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This episode is sponsored by the Rush University Series at The Podcast by KevinMD.
As we enter a year and a half into a worldwide pandemic, many of us working in health care are fatigued, over-worked, and burned out on compassion. Burnout has been so widespread that the CDC published guidelines on how to cope with the stresses of the job as COVID-19 cases persist. As the Delta variant continues to spread and individuals remain unvaccinated despite the data, health care workers find themselves attempting to care for their patients and simultaneously try and care for themselves.
This article outlines some myths about the “softer side” of health care and focuses on compassion and rapport building— exploring the ways in which providing patient-centered care for those who seek our help not only improves clinical outcomes but can also help improve ourselves.
Myth 1: Rapport building takes too much time
With ever-mounting administrative duties, clinicians are often pressed for time while seeing patients. Adding in pressing urgencies brought on by the pandemic has only intensified this. From primary care and community settings to intensive care floors, doctors, nurses, and other health care workers have been dealing with COVID-19 patients directly or handling the fallout due to the pandemic response. These difficulties may leave patient encounters feeling rushed and frantic, compelling clinicians to leave seemingly extraneous interactions for another time. One small study found that, during a patient interview, physicians interrupted patients after a median of 11 seconds. A randomized controlled trial done at Johns Hopkins University found that compassion from a clinician can be conveyed in just 40 seconds during a patient encounter, significantly reducing anxiety and stress experienced by patients in the study. Much has been written about how to build rapport and trust with patients, and investing small amounts of time in this type of intervention has proven to yield positive results. This leads to our next myth.
Myth 2: The “soft skills” of expressing compassion and empathy don’t yield any positive, measurable clinical outcomes
While quality in clinical skill is the greatest predictor of clinical outcomes, several studies have exhibited that empathetic, patient-centered care has been shown to be significant in yielding positive results. One study conducted at Harvard Medical School found that patients diagnosed and treated for IBS expressed a significant improvement in symptom relief when physicians expressed empathy in a randomized controlled trial. Another smaller study done at Michigan State University also found that participants’ pain was modulated by engaging in pleasant conversation with a doctor. More interestingly, empathetic care may have some involvement in improving the immune system as well. A study published in Family Medicine examined the course and duration of colds in 350 patients. The results showed that individuals treated with empathy and compassion by clinicians had a significantly shorter and milder course of illness.
Myth 3: Compassion doesn’t lead to any long-term positive outcomes
Dr. Avril Danczak, a primary care physician and educator in the U.K., explains, “Rapport is like money. It increases in importance when you don’t have any … and when you do have rapport, a lot of opportunities appear.” Longer-term relationships necessitate several encounters with a patient over a period of time. When good rapport is established, many opportunities for intervention can lead to better chances for change. A correlative study published in the Journal of Academic Medicine found that a patient-physician relationship grounded in empathy and compassion leads to better hemoglobin A1C control and consistently lower LDLs over 3 years. Of the 891 patients who participated in the study, 59 percent performed better with medication adherence, demonstrating a positive relationship between physician compassion and positive clinical outcomes.
Myth 4: I’m probably showing compassion already. I’m a doctor/nurse, after all!
The choice to go into health care not only requires patience and a desire to help, but also years of hard work and dedication to the profession. However, the assumption that the choice to pursue a profession in health care implicates a natural propensity for compassion is too broad of a generalization that may not capture everyone’s motivations. A survey conducted by the Schwartz Center for Compassionate Healthcare found that of the 800 hospitalized patients surveyed, only 54 percent of respondents reported that they felt they experienced compassionate care while in the hospital. This figure when compared to the 78 percent of clinicians who felt they provided empathetic care appears to be incongruent. For this reason, compassionate care and patient communication have started to be taught in medical schools across the country to improve the translation between the clinician’s empathy and the patient’s perception.
