Our next topic is humanizing your patient interaction in an era of growing technology. And I think that's perfect on the heels of the prior talk in terms of how do we keep this personal and human when we're interacting with our patients on a day-to-day basis. The talk is given by speaker Dr. Harish Gagneja, who is in private practice in Austin gastroenterology since 2004. And prior to that, he has had academic engagements as an assistant professor of medicine and co-director of GI fellowship at UT MD Anderson, and has been a speaker and engaged in multiple different aspects of private practice and topics. We are really happy to have Dr. Gagneja talking about this very important topic and relevant one for this era. Thank you. Harish, take it away. Thank you, Lata. As you said, my topic is humanizing your patient interactions in an era of growing technology. Medicine, what is medicine? Medicine really is the art of restoring and preserving the health of human beings by giving remedial substances, regulation of diet and habits. But truly speaking, if you really look at it, it is just not about the disease. It is about the dis-ease of your patient. You have to really keep that in mind. Today's medicine has become depersonalized, dehumanized, as well as it becomes very automatic. Doctors, we are the healers. Our first role is to relieve the sufferings of human beings. Why is that we have become so desperate and disillusioned and discontent? We all have time pressures on us, multiple screens to look at all day, bureaucracy of medicine, as you all know, reimbursement pressures, and hence you have to see more patients to keep up the reimbursements, and that contributes to your decrease of time, a lot of paperwork still, even though in the era of electronic health records, we still have a lot of paperwork. We really truly do not have an opportunity to express our love and caring for our patients. This is from a very recent article. This is provided in your references from Dr. Drossman. If you look at comparison of the time allocation during office hours in 2005 versus 2016, face time for the patient has gone down to one fourth of your interactions. Look at the EHR and desk work, which is about 50%. So 50% of the time, whatever time we allocate is spent on the screens or doing the paperwork. This is a snapshot of 15 minute clinic visit time allocation. You can see that seven to eight minutes are spent on EHR or other administrative work, and only about half the time is spent with the patient face to face. I can assure you that face to face also is truly not face to face, because yes, face to face, but people are still typing, looking at their screens as well. What are the challenges? We have challenges for the patients and their families and the physicians, of course, as well. Patients are sick, they're in pain, they're anxious. They do have expectations from us, especially these days of social media and also internet availability of what I call it, Googlitus. They're vulnerable, they're feeling out of control. Families are distressed because their loved ones are distressed, and again, they also have high expectations. For us, there's a lot of challenges. We have a competition for referrals and patient loyalty. We have extreme job stress, but there's some reasons I outlined earlier already, and a lot of pressures. Every day you see change, there's more change and there's more change coming. You have this pay for performance thing, patient-centered medical homes, productivity pressures, accountable care organizations, then there's patient experience strategies. We basically have become a five-star hotel rather than a hospital, so a lot of challenging for us as well. If you look at really the patient's perspective, patient's perspective, what do they want? They want the healing environments, compassionate human interactions, caring touch. I'll really touch very briefly on caring touch because that's a very, very important piece of the puzzle. Arts and entertainment, healthy food and nutrition, integrative therapies, they really want support for mind, body, and spirit, and also access to meaningful information. If we don't do anything and keep on going this path of machinizing, not humanizing, but machinizing the medicine, there are some dangers, which are lack of patient adherence to care plans, which will lead to medical errors, adverse events, and complications. If that happens, lawsuits follow, a less-than-stellar reputation, limited referrals, patient defections, unsatisfying patient-doctor relationship. For me, that's one of the most dreaded consequences, which makes the practice of medicine unfulfilling. We are all in this practice of medicine because that gives us fulfillment. If we strengthen the physician communication with the patient, everyone benefits. We'll have higher earnings, improved outcomes, patient respect and loyalty will be earned, more fulfilling work, personal growth, and on top of all that, improved patient and family experience. So how do we do this? How do we do this? There are some practices which we can do to humanize medicine. One is a mindful practice. We'll talk a little bit about that in detail. Communicating with empathy gives some effective explanations. Engage patients