Breaking the Vicious Cycle

I wrote in the past on how transactional relationships hurt how patients and clinicians approach healthcare.  The problem with this model is that, perhaps more than any other customer relationship, healthcare succeeds when the relationships build on each other, feed on each other and do NOT exist in a transactional vacuum.  This is a fact that many clinicians will reference, though often only to justify their lack of engagement.  By saying things like, “Well, by the time they get admitted, it’s too late to build a positive experience” you are acknowledging that healthcare is NOT transactional and that which happened in the past affects the present.  If you thought it was transactional, you would accept that whatever happened in the ED was immaterial, because once the patient is on your floor, the slate has been wiped clean.  But if you DO acknowledge the past is a prologue (and use that as an excuse), you are saying that everything affects everything.  It is really your glass-half-empty mindset that is framing these past encounters in only a negative way.  This spiral, though, doesn’t only go downwards.  That spiral can also go upwards.  Just as there is a virtuous cycle in contrast to the vicious cycle.  This essay will explore how to break the negative pattern, usually focused on past experiences, and build a future-focused positive experience.

One of the biggest lessons we must learn in our private life is when to LISTEN and when to FIX.  When your significant other comes home and complains about something, sometimes they simply want to be validated, so you nod and listen and provide supportive comments like, “Yeah, that really sucked.”  Sometimes they want you to provide solutions to their problems and they are looking for “Do you want to talk about how to deal with the situation when you get to work tomorrow?”  Most fights then arise when you deliver the wrong response to their soliloquy.  Dealing with patients requires the same attention.  The challenge is that, in the workplace we tend to DISCOUNT or DEFEND instead of LISTEN or FIX. 

When you greet a patient who has already had interactions in your care space (inpatient after being in the ED, lab after seeing the doctor, triage nurse after seeing registration, etc.) and they are upset about something, too often the response is to move past their feelings with a “I can’t do anything about that, but you are with me now…” response.  This does not make the patient happy and can even make them more agitated.  Staff are often reticent to explore a patient’s feelings because the clinician feels rushed and does not want to ‘waste time’ going down some feeling rabbit-hole that they can do nothing about.

The problem is that without addressing their concern, the patient will never get over it.  Every conversation has a past, a present, and a future component.  Most transactional conversations will only focus on the present and perhaps address the future but avoid the past.  But in the real world, the past informs the present which can drive the future.  By not confronting the past, a patient cannot move forward.  This is why transactional conversations don’t yield best outcomes. 

A couple of years ago, a family member of mine went to her doctor in November and complained about a pain under her arm.  The doctor did a cursory review and diagnosed it as a rotator cuff issue with a “getting older sucks” and a suggestion to take ibuprofen.  My friend was of an age when you accepted what the doctor said and moved on.  But it persisted and in January she was back complaining about it.  He again waved it off, but when she got her mammogram in February, she cajoled the imaging tech to take an image of the troubled spot.  It revealed an issue, which meant a trip back to the doctor, followed by a trip to a specialist for a second opinion and a diagnosis of cancer.  She finally received a plan of care and started on treatment in May.  As you can imagine, she was livid.  After all, SHE identified this back November and here we were six or seven months later, only now starting treatment.  When she saw her doctor, she let him have it with both barrels.  Nothing fuels anger like a lifetime of trust being shattered.

When confronted with this frustration,

• You WANT the doctor to say something like, “Boy, you were right and I didn’t listen to you.  I am sorry.  I will learn from this.  But for now, we have you on the right course of action and this delay will not compromise the treatment’s ability to address the cancer.”
• But what he ACTUALLY said was, “Hey, you are lucky to be starting treatment so quickly.  If this was New York, you would probably still be waiting another six months to start treatment.”

Not surprisingly, she fired him on the spot and got a new doctor.  The point of this story, though, is that this wasn’t the end.  It is the fact that EVERY TIME she goes in for infusion, she will tell a version of this story to the technician.  Everyone there now knows this story by heart, but she is trapped in the past.  By not acknowledging the hurt at the beginning, the doctor prevented her from being heard and prevented her from moving forward.  Or, to paraphrase U2, she is stuck in a moment she can’t get out of.¹   

In smaller scale, every day we meet patients who have a past that we can help them move past.  Sometimes it is a past of their own making and sometimes it is a past that we made for them.  We have all heard patients make fatalistic comments, like “I really should have managed my diabetes better…”, or “If only I could tell my 17-year-old self to never start smoking…” or even, “I knew I shouldn’t have overindulged over the holidays…”  Even if the patient doesn’t say it explicitly, these comments all come with an implicit statement of “and now it’s too late.”  This fatalism will have the patient challenge, reject, or simply ignore the care plan that we suggest. 