Myth 5: Compassionate care only benefits the patient
Helen Riess, MD is an assistant professor of psychiatry at Harvard Medical School and the director of the Empathy and Relational Science Program there. She states that physician burnout can often be attributed to a kind of “depersonalization, where patients are seen more like as a number, or a diagnosis, one on a list instead of like real people.” Several cross-cultural studies have shown a negative relationship between empathy and burnout. In an article published in the Journal of General Internal Medicine, Dr. Riess states that this is in part by the pressures exerted on us by the medical system in general, and our subsequent perceived inefficacy as health care professionals because of it. Conversely, several studies have linked clinician empathy to higher levels of satisfaction, and some have even demonstrated that providing compassionate care can be a protective factor in preventing burnout.
As we continue to contend with the marathon of the pandemic, a collective self-check-in is in order. Physician and nurse burnout has consistently been a fixture in each discipline, adding to that the continual addition of COVID-19 cases. While it can be tempting to muddle through every day of our duties, it stands to reason that a reevaluation of priorities can only provide benefits. Many resources are available to clinicians who want to incorporate empathy into their practice. Strategies like including motivational interviewing and the use of consultation models can be deployed to help guide patient interviews in a way that helps a patient feel heard and understood. Like any clinical skill, these strategies for communicating with patients require time and practice. And, like many of the skills we learn, the data suggests that compassion is a skill worth investing time in practicing, not only for our patients but for ourselves, too.
Katherine Buaron is a community nurse consultant, Rush University.
Image credit: Shutterstock.com
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Katherine Buaron. She is a community nurse consultant and clinical instructor at Rush University. She wrote the KevinMD article “5 myths about compassion and patient rapport building in health care.” Katherine, welcome to the show.
Katherine Buaron: It’s a pleasure to be with you. Thank you so much for having me.
Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?
Katherine Buaron: I’m a nurse. I got my master’s degree over at Rush University, and it was actually a nontraditional route. I got my bachelor’s degree in anthropology from San Jose State, over here in California, and I actually wanted to go into research. I thought I wanted to do bioanthropology and study human evolution. But just interfacing with the health care system, I was able to really see what nurses and doctors do and have that practical application of the science, and the art of being a clinician, and how practical that is. So that really drew me to the field of nursing.
Kevin Pho: Now, over the last 18, 19 months of the pandemic, how has that affected your role as a community nurse consultant? And perhaps you could share a story or a case study that really paints a picture of what you’re seeing every day.
Katherine Buaron: So much of my work with patients is through communication. Obviously, there are the things that we say, the verbiage that we use, but such a big component of communication is also nonverbal. This concept of paralinguistics is such a big component of that, and having to don our PPE has created a bit of a barrier in terms of transmitting what I’m trying to say and connecting with my patients. So the PPE has been pretty cumbersome in that regard.
And so, actually, during the brief window when we were able to be unmasked, outdoors or wherever, depending on the setting, for some of my patients it was a big shock to them. They actually didn’t even recognize who I was. At some point, I had to start from square one a little bit with some of my patients, because they didn’t even recognize who I was. So, yeah, trust and rapport building are so important in my practice, so that part was really tough.
Kevin Pho: When you were donning PPE and patients could only see your eyes, what are some of the things that you did to really build that trust and build that connection with patients, even under layers of PPE?
Katherine Buaron: That’s such a good question. A lot of it is body language and intonation. Obviously, the way that we communicate through facial expression transmits so much of what you’re trying to say, as does the tone. Also, the cadence with which you say things, and the intonation, is very important, because as clinicians, we always want to maintain a nonjudgmental space, so our patients can trust us and tell us what we need to know to help them. And a lot of it is body language, a lot of eyebrow movements. I’ve practiced a lot of eyebrow movements. So intonation, tone, and body language are some of the things that helped carry me through having to don the PPE and having to communicate.
Kevin Pho: So when you talk about cadence and intonation and tone, what specifically do you mean? What specifically do you have to be aware of with those three aspects, that you have to keep in mind when you’re talking to patients behind PPE?
Katherine Buaron: So it’s asking the question, “How are you going to do that?” Or changing the verbiage a little bit: “How do you think you’re going to do that?” versus “How do you think you’re going to do that?” So it’s a little bit of the difference in the way you phrase the question, as well as, and it’s a little subtle, where the inflections are in the sentence, if that makes sense.
