Bridging the Patient/Provider Divide

Lately at work, it feels like every patient I see is having a communication issue with medical providers. One person has been trying for 6 weeks with 3 different providers to get a UTI diagnosed. Another has been waiting for 4 weeks for a doctor’s office to call him back to schedule a spasticity reduction treatment. A third actually did get in to see a physician about her new symptoms, but left feeling discouraged, more confused than she did prior to her appointment. There is clearly a disconnect between patient and provider experience, and it seems that in this moment in time, where stress is high and every day brings new challenges, this disconnect is widening. It feels like the health care system can't sustainably proceed like this - these kinds of wait times for basic things like UTI cultures and getting a call back are unacceptable and can be dangerous. Compassion training could potentially make a huge impact on these communication issues, and I’ve been reading a lot about it.

In the study about compassion training that I’ve discussed for the past few weeks[1] (which states that an organization’s unwillingness to adopt a compassionate ethos is a primary barrier to the success of compassion training), two points stood out to me as being inextricably linked, and a critical missing piece in this compassionate care issue. First, one barrier to compassion training success was that most participants felt themselves to be already competent at delivering compassionate care. Second, researchers noted that only one of the programs studied included perspectives from actual patients and patient family members. Of course, as providers we all assume the best motivations about ourselves, and we all would like to see ourselves as compassionate actors. But, based on the types of complaints I’m hearing from my patients, certainly all medical providers are not acting compassionately. If we are assuming competence but not asking for feedback from the people whose opinions actually matter, then no wonder there is a disconnect between patient and provider experiences.

When I started digging a little deeper, I found out this isn't even breaking news. A 1998 study demonstrated that, while 75% of orthopedic surgeons believed they communicated in a satisfactory way with their patients, only 21% of the patients reported satisfactory communication[2]. That's a huge difference! But, in 1998, there was no way to measure patient experience of compassion in practice, and patient satisfaction surveys were not the norm. Today, we have items like the Sinclair Compassion Questionnaire which can be administered in the clinic along with traditional patient satisfaction surveys to ensure that our intentions match our actions, and that patients perceive compassion and clear communication from their providers. However, I don't know personally of any clinics (including the one where I work) using such a questionnaire. Perhaps it would be valuable for any workplace considering compassion training to utilize such a questionnaire with patients for several months prior to training, so that providers attending the training can begin with a sense of their weak spots and areas for growth. It would be a great addition to any practice's regular patient survey with or without compassion training on the horizon.

Without patient perspectives, both in our clinical environments and in training environments, it's impossible to know if provider intent to be compassionate actually translates into patient perception of compassion. One study[3] demonstrates that patients feel dissatisfied with providers when there is lack of eye contact, bored tone of voice, blank facial expression, lack of detailed discussion about test results, lack of shared decision making, and interrupting. These are teachable behaviors that can and should be included in compassion trainings in order to improve communication and bridge the patient/provider divide. Additionally, without patient perspectives, how can we understand their position enough to generate the empathy required for compassionate action? It is difficult to understand what patients and families need if we don’t ask them to share their lived experiences and constructive criticisms. Interestingly, most compassion trainings in the study were actually meditation or self-awareness trainings that had been modified to teach compassion. Perhaps for this reason, very few of the training programs included in the study taught actual behaviors that providers could engage in that are perceived by patients to be compassionate.

The main take away for me was that, in my clinical experience, patients feel like they are not connecting at all with their providers. Long standing research supports this perception, and, based on this new study of compassion training programs, it seems that this disconnect may be baked into our training as well as our clinical experiences. We aren't asking patients for feedback in this area in the clinic, and we aren't including patients in the discussions about what behaviors they need to feel seen, heard, and taken seriously by their medical providers. If all our efforts to creating, teaching, and attending compassion training programs fail to include actual patient perspectives, we have missed the point. We can't increase compassion in health care by shouting into an echo chamber of other well-intentioned clinicians. Patient/provider communication needs to be at the center of clinical practice and compassion training in order to be effective.

[1] Program Leaders' and Educators' Perspectives on the Factors Impacting the Implementation and Sustainment of Compassion Training Programs: A Qualitative Study. https://www.tandfonline.com/doi/full/10.1080/10401334.2021.2017941#.YfQBI19Cirg.twitter [2] Communication Skills for Patient-Centered Care. https://healthliteracycentre.eu/wp-content/uploads/2015/11/Tongue-2005-.pdf [3] Communication Skills in Patient-Doctor Interactions: Learning from Patient Complaints. https://www.sciencedirect.com/science/article/pii/S2452301116301225?via%3Dihub#bib12