We Went There
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.
‘Fake Patients’
“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.
Great Expectations
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.
Common Ground
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.