and families as partners, and collaboration and teamwork with your team. That is one of the very important aspects as well. So what is mindful? Mindful practice. According to the mindfulness expert, Kabat-Zinn, it really truly is paying attention, your undivided attention, basically your presence where you are, staying on the purpose consciously in the present moment and without judging. Only when you are mindful with your patients, you will release your innate compassion and mindfulness really is presence of heart. How do we do this? A few tips. Quiet your raising mind, take a deep breath, bring your full attention to the present and the person at hand. When you are in the office, sit, lean in, adopt an open, receptive posture rather than having your two arms across. And when the person is speaking, make sure to maintain eye contact, be quiet, don't interrupt, think about what you're going to do next. Avoid multitasking. What are the multitasking? These are shuffling papers, texting, typing, and looking at the computer screen, not paying attention. Resist interruptions. And if necessary, there's an interruption, ask politely and tune into your patients fully. This really leads to stronger connection with your patients. It gives you a greater patient satisfaction and loyalty. It does reduce stress and it also instills pride in your positive impact on patient experience. At the end, reflect an attitude of kindness, interest, and acceptance. Yes, you will say, yeah, it's easy to say, how do I do this? Because I have this computer all the time in front of me, there's interruptions, there's a time constraint. How do we do this? So using some technology, which is helpful to do this, will be with the technology. When you are using the computer, yes, you're using the computer, but then you also engage your patient with you while using the computer. Log in and explain to the patient what you're doing. Alternate the focus of your attention instead of doing just looking at the screen and looking at the patient. You can do screen and patient, but alternate your focus instead of just trying to do the multitasking. Rule of thumb is not more than 10 seconds out of eye contact. Engage the patient with the device. What I do usually in my practice is I show them all the endoscopy pictures. They will ask, oh, this is my pictures, yes, it is your pictures. And somebody will say, oh, my hemorrhoid looks kind of bad. I'm like, this is not a beauty contest on your hemorrhoid. Just make it a little bit more lively for the patient. Log in and out in front of the patient. That really tells them, that gives them, okay, there's a confidentiality of the records. And that's a very important part as well. We talked about this. So what is, we talked about what is mindful? What is not mindful? What are the behaviors that indicate an absence of mindfulness? It will be lack of eye contact, again, turning to your computer all the time while patient is talking, standing throughout the encounter, hand on the doorknob, looking at your watch and pager repeatedly, interrupting the patient, and while the patient is talking, texting as well. Team, team, team, team is very important because without your team, you really cannot provide the humanized experience for your patient. So together, our care is greater than the sum of its part. I call it one plus one equals 11, not two. So collaboration team with some facts. These are, I can tell you, there's about more than a hundred studies. There are seven or eight other studies as well, which tells you that if you have a good team, there's a better coordination of patient care. There's an improved compliance of core measures such as safety, pain control, patient outcomes, short length of stay for the inpatients, decrease ER use, fewer nursing home admissions following inpatient stays, and overall improved satisfaction and decreased healthcare costs, improved satisfaction for patient, employee, and physician. What kind of collaboration breakdowns can occur, if there is any? Ridiculing an employee in front of a patient, not getting back to your colleagues after seeing another patient, if they're calling you, because that also is really a collaboration and teamwork, and condescending tones, so we should avoid those things. Interactive openings, so when you see the patient, again, this is part of humanizing the medicine, before entering, scan the chart, be fully present, and wait for three seconds before entering the room after knock on the door. Make the most of your first six seconds, which includes eye contact, greeting introductions, and one important, younger physicians in this era of political correctness don't use this, but physicians or practitioners who are in practice for a long period of time, they will use these words such as honey, sweetheart, or dear, avoid using those words. Elicit all of patients' and families' concerns. I always ask one question, that would be, what else? What else we can talk about? And together, negotiate the agenda. The words which are very important, this is a partnership language, such as we, us, together. Next would be, when you're done with your clinic visit, effective closings. Check the patient's or family's understandings and comfort with the