.

Howe and her team recruited 50 kids to join their trial, including then-10-year-old Natalie Levinson, with the promise that the study could help the children overcome their allergies. 

On the trial’s first day, all 50 kids received a small dose of nut powder, about an eighth of a teaspoon. “I was nervous that I would faint. I was nervous that I would die. I was nervous that my throat would close up,” Natalie said. 

Doctors explained to half of the kids, including Natalie, that if they felt symptoms it just meant their bodies were getting stronger, like an athlete in training. The other half of the kids got a more neutral explanation—any symptoms were just an unfortunate side effect of the treatment.

In the few moments during the trial when Natalie experienced discomfort, her mom Jessika Welcome leaned into the positive message they had received. “I am not someone who is particularly trusting of the medical profession, but there was something about the way they did the work that I didn’t even question what they were telling us. When they said, ‘You are going to become stronger because of this, I was like, ‘OK, that’s good to know.’”

The positive framing affected Natalie’s experience, too. “My body felt like it was getting stronger. I felt a lot more comfortable eating. I felt braver than I did before the study,” she recalled.

The study results show Natalie wasn’t the only success story either. Parents and kids in the “you’re getting stronger” cohort reported less anxiety. They also called the patient support team almost half as often as the other group. “As the treatment progressed, patients who had gotten that positive message were actually less likely to show symptoms,” Howe said.  

As for Natalie, as wonderful as it was to address her nut allergy, she was finally able to answer a question that had long gnawed at her. “I always wanted to eat a Twix because everybody said it was their favorite candy, [but] I couldn’t eat it before. And now I’ve eaten a Twix.”

Her verdict? “I still like Kit Kats better.”

There are a couple of important caveats about this story. 

First, this study was based on self-reported information, and it included just 50 kids. However, it is 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. 

Second, although the power of framing had a positive effect on Levinson, it is important to realize that anything that potent can also be problematic. Studies have also shown that doctors can, intentionally or not, push patients toward excessive and even harmful care depending on how they explain and frame things like treatment options.

One JAMA Dermatology study showed that when a skin growth was framed as “pre-cancer,” 9 out of 10 patients said they would opt for treatment. When the same growth was framed as something that only turns into cancer less than 1% of the time, only 6 in 10 patients said they would choose treatment.

As a whole, this body of research on framing speaks to just how influential doctors and nurses can be in the health care that we get—or don’t get.

One Tuesday in 2016, medical resident Hannah Herman was sitting with a social worker and a man recently released from jail. It was part of a weekly rotation she did at a jail reentry program in Washington, D.C. 

Herman listened as the former inmate ran through his to-do list: getting a Metro Card, figuring out job training, hammering out a daily routine. “As they’re 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,” Herman recalled. “And that was a big moment.”

Herman trains 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. As she explained it, “I grew up in your basic suburbia,” she explained. “My dad is a physician. My mom is a nurse.” Herman knew that at Unity, she’d be working with a very different group of 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 they brought to the job. 

The premise, explained Dr. Andrea Anderson, who runs the training program, was that if providers could become more aware of their own prejudices, they would be more likely to create meaningful connections with their patients, and that could lead to better care.

To illustrate her point, Anderson gave the example of a patient who did not take their medication as directed and might be ashamed of it. If that patient had a doctor they trusted, they might disclose that they had trouble affording it or making it to the pharmacy before it closed because of a long shift at work. The patient who did not trust their doctor might just say, “Oh yeah, I took it; and the physician [would be] wondering [why] they’re not getting better,’” Anderson explained. 

Herman felt good about her relationships with her patients. She worked hard to find common ground, asking patients about their kids or their jobs.

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

“They were going through health insurance, metro access, where he was living. [There were] all of these complicated moving parts,” she said. Those details of daily living sound so mundane, but they were actually the very thing that set off the light bulb inside Herman’s head. 

Sitting there, she remembered visits with other patients who had been locked up. Appointments with those people had been transactions. They needed medical care. Herman had medical expertise. End of story. 

She had skipped trying to find common ground with those patients because she had assumed there wasn’t any.  “They’ve done this bad thing. So aren’t they bad people?” Herman recalled of her old mindset. “Feeling [like], ‘Well, you broke a law, maybe you deserve what you got.’” 

But after witnessing that man dealing with the simple logistics of life, Herman suddenly saw the shared humanity in a place where she had failed to see any before. It dawned on her that this was her bias. She had been giving formerly incarcerated patients a different level of care.

The differences might have seemed slight to some—a question skipped here or less eye contact there. She had still met their medical needs. But Herman knew it was not the same.

“Have I been treating this type of patient the same way I would want to be treated?” Herman recalled asking herself. “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. This was a moment where I realized I wasn’t.”

Herman credits the Unity trainings for helping her see a part of herself that was hard to admit. She also acknowledges that bias is not a thing that can be easily beaten or buried. If she wants to engage equally with all of her patients, then she must also engage with that bias, every single day.

Herman is not unique. As Aaron Carroll wrote in a recent New York Times Upshot column, dozens of studies show that doctors are just like everyone else: biased. While some critics question the methods used to measure bias, it is hard to argue with another body of evidence that shows African Americans are less likely to receive optimal care for a range of conditions. 

For those who are convinced that bias plays a role in causing those larger disparities, there is not much solace in the available solutions. The program at Unity Health, for example, has been running for four years, but there is nothing definitive showing it works beyond anecdotes like Herman’s. 

For some health care leaders, though, the problem is important enough, that even when you can’t prove your program works, you have to do something, because something has to be better than nothing.

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.