Kevin Pho: Is it something that you have to practice regularly?
Katherine Buaron: Certainly, certainly. Practicing communication skills and rapport building, these are all worth, and that’s kind of the point of my article, these are all worth the investment and time in practicing as clinicians, for a multitude of reasons: mainly the reasons that I’ll outline here in this interview, but certainly the reasons that are outlined in the article itself.
Kevin Pho: So let’s get to that article, and it’s titled “5 myths about compassion and patient rapport building in health care.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?
Katherine Buaron: What inspired this article was a book I had read recently called Compassionomics, by Stephen Trzeciak and Anthony Mazzarelli, both of whom are physicians. From what I can recall, it’s actually one of the first pieces of work that outlines, very neatly and very nicely, the actual data behind compassion, and how it works and why it works with regard to patient outcomes, and particularly clinician burnout: physician burnout and nursing burnout. And I actually also borrowed the “Five myths” series concept from the Washington Post. I wanted to show some versatility with the listicle format. I thought it was a really elegant way to put together sets of data.
I was getting these email blasts from the institutions that I work with, emails about wellness, about burnout workshops, these types of things, especially as the Delta variant has reached its peak and is hitting the Sun Belt particularly hard, and yet again, our system is being pushed to the brink in that way. And just being in that context, and thinking about checking in with ourselves, doing a bit of a re-evaluation, and looking beyond the yoga poses and the spa days, which are absolutely helpful, I wanted to look at a different way to cope with the difficulties of our workload sometimes.
Kevin Pho: Is there a difference between empathy and compassion, and if so, what is that difference?
Katherine Buaron: Empathy is actually just the ability to understand and comprehend someone’s difficulty, someone’s plight, just being able to intellectually understand the experience of someone else. And compassion is the emotional component, the part where you feel something, and the ensuing desire to help.
Kevin Pho: What do you feel is the single simplest but still effective technique clinicians can use to build rapport with each of their patients?
Katherine Buaron: I spoke about it earlier, but body language and facial expression, and eye contact also. I read this article in Scientific American about the concept of paralinguistics, and how the intonation and cadence component of speech can really alter the way that things are delivered, the way messages are delivered to patients. And a lot of my work in community nursing is to be able to educate and sway hearts and minds sometimes. That’s one of the greatest challenges in community nursing in general.
Kevin Pho: So tell me right now some of the situations that you’re seeing as a community nurse, because I know we’re talking right now at the end of August, and there is some vaccine hesitancy among some segments of the population. Are those some of the cases that you’re seeing right now?
Katherine Buaron: So I had been working with my patients about the vaccine since November, even before Pfizer or Moderna had released anything, before they got emergency approval for distribution. So I was establishing that dialogue with them way in advance, and because my patients know me and they trust me, my team and I have been able to get over 80 percent of our caseload vaccinated. I am just so proud of the accomplishment my team and I have been able to achieve with my patients, with our patients. And, yeah, I think a lot of that had to do with communicating and rapport building, which of course takes multiple encounters in order for a patient to really trust you and really know you, and for you to know them and what strategies work and what don’t for every individual case. And so, yeah, we were able to yield a really good result, so we’re happy about that.
Kevin Pho: Now, is there an instance or a case study where one of your patients initially was hesitant to get the vaccine, and what did you do to eventually convince that patient?
Katherine Buaron: Yeah, one particular case. I have a patient who is diagnosed with bipolar type 1, and she struggles with some paranoia and rather high anxiety. So she knows me and knows how I work, and the converse is true. Having multiple conversations with her over the course of several months, kind of playing the long game here, really empowering her with the information, sifting through what she’s read on Facebook and evaluating the validity of that, has been very, very helpful in convincing her to get vaccinated. So now she’s fully vaccinated as of last month. It took a while, but we got there.
Kevin Pho: Now, what do you think is the biggest or most common mistake clinicians should avoid in their interactions with patients?