next steps, like teachback technique, talk to them, you say, okay, did you repeat everything and see whether they have any other questions. Ensure the closure of the meeting, rather than leaving the patient with a question mark on their face. Remember, the last impression you make leaves the lasting impression. So make the last six seconds a very positive memory for your patient. If patient leaves with a positive memory of you and the encounter, they will be a loyal and happy patient for you all the time. We need to engage patients and families as partners. We are expert on diagnoses, diseases, treatments, remedies, what ifs, and medical resources. Whatever patient or their families are expert on symptoms, goals and priorities, their feelings and their concerns, their tradition, culture, culture and values are very important. Different cultures behave differently in times of stress or distress. So that's important to take into account, as well as personal resources. Yes, we can provide or prescribe all the expensive medications all day. If your patient is not going to be able to afford it, it's of no use. Patients really want to get involved. So how do I start this? Basically, you say, how would you like to participate in your care? How might you and I work together to solve this problem? So it's a shared information, shared mind and shared deliberation. I see that you have been browsing the internet for information. Let's sort things out. Encourage the patient and the family to speak up. Find something, something what they're saying to validate. Yeah, that's true. Yeah, I agree with that. And then go on so that they know that you're listening. Share responsibility for the direction of discussion. Give them choices. Find out patient's views and theories. I always ask this question. If somebody is complaining of abdominal pain, coming into my office, I know the young person, I always ask the question, hey, what do you think is going on? And then they will open up sometimes, hey, my cousin who recently was diagnosed with colon cancer, I'm worried about this. So you always find out what is patient theory? What are they thinking that what is going on? Use the language of partnership. As I said earlier, three words, very, very good is we, us, and together. Collaborate on goal setting and decision making with the patient. But remember, those goals must be doable. You cannot do some goals which are undoable. Involve the patient's family throughout the process. When patient is actively involved in their healthcare, it leads to really healthier behaviors, more effective self-monitoring, and greater adherence to their care plans. Collaborating with empathy. So there's a rule with that. Rule is heart, head, heart. What is that? Heart. Heart is all about, heart to heart is emotions and concerns. It can be either personal or subjective. Head is about the task or problem at hand, which is rational and also information oriented. What is information available to you at that time? So a heart to heart conversation will be for emotions, caring, and empathy. You start with that, emotions, caring, and empathy. But then you move on to quickly to head to head conversation, which is really regarding the task on hand, information, analysis, questions, solutions for your patients. And then you go back to the end of the conversation with heart. So that is what communicating with empathy is all about. Acknowledge your patient's and person's feelings. Like you sound worried, you look unsure. What is going on? Tell me more about it. Pursue the feelings. Just look at their face, pursue the feelings. It sounds like you're pretty frustrated with these exercises. What's going on? Validate or legitimize the patient or family member's feelings. You certainly have a reason to. It is hard decision to make. I know. I hear you. I hear you, what you're saying. So those are the words, those are the words you need to do. You never say nothing, even when you're not talking. So show your empathy non-verbally as well. There's some rules of thumb on that as well. Meet anger with lack, with look of concern, with look of concern. Meet urgency with urgency. Meet calm with calm. 81% of the encounters contained at least one unclarified jargon term, misunderstanding, will or can result in potential adverse outcomes. I was talking about earlier about effective explanations. So that's what it is. Ask, tell, ask. Ask what the person already knows and wants to know. Tell, provide your explanation to meet the person's, what they know, what they don't know, and fill in the gaps. And again, ask, verify the understanding, address information gap, and questions and concerns of your patients. So effective communications. How do we do this? Encourage the patient to ask questions at any time during your explanation. Elicit the patient's knowledge. State your positive intent. All about patient. Explain in a way that is easy to understand. Some things we use in our practice, we think everybody knows this, but really, truly not. I'll give you some examples. Examples are, we use this word modify all the time. Most people don't know that. So use word change. Benign, instead of benign, not cancer. Fracture, instead of fracture, break. Interaction, how things