Transforming the Patient Experience Through the Power of Ritual

For many thousands of years, medicine had little to offer patients in the way of diagnosis and treatment. Early healers were limited to a listening ear, a caring touch, and an empathetic voice. With the transition to evidence-based medicine and its resulting explosion of medical knowledge, physicians focused ever more on learning and practicing interventions based in physical biology. Unfortunately, despite the great benefit of clinical understanding, some of what was good in medicine has been lost.

Skilled communication can help lower A1c, cortisol levels, heart rate, and blood pressure, all of which result in measurable relief of suffering and reduced dependence on the varied chemical supplements we are all too fond of prescribing.

Conversely, patients can show improvement in clinical measures yet also suffer anxiety, loneliness, fear, and pain, which may aggravate and even endanger an otherwise positive prognosis.

Patients today need physicians who practice both the science of medicine and the art of healing. A positive patient experience is strongly correlated with positive clinical outcomes, financial performance, and an inverse relationship to lawsuits. Longitudinal patient experience data represents the effectiveness of a therapeutic relationship, not the impression of a single visit.

Transforming the patient experience requires relationship-building and communication skills, which can be taught just as clinical exam knowledge is. The value of these skills is in relieving emotional suffering and building a therapeutic relationship. Patients are more likely to comply with therapy and continue care when they trust us and feel safe.

While the term “ritual” may feel uncomfortable in the world of randomized controlled trials, ritual is in fact a primitive checklist — in this case, a series of steps that, when repeated consistently, serve to create feelings of safety and trust between client and caregiver.

Abraham Verghese, MD, has pointed out that the clinician’s white coat of today is purely a ritualistic symbol, and continues to be worn despite its negative impact on infection control. The stethoscope has attained similar symbolic status. Just as these symbols help to inspire confidence, clinical and business literature on communication reveals that there are also specific actions that, when consistently performed during a patient encounter, foster feelings of trust and safety. These include sitting down, making eye contact, being cognizant of nonverbal cues, reflective listening, proper computer etiquette, and the use of a patient agenda.

At Hawaii Pacific Health, in January 2016 we began applying an evidence-based approach to the art of healing. From a list of best practices culled from literature searches and direct observation of high-performing physicians, we created a checklist of steps for physicians to consistently perform during patient office and hospital visits. While our physicians were not required to perform the entire list, they self-identified those items they already practiced, and then were asked to select at least two more from the checklist. In some cases, exam rooms were modified to allow proper performance of the checklist, such as moving handwashing stations to just inside the door so this could be the first action upon entering the room, or replacing fixed wall mounts with tethered computer carts to allow physicians to sit facing the patient.

Our system’s overall performance on the CGCAHPS physician communication composite score improved from the 54^th percentile to 75^th percentile over a period of one year for a group of 200 physicians, 50 of whom received coaching for communication skills.

Physicians selected for coaching were identified from the 30^th to 75^th percentile according to Press Ganey national rankings, as they were felt to be actively engaged but possibly lacking in knowledge of clinical communication skills. These physicians were encouraged to choose one or two new skills from the list and incorporate them until they could perform them consistently and sincerely in each office visit, with scripting if necessary. However, physicians at the low end of the Press Ganey performance data who volunteered for coaching also received training, sometimes with dramatic results. The most important criterion was a willingness to learn.

Though we may not normally think of the modern patient-physician encounter as a ritual, it is in fact susceptible to the same process improvement that use of a checklist has demonstrated in the operating room and the airline industry.

Physicians with good relationship skills have lower rates of burnout, experience greater career enjoyment, and can apply these skills in building relationships with their colleagues and staff. Communication skills that reduce pain, relieve anxiety, and create understanding help transform the dry term of “patient experience” into a therapeutic relationship, in which both the provider and patient benefit.