Leadership

Careful and Kind Care Requires Unhurried Conversations

Article · October 29, 2019

As we argue in Why We Revolt, careful and kind care makes the health care system responsive and responsible to patients and clinicians. Within unhurried conversations, patients and clinicians work together to advance the problematic human situation of patients, to celebrate and to grieve, to establish and renew relationships of care to which they return to regroup after a disappointment. Care requires clinicians to see the patient situation in “high definition”. When care is safe and effective, it is more likely to do good than harm as defined by what matters to each person. Clinicians must understand the situation of each person in “high definition” and co-create with each person a plan of care for that person not for people like that person

In order to provide proper care, patients and clinicians must be able to have unhurried conversations — either in one-time visits (as is typical of specialty consultations) or over the course of their ongoing relationship (a hallmark of primary care) in which they can see the patient situation in “high definition” — both content and context, biology and biography — to uncover what aspect of that situation demands action, and discover together the action that this situation demands. This shared decision making approach, in turn, makes it possible to develop care that makes intellectual, practical and emotional sense to the patient. Seen in this way, unhurried conversations should be a core accomplishment of any caring health care system and its professionals.

A clinical conversation is unhurried when neither party is rushed, either for their own intrinsic reasons or to satisfy the system’s expectations. It is one in which the rhythm of the conversation is appropriate to the work of care, as determined by the participants and not by standards blind to purpose or context.

Those actively and meaningfully participating in the conversation conduct an unhurried one naturally. While the term “unhurried conversations” seems to imply a long interaction, this implication points to duration and here we are concerned with tempo. While an excessively brief duration necessarily accelerates the rhythm of care beyond its usefulness, it does not follow that hurry can be avoided by only extending the time allotted. The figure describes other factors that determine rhythm and participation.

A Preliminary Model of Determinants and Consequences of Unhurried Conversations with Patients

Figure 1 Click To Enlarge.

Rhythm and Participation

Rhythm refers to the temporal quality of the conversation: the sequence, spacing, and speed with which facts and feelings, utterances and silences, and responses flow forward from one person to the other. In addition to the sequence of information exchange and communicative acts, rhythm also encompasses how understanding, relationships, purpose, and the humanity of the encounter build and conclude in action.

Thus, rhythm is not the passing of seconds, or the rate of data exchanged per second, but a tempo that the participants create as they converse. The organization of policies, clinical information, teams, and structures can determine the fulfilment of this achievement. Poorly supported, conversations become hurried. Supportive environments, on the other hand, foster unhurried conversations. Key organizational contributors to rhythm include how much time the system allots for the conversation, how much time that conversation should take, and what participants are required to do during that time. The rhythm of a conversation is an achievement of the participants interacting within the conditions of the practice.

Clinician and patient should feel neither hurried nor that they are wasting the time of the system (i.e., the opportunity to take care of other people) or of each other (i.e., the opportunity to return promptly to life or work routines). Care has its own tempo, which depends on the nature of the problem, the participants, and what is at stake. A difficult patient problem, a clinician and patient new to each other or to the problem, and a high-stakes treatment decision all call for a slow and long conversation. A faster conversation, in this instance, may lead to errors in appreciating the problem, the aspect of the problem that requires action, and in selecting how to respond. Alternatively, a simple patient problem, a clinician and patient who have an established relationship (thanks to continuity of care, for example), or a low-risk treatment decision may be addressed quickly but without rush (i.e., no faster than what is appropriate to respond well to the problem at hand). A slower conversation, in these cases, may waste the time of both parties, takes longer, introduces opportunity costs without an upside, and reduces access to care.

Unhurried conversations also require participation. To enable unhurried conversations, whether face-to-face, via telemedicine, asynchronous or virtual, participants need to make themselves cognitively and emotionally available. They should be able to generously contribute their knowledge and expertise to the process of uncovering the situation and discovering the solutions. They should be able to respond with empathy and compassion as the issues emerge. Participation therefore calls for participants to bring to bear their sense of self-efficacy and their prior experiences (including, for example, trauma caused by health care). They must be present. Presence requires the removal or suspension of distractions from the environment and from their own selves (e.g., worries, pain). They must carefully listen to ensure their counterpart is actively following what has been shared and understands its relevance to the conversation’s purpose. Moreover, there are different levels of participation that may be needed depending on the purpose of the conversation: a conversation about the treatment of an ear infection may require less participation than a conversation about suicide. In this sense, both rhythm and participation must be accurately calibrated to achieve an unhurried conversation.