work together. Intermittent, on and off. Lesion, wound. Enlarge, get bigger. Oral, by mouth. Optimal, best. So there are some examples I gave you, but there are multiple examples like that. I also use immune system. I say, this is the defending army for our body. And rash, it's like a sunburn. And don't overwhelm your patient. Rule of thumb is, give no more than three bits of information at once before checking your patient's understanding and then move forward. What behaviors we need to avoid. We need to avoid talking too fast. Don't use jargons and acronyms. Like for example, EKG, or increased QT interval, or serial EKGs, or ECHO, or PRN, or CABG. Instead of use myocardial infarction as needed, and so on. Get to the patient's language, or patient understanding. Don't talk down to your patient. Talking louder on the face of the language barrier, which I see it all the time. That's not going to change. Patient is not going to understand that. Don't interrupt or discourage questions. And again, I said before, explaining too much at a time should be avoided. Rule of thumb is, three bits of information, ask for understanding, then move on. This is a very interesting slide. What I will talk about this is, there's a recent article in journal Lancet. It's a small little essay by Dr. Richard Norton. I gave the reference and my references on that. I highly recommend, highly encourage everybody to read this essay. Dr. Norton, who has been editor-in-chief for Lancet for a while, for 30 years, I think. And he recently had a metastatic melanoma, and he had surgery. He had chemo radiation. He describes his, what happened in doctor's offices, and how nobody examined him for those multiple visits when he went to see his physicians. And he wrote this essay, and really talk about this. And there's a very nice podcast as well. This is by Eric Topol, Dr. Norton, and Dr. Verghese, Abraham Verghese. That's on Medscape. If you go medscape.com forward slash machine, I believe, or human machine, machine, I believe. There's multiple podcasts like that. I would highly recommend listening to those podcasts. Touch really builds reassurance and trust. It's really about a social bond of sympathy, compassion, and tenderness. It communicates comfort and concern for our patient. It encouraging cooperation. And touch really humanizes the interaction. This is really the Achilles heel, which we are losing already, that we are not humanizing a medicine. This is very, very important. I really think that this is time to, which Dr. Norton and a lot of people, other people who are talking about this, think it's time to bring back touch into medicine with incorporating good physical examination right at the medical school level, which is not happening these days. More important to humanize, in addition to what we do, interactions, but also healing environments. Patients really want a better environment. Infection prevention, that really is humanizing the patient interaction. Make sure there's less infection. Patient falls, elimination needs associated with the, this usually happens with the elimination needs from the patient. So do some changes in your exam rooms or hospital rooms to decrease the patient falls. Patients privacy, noise controls, just beeping noise all the time. Views and access to nature, like daylights, some gardens, some therapy tattoos for your patients, therapeutic distractions in the room or in the lobbies. And one most important thing, which I was researching this topic was improved wayfinding is really humanizing because if you're coming to the hospital, you don't even know where to go. I mean, you really get stressed, anxious. So really this reduces stress, provides a welcoming, friendly environment for your patient. Music, there's multiple studies, which has shown that music decreases the use of analgesics and hastens recovery from surgery. This was in a 90 hysterectomy patients in a study in 2001. Early programs timed to a surgical procedure produced significant reduction in the amount of perceived pain and decrease in the level of stress hormones in the blood. This was also a study in 2001. These are only two examples I provided. There are hundreds of studies on that. Unpleasant odors stimulate anxiety, fear, and stress. So we need to eliminate those. Pleasing aromas reduces blood pressure, slower aspiration, and lower pain perception level for your patients. There's one study which was done in 1994, they said a pleasant fragrance lowered patient rated anxiety during MRIs. Most important, there's a final slide. Do not forget the professionals. We are also under a lot of stress. If your professional is stress, anxious, they're burned out. They're not going to provide a humanized service to your patient. So it's important we take care of our professionals as well, which include all of us and our APPs and all our sports staff. These are some references. And I apologize, I will not be present at the question answer session, but I will be happy to take calls, sorry, email a question and I'll be happy to answer those questions if anybody has any specific questions on that.

humanizing patient interactions

technology-driven era

depersonalization of medicine

patient care

mindful practices

healing environments