Katherine Buaron: It’s a good question, and it’s such a nuanced answer, but probably the biggest mistake clinicians make is interrupting a patient. In my article, I wrote about a study that was published in the Journal of General Internal Medicine, and the median time it took for a physician to interrupt a patient was 11 seconds. So that’s quite short. Nurses do it too. We all do it. We’re tired, we’ve gone from patient to patient doing all the things we need to do throughout the day, and it’s sometimes easy to forget that we’re talking to a thinking, feeling individual who’s seeking our help. And so doing that kind of re-centering and re-evaluation, even before you go into the room, can be really great in terms of being able to speak to the patient, figure out what’s bothering them, sift through the information to figure out what’s the best course of action, and take care of them.
Kevin Pho: Now, let’s turn the tables. From your experiences as a patient, what did one clinician do that stands out to you for helping to build rapport between both of you?
Katherine Buaron: So, the first visit I had with my previous PCP back in San Francisco, I came in for an earache, and I came in again for the follow-up. During my follow-up, she remembered my aspirations to be a nurse. She explained to me all the things that she was doing while she was doing them. She really just took the time to get to know me and what I wanted to do, and that really helped me trust her judgment as a physician and also as a person. So that was probably the moment that really stood out to me in terms of how important rapport building is, so early on.
Kevin Pho: Now, what got you interested in rapport building in patient care? Was there an experience, even if it was a negative one, that motivated you to focus on rapport building between clinicians, nurses, and patients?
Katherine Buaron: I work with a vulnerable, underserved population, all of whom suffer from conditions and circumstances that would make vaccine hesitancy a very real and enduring obstacle and barrier to getting my patients vaccinated. Through rapport building, as I had said before, playing that long game in terms of trying to sway their hearts and minds about the vaccine, my team and I were able to get such a great turnout: over 80 percent vaccinated in our caseload.
Kevin Pho: We work in the business of medicine, whether we like it or not, right? And there’s a lot of financial motivation, certainly, in our health care system, and sometimes that impedes rapport building. You have a lot of clinicians who have to see more patients in less time, and that pressures them to interrupt patients after 11 seconds of speaking. How do you resolve that tension between rapport building and the economics of health care?
Katherine Buaron: So in the book I mentioned, Compassionomics, the authors performed a systematic review of the literature and found some very compelling evidence for the correlation of high compassion with high quality of care. Unfortunately, the inverse of that is also true. There’s unfortunately so much more data to back that up, in terms of low compassion and low quality of care. And to this point, CMS adjusts hospital reimbursements based on the rate of error. They also reward the hospitals that have the fewest errors. HCAHPS patient experience surveys also affect Medicaid and Medicare reimbursement. Another reason is litigation. Physicians who are perceived to be compassionate just get sued less; nurses too, to a lesser extent, of course.
And just to follow up on your second question, how do you resolve that? The misconception is that compassion and rapport building are extra things that take too much time out of a clinician’s day. But really, we’re talking about 40 seconds to transmit compassionate care. To allow the patient to finish their primary concern, allowing the patient a few minutes to really talk about their primary concern, we’re talking maybe two, three, five minutes. Just letting the patient finish their story is such a big deal, and it allows them to let you know exactly what’s going on with them.
Kevin Pho: So one of the other things that’s also brought up a lot is the concept of nurse and clinician burnout, right? And you, of course, mention how compassionate care not only helps the patient but also helps doctors and nurses as well. Could you tell us more about your experience, or the experience of others, with burnout and finding meaning in their daily practice, and how can compassion help in that regard?
Katherine Buaron: So the first time I ever experienced burnout was in nursing school. A mentor of mine and I were talking through it, and she just put a name to it. She said, “It sounds like you’re burnt out.” And more recently, working as a nurse in the community, I felt it culminating again. My patients, of whom I typically have plenty, began to weigh on me a bit. I felt myself getting a little more irritable over things that I typically wouldn’t get irritable about. Luckily, I caught it. In my day-to-day, I caught how I was feeling, and I caught it before it really started to affect my work. I have some wonderful colleagues and mentors right now, and bouncing ideas off of them and doing a check-in with myself really helped balance it all out.