Organization and People

Rhythm and participation are functions of the interactions between the organization and people. The organization sets up the conditions, the policies, the allocation of facilities, information, and people that result in encounters, conversations, and care. They set up barriers, facilitators, and distractions that affect the quality of the conversation. Without intervention from the organization — for example by implementing “smart” schedules that allocate time and buffers between appointments purposefully and flexibly — it is hard for participants to unilaterally enact unhurried conversations. Doing so may make them late to see subsequent patients (when encounters are scheduled for a duration much briefer than needed without buffers between them), miss family commitments, or delay the staff’s return home at the end of the day. Similarly, modifications in the organization of care, while necessary, may not be sufficient to achieve unhurried conversations. People must participate. The clinician must bring their expertise, compassion, communicative skills, and experience to bear in meeting patient needs and acknowledging their fears. The patient, in turn, must be willing to participate in the conversation, be ready to offer information and insight, ask questions and offer ideas and suggestions regarding their care. Together, they must be willing to cultivate a relationship, and develop an understanding of what is going on and what must be done.

Unhurried Conversations as Achievement

Understood in this way, unhurried conversations are a collective achievement of the health care system, its organization, and the participants in the conversation. These contributors in harmony set the right rhythm and the right level of participation for the purpose at play. Unhurried conversations should provide the essential environment in which plans of care that are pertinent to each person, particularly those who face complex biology (e.g., experiencing multiple chronic conditions) and complex biographies (e.g., experiencing poverty and loneliness), can emerge and be responsive and responsible, effective, feasible, and safe. They create the context for the true gestalt benefits of having unhurried conversations: careful and kind care. (Remember that the opposite is hurried conversations).

The Impact of Unhurried Conversation

This framework is only a first iteration. Additional research and deliberation will be necessary to determine the key elements and determinants of unhurried conversations and to set up research projects to elicit their relationships and contributions.

Measures to identify places and circumstances in which unhurried conversations take place may help quantify their prevalence and identify best practices and the costs and trade-offs of their implementation. Some early efforts have sought to quantify consequences of rushed care, such as practice chaos and incomplete care.

Interventions to promote unhurried conversations should be designed, as well as studies to determine their ability to effectively promote unhurried conversations. These interventions may involve innovations in scheduling or technologies to support the functions of the clinical encounter; they may involve the introduction of facilitators or the deletion of distractions. We must keep in mind that health care personnel who participate in the clinical encounter to help with documentation, referred to as medical scribes, or ninjas, have the potential to contribute to unhurried conversations by taking on tasks (thus removing them from the to-do list for the encounter) and by removing distractions (entry of orders, scheduling, documentation, billing). Yet, in many places they contribute to improve access, throughput, and revenue. What makes their use different in this context is the primary motivation to achieve unhurried conversations.

Studies must also be conducted to determine the extent to which unhurried conversations contribute to safe and high-quality patient-centered care and to improve health outcomes.

The design of such a study may exceed the scope of this article, which simply proposes a conceptual model. However, there are published studies that have attempted to manipulate variables such as the duration of the visit. Unfortunately, the studies found are old, poorly protected from bias, and yield imprecise results. There are also clinical trials of medical scribes, but hurry was not assessed.

It is important to note that we don’t have a routinely assessed measure of hurry in the consultation, and one is likely needed to aid in this work. We could use observational studies, either prospective (in which schedules, slots, and calendars are manipulated, for example) or retrospective (in which we take advantage of random no-shows, for example due to road-busting storms or of random ramp-ups, for example due to a colleague going home early because of sickness).

Pursuing unhurried conversation is subversive as these need to happen within the walls of a system bent on efficiency, a system which appears at times set on unmaking them. Their achievement requires changing the rules of industrial health care’s game for the rules of care. It demands of industrial and business processes the right to be focused on supporting care first, rather than primarily attend to industrial (access and throughput) or business (financial targets, payer mix) goals. It demonstrates a professional commitment to care for and about each person, by a clinician present in the moment and able to collaborate with each patient to form a sensible care plan. The achievement of unhurriedness, of the tempo and rhythm of care, may represent the finest expression of an elegant system and its expert professionals committed to careful and kind care for all.

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