In these cases, we are often pretty good in helping them move past this, with something like “Yeah, we all make bad choices when we are young, but we can all still get back on track…” This sentiment acknowledges the past decisions without wallowing in them and reframes the conversation to what we can do NOW and how this will affect the future.  It is analogous to the investment truism that the best time to plant a tree was five years ago, but the second-best time is today.  We cannot relive or relitigate the past, but we can make the best decision for today.  The best time to quit smoking was five years ago, but quitting today will still make things better. 

While we may be good at this, when the past hurt is patient-inflicted, we tend to be too defensive to use this logic when we are the culprit.  You know that the emergency department is on-fire at the best of times, so when a patient gets admitted after sitting as a boarder for 24-hours and they complain, you might want to say, “Hey, some people NEVER get a bed, so a 24-hour wait is nothing.  You should have been here on the weekend when people were in the hallway!”  The funny thing is that, in reading that response, you probably know two things.  First, this is the textbook example of the wrong thing to say.  Second, you have heard someone talk to a patient like this in the past month. 

By not addressing the past, though, that patient will mention that experience EVERY TIME someone comes into the room.  This not only prevents the patient from moving forward, it also creates a vicious cycle, since the care team will dread going into the room, or, when they do, they will say some version of, “Yeah, yeah, yeah.  I heard that story.  Now about your lunch options…”  This response will further spiral the patient down, since not only did they get treated poorly, but no one seems to care that they were treated poorly.  Now they get defensive when engaging with the staff and the staff gets defensive when they enter the room and the vicious cycle has begun.

But what if the first nurse said, “Wow.  I know that is frustrating; that is certainly not how we want to provide care and we did not get our best foot forward.  But, we have you here now and we will continue to take great care of you…”  You have moved the patient out of the past and into the present.  They may still reference the past experience, but it will often be present- or future-focused, as in, “It took a while to get me here, but the staff here is great and are really listening to me and helping me.”  You have likely figured out how to navigate this in your private life.  So, when your significant other vents about their day, you need to say, “Wow that really sucked!  Do you want to talk about it some more or talk about what to do about it?”² This is the same basic premise for your work life.

Now, I can hear you saying, “But, Joe, this happens all day long every single day!  How much of this do I have to put up with?”  This can be especially frustrating when it feels like the same complaint every single time.  There are always complaints about Doctor X, or delays in the ED, or the bland food, etc.  If you are someone who feels like this is your own personal Groundhog Day, I have two things to consider.

First—and I say this with great love and respect—get over yourself.  I will never understand why professionals always expect civilians to act like professionals.  Why are you expecting a patient to be more composed than a clinician?  Why do you expect the patient to be less frustrated with the delays than you are?  They haven’t had lifetime to build up the calluses that you have for the petty annoyances that plague every workday.  Why are you surprised that they are surprised that the real world does not function like television?  While this is not your first day, for a vast majority of your patients, it IS their first day.  Just because you get the question or comment seventeen times a day does not mean that this one patient has given it to you seventeen times a day.  I met an imaging person, who told me that she said the mantra “This is this person’s first x-ray ever” EVERY TIME before a patient came into their space.  This allowed her to reframe her view and know that the same questions she gets twenty times a day are coming from this person for the first time. 

I also think that the failure to reset or reframe an interaction with a patient means that the care team often gets stuck in the past.  I remember talking with an emergency department doctor and he said, “The problem is that half of the patients are just drug seekers.”  We sat down and looked at the patient list from the night before and we both concluded that, in reality, there was only two or three patients out of the 80+ patients that he would consider drug seekers.  I pointed out that the real problem was that after one particularly contentious patient, the experience colored the next five or seven patients he saw.  So, like the patients, HE could not get out of his own past. 

Second, embrace the fact that insanity is defined as doing the same thing over and over again expecting a different result.  You know that you answer questions about why a patient was boarded in the ED precisely because no one in the ED addressed this care path with them.  So if you don’t raise this with your supervisor, or the ED Director, then how is this getting fixed?  Yes, the ED knows boarding is a problem, but they probably don’t know what questions you get when they move up to a unit.  Working with them to structure some scripting or talking points will make the patients less anxious and therefore make the ED staff’s life (and your life) a bit easier.  Don’t assume that “everyone already knows” because while they may know the problem exists, they are likely not aware of how this problem affects downstream care.  If you have done this and they don’t seem to respond, well, that is the subject for another essay.

Perhaps I could have saved myself a couple of thousand words and ten minutes of your life by simply saying be the bigger person.  But I am not sure that is helpful, since I cannot be the first person in your life to say that to you.  The reality here is not that you don’t know this, but that often the real world can short-circuit your brain and the first thing you say isn’t the best option.  So, really, the best advice I have is to relieve yourself of the responsibility to address a statement instantaneously.  If you give yourself a half-second to pause and reflect, you will often realize that the first-thing and the second-thing you were gonna say were not the best options.  While the third-thing may not be perfect, I am wagering it is the best of the three options you have.

¹For those who don’t know…

²If you haven’t figured this out yet, well, consider this my gift to you.