We as health care workers and clinicians are tasked with actively treating, preventing, and protecting our patients from harm. It’s an important role, and sometimes it’s a really heavy one. I think it’s important for us to take a step back and remember that we’re really making a difference in someone’s life, often for the better. They came to us seeking our help, and it’s an honor to serve that need. Remembering that can really help center us and get us back to why we got into all this in the first place.
Kevin Pho: Now, when you were going through nursing school, in your nursing education, you felt that you caught yourself from becoming burned out. Did you have anyone to turn to, or was this something that you had to deal with by yourself?
Katherine Buaron: I had a whole community of people to turn to: my nursing mentors, some of my professors, and also my colleagues, fellow nursing students. There’s that ability to commiserate together. And that’s the hard part, too, especially last year, when medical school and nursing school were done over Zoom. It’s so tough for that kind of rapport building with your colleagues. Being able to commiserate with the people you’re going through it with is so valuable in nursing and medical education, and that played a huge part in how I was able to deal with the stress and my own burnout.
Kevin Pho: Now, I’m reading a lot of articles about nurses getting burned out and quitting, especially in hospitals that are overrun with COVID. Tell me some of the feelings that they may be feeling that could lead to burnout, and what kind of advice can you give to these nurses who are currently burned out?
Katherine Buaron: It’s such a multifaceted question. I know that there are some nurses who feel that they’re not being heard: their needs on the floors, patient ratios, of course. We need to do what we can for the patient, and feeling limited in that capacity can be very draining. And so I think a lot of that has to do with the current burnout among nurses, especially the nurses in the ICUs and the EDs who are really caring for the COVID patients.
There’s doing that self-care piece, right, the yoga and the exercise and these types of things that are very, very helpful in lifting mood. Also, being able to commiserate with your colleagues, that’s a big thing too: feeling that connection with your colleagues in terms of going through it together, going through this hardship together. And also checking in with yourself and figuring out what you really need, for you.
Kevin Pho: We’re talking to Katherine Buaron. She is a community nurse consultant and clinical instructor at Rush University, and she wrote the KevinMD article “5 myths about compassion and patient rapport building in health care.” Katherine, let’s take a step back. What are some of the challenges facing community nurses today that you’re seeing in your everyday workflow?
Katherine Buaron: One of the challenges that I face every day is definitely vaccine hesitancy, not just in my patient caseload, but certainly in the public at large. Community health is so dependent on taking care of each other, and vaccine hesitancy puts a damper on that. Being vaccinated really helps protect not only you, but the people around you. And working in the community, having people who are unvaccinated creates a barrier to making sure not only that my patients are safe, but that the public at large is safe as well.
Kevin Pho: Now, for those nurses and aspiring nurses who are interested in community health, tell me about some of the rewards of what you see every day, and the rewards of your profession.
Katherine Buaron: Some of the rewards in community health are being able to see the long-term positive outcomes that you’re able to influence with your patients: getting them adherent to medication, seeing that A1C lower. These are all things that are so gratifying. And the model of care as a community nurse, being able to interface with your patient over a long period of time, is such a unique perspective in health care, and also such a needed and effective one.
Kevin Pho: And what kind of advice would you like to give nurses, clinicians, and medical students about compassion and rapport building?
Katherine Buaron: First of all, first things first: Listen to your patients. Don’t just hear them. Ask follow-up questions. Be curious about your patient. The simple act of summarizing what your patient has just said to you can be extremely powerful. It can allow patients to know that they’re being heard, and it enables both the clinician and the patient to be exactly sure that the message being transmitted is the one intended, and that all things are clear in terms of what the patient came in for, what kind of challenges they’re having, and how you can help navigate that.
Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?
Katherine Buaron: Compassion and rapport building don’t just benefit our patients. They also help protect us from compassion fatigue and burnout, and the data bears this out. Just like any good evidence-based intervention, it’s definitely worth practicing.
Kevin Pho: Katherine, thank you so much for sharing your time, insight, and stories, and thanks again for being on the show.
Katherine Buaron: Thank you so much for having me. It’s been a pleasure.
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