Care Redesign

The Living History Project: Open-Ended Patient Interviews Create a Therapeutic Bridge

Interview · March 12, 2019

Michael Bennick and Tom Lee head shots


Thomas H. Lee, MD, interviews Michael Bennick, MD, a gastroenterologist and Medical Director of the Patient Experience at Yale New Haven Hospital.

 

Tom Lee:  This is Tom Lee from NEJM Catalyst. We’re talking today with Dr. Michael Bennick, a gastroenterologist and senior physician at Yale, who is the Medical Director of the Patient Experience at Yale New Haven Hospital. When I visited there recently, I learned from him about an extraordinary program, the Yale living history initiative that he and some of his colleagues have helped create. It’s really touching, and it made me jealous, frankly. Michael, can you give a quick summary of what is the Yale living history initiative?

Michael Bennick:  Thank you, Tom, for this opportunity. It’s something that is truly near and dear to my heart. The Living History Project at Yale was born out of some work that Sheila Brune did several years ago when she developed the Living History Program to provide basic life information about patients in order to provide care to the heart and soul of those who are privileged to care for these patients.

What we did at Yale was to train undergraduates at the Trumbull College, which is one of the colleges at Yale University, to take open-ended interviews with patients using the same open-ended interviewing skills we teach the medical students, and to sit by the bedside, to listen to the stories of our patients, to provide them with a written record of that story and review it with the patient to ensure accuracy, teaching them the power of a teach-back. Once the story has been okayed by the patient, this gets uploaded into Epic and made available to the physicians and nurses who are caring for those patients, giving them an opportunity to understand them in a much richer fashion.

Lee:  This reminded me about an article that was in The New England Journal [of Medicine] itself right at around the time I visited Yale, that turned out to be one of the most widely read New England Journal Perspective pieces of the year of 2018. It was called “The Name of the Dog,” and you probably saw it. It was about how a resident presented a patient with chest pain that had developed while the patient was walking his dog, and the attending physician asked, “What was the name of his dog?” The point was that the attending was trying to teach the resident to really learn something about the patient’s life. So, there’s clearly some deep and important values conveyed by this initiative. How did you come to do this at Yale? This is not something that is a standard part of, say, the electronic record information that I’m looking at.

Bennick:  I think that that observation, when you get to know somebody, you have to honor the pieces of their life that are truly important to them. We take a history, often in medicine, as a functional task, and [we] don’t view it as the opportunity to create a therapeutic bridge with the patient. We so quickly gloss over the young patient who tells us that they have a 3-month-old at home, and don’t event ask the name of the baby or whether the baby is a boy or a girl. Curiosity is how we learn about the world. It’s how strangers get converted into people with whom we can empathize. It’s an opportunity to understand the feelings and ideas of one’s patients so that we are in a position to empathize with them, to create that therapeutic bridge, that allows us to talk about deeply important issues.

Lee:  Can you give me an example of the kind of information that the students are capturing that regular old clinicians like me might miss during our regular workups?

Bennick:  I can, and it will be self-revelatory at the same time. I have always enjoyed sitting with my patients and talking to them about them and their lives, and I tend to know my patients fairly well. I don’t sit behind a desk. I have a living room–like atmosphere in my office. I had a patient who had an unusual form of sarcoid that ended up infiltrating her GI tract, making it more and more difficult for her to eat, and she ended up requiring a feeding tube and at some point. When her small bowel no longer worked, we ended up having to give her TPN (total parenteral nutrition). I knew her well because I cared for her since I was a fellow at Yale, and over the years, she developed repeated infections of her line.

It turns out that this woman was born in the south. I knew that, but what I didn’t know was that she was born on a farm and her favorite memory was to sneak out the back window of her house and break into the watermelon patch at night, reach in, and grab that rich, red fruit. She would slather herself with that fruit only to be discovered the next morning by her mom, as the pits were on her pajamas.

When the young university student obtained that story and wrote about it, and the team read that story and recognized this was one of many replacements of an infected line, it gave them an opportunity to realize how important eating was to this patient, and it led them to an earlier conversation about what the goals of care should be.

Without that story, they wouldn’t have explored that goal and wouldn’t have been able to do it in a way that was an opportunity to really reach out to a human being as in the most elemental of ways. It was just serendipity that this turned out to be a patient of mine, not when I was on service but when my colleague was on service, and it changed the way the whole conversation and plan unfolded. What would have been a unique missed opportunity became an opportunity to have a much more meaningful conversation with this patient rather than just replace the line yet again.

Lee:  That is interesting because, of course, eating is important to everyone, but getting a story from the past made that issue vivid and compelling for the clinicians taking care of the patient. What is this process like for patients? Are they confused, or do they enjoy having an undergraduate sit down and talk with them about their lives?

Bennick:  They absolutely do love the opportunity, because how unusual is it to have an hour where you are asked questions and given the opportunity to share with another human being things that are mightily important, especially at a time when you are vulnerable and often have deep feelings easily accessible?

The nurse managers on each of our floors involved in this project have been trained on whom would make a good candidate for this story, and they go in advance and ask the patients if they would be willing to have a conversation with our students. After our students have been trained and shadowed a more senior member of the Living History Project at Yale, they then go into a room, they pull up a chair after introducing themselves, explaining why they are there and asking permission if this is a good time to have a conversation, and once they have gotten the yes, the conversation ensues.

Lee:  Do you have a feeling for what it’s like for the students? They are a self-selected group, but what have they said about the process?

Bennick:  The first year we did this, we studied the response. We studied the first 18 students in 2012, when we began the program, and we interviewed qualitatively our student historians, the nurses, the patients, and the physicians who had the opportunity to be interviewed, and we compared it with a control, which was the other side of the unit that did not have this. Needless to say, in all of the groups that were interviewed versus the control groups, we had a statistically significant response that nurses felt more responsive to emotional needs, that the care provided by the physician staff was improved, that patients felt appreciated and understood by their caregivers, and their overall satisfaction improved, as well.

When we ask the patients what they felt, they said things like, “For my nurses and doctors, I would just like for you to know that I am a human being.” That was in response to one of the questions we tend to have our students ask before the conclusion of their history. We ask them several things: What do you most value or love? Is there anything you have always wanted to do but haven’t? But we also always encourage them to end the conversation with: What do you most want your medical team to know about you? And that’s what the patients have said.

For the students, they are unbelievably happy to leave the hospital on a Saturday, and they can’t wait to do it over and over and over again.

Lee:  Well, it is sounds like it may not change mortality, but it’s making care better in a variety of other ways for patients, as well as providers and trainees. It’s wonderful work, and we’re looking forward to hearing where it goes, like how much gets used and how it evolves with time. Thanks for this and many, many other wonderful initiatives that you lead at Yale, Michael. I’m sure we’ll be finding time to talk about some of them in upcoming podcasts.

Bennick:  Thank you so much, Tom. Thanks for the opportunity to share.

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