Listen in to discover what doctors (and patients) actually need from each other . . .
Sydney Ashland: For the past six months or so, Pamela and I have talked a lot about the physician-patient relationship. She has recorded and written a lot about her relationship-centered practice, and I have shared a lot with her about my perspective from working with many physicians and medical students about what they need in a relationship. We’ve come together, both with lots of perspective, and recently because I have had a lot of opportunity to be the patient, that has even helped me become much, much more clear about what it is the patient needs in this relationship—as well as what the physician needs.
I have come up with a few things that doctors and patients need. I think we have five top needs that doctors have, and five top needs that patients have. I would say, the number one need that physicians have right out of medical school is validation. There has been so much eradicating of what physicians think they know through the process of medical school and internship, and residency, and fellowship, that they are often a shell of the person they were when they went to medical school.
That confidence, that knowing that they’re brilliant, that sense of “I can do anything and I’m here to serve” has been so devolved over this time period that the number one thing they need is just to feel validated. That they can be in the presence of peers and patients and feel as if their very presence is valid. It’s at that core confidence level. Validation and confidence is the number one need physicians have in the physician-patient relationship. Even practicing physicians who have worked for many, many years often in the big-box systems are demoralized and working with difficult patients that they can’t always choose—that increases that need for validation.
Whether I’m dealing with someone who is inexperienced, the newbie fresh out on the circuit treating patients, or whether it’s somebody who’s weathered a lot of years, that’s the number one thing—validation and confidence.
Number two is the opportunity to get it right. Once you feel somewhat validated and have some confidence to have that reinforced by being given an opportunity to get it right. To have your peers and patients, and colleagues validate that for you that. This is your opportunity to get it right—and you did. It’s not about what you didn’t chart or what you didn’t get done, or who you didn’t see, or how long you took, it’s “I need the opportunity to get it right, and when I do, it makes it all worthwhile.”
The third need that physicians have is the sense that they make a difference. What good is being validated, and even having an opportunity to get it right if you’ve lost your sense of making a difference? That’s the whole reason that 90% of physicians get into the field in the first place. There are a few that get into science just because they love science, and medical school seems the right route, but most physicians have the sense of service. They have a backstory, that Pamela is so good at getting from people.
The reason they went to medical school in the first place.The mother who died of cancer, the father who had schizophrenia, the uncle who struggled with arthritis all his life. To be able to be back in the physician-patient relationship feeling validated, having an opportunity to get it right, then the third piece is, I want to feel like I make a difference. When I feel like I make a difference, it all makes sense and comes together, and I can even put up with a lot of crap if I feel like what I’m doing makes a difference.
The fourth need that physicians have is patient trust as evidenced by following the treatment plan. So many physicians feel really undermined and dismissed when they see their patients coming to them time after time after time and not following the treatment plan. Even though intellectually, everyone knows not to take it personally, there is this sense that, “Do they really trust me? I’ve been telling them that they need to do this and if only they exercise or if only they drink more water, those kidney stones are going to go away or dramatically improve.” But every time a patient shows up and hasn’t followed the treatment plan, physicians feel somehow that they aren’t trusted. “Why are you even coming to me? You don’t trust what I say.”
That’s important information to have, because when you’re in relationship with patients, if you know that these are very common, almost universal needs, then you can pay some attention to, “How can I build trust with that patient? How can I let them know that their trust as evidenced by them following the treatment plan is important for me to feel good about things?”
We have a lot of soundbites about what it means to have the doctor-patient relationship and bedside manner, but if you can just be real and say to the patient, “I want more than anything to feel like we have mutual trust. That you can trust me, and I can trust you, and therefore, we come up with a treatment plan together, and when you come back victorious in that treatment plan, we’re both better for it and our relationship is stronger.”
You may not be able to have that overt conversation with every patient, but it’s an important conversation to have at least inside yourself if not to have portions of that conversation with your patients so they understand.
The fifth need that physicians have is to be seen as human too. Because when they are objectified, put on a pedestal, lumped together as, “Oh, that’s what my last doctor told me, and none of you are worth much,” or whatever it is we feel emanating from that patient in urgent care. It’s important for us to acknowledge to ourselves that one of our needs in the patient-physician relationship is to be allowed to be human because when we’re expected to know it all and fix it all, and be the savior of the day, and have unlimited patience, and unlimited resources, and unlimited answers, it’s too much. Nobody can fit that bell.
Coming into the relationship, if you as physicians, nurse practitioners, therapists know that these are some of the internal, most common needs that healthcare providers like you have, then you go about meeting those needs. Validation, an opportunity to get it right, the opportunity to make a difference and know it, patient trust as evidenced by following the treatment plan, and to be seen as human as well.
Having identified the side of the relationship that is the physician’s part, the side of the relationship that is the patient’s part is every bit as important for us to know and understand, because if we know and understand what the patient needs, then when we address those needs and address our own needs, we will have a dynamic, growing, evolving relationship.
The number one thing patients need is to be heard. They feel like everybody’s in a hurry, nobody’s really listening. They said this, and this, and this, and nobody wrote it down or it was missed. That may be perception more than reality but it doesn’t really matter if that’s the way they feel. Number one is to be heard. The way for a patient to feel heard is for us to repeatedly mirror for them and reflect what they just said. “What I hear you saying is you fainted yesterday. What time did you faint?” Rather than, “uh-huh, mm-hmm,” looking at your chart or your keyboard, and then later risking the perception that they feel that they were not heard.
Second, to be believed. I think that as scientists, all healthcare professionals are taught to look at the data. When you have someone in front of you who says that they have a certain sensation or physical complaint, but the blood tests are good, I was one of those people, “Well your blood tests are wonderful. You’re fine.” But if a patient is showing up with specific complaints, it’s really important for them to have a sense that you believe them. Even if you don’t know the “Why.” Long ago, I had someone tell me, in my practice, that I really needed to believe what people told me. Because I would have people come and tell me, I’m hopeless, I’m a liar, I’m a hopeless addict, and I always would hold the light. “Well, you’re that and more,” or, “You’re not just that,” or “You’re not that at all,” in my early days.
Then I would be disappointed and often betrayed or taken advantage of because I didn’t believe what people said. If somebody comes to me now and says, “I’m a liar,” I say, “Wow, that’s a heavy burden. How does it feel to have a sense that you lie uncontrollably, pathologically?” I’m careful, and I protect myself, because they just warned me. Listen to the patient, let them hear your reflection and you’re sharing back with them what you heard, and let them know you believe them, because that’s very, very important.
Number three is to feel valued. Like they’re just not a number. One of the ways you can do that, I’m sure everyone has heard this at some point, is to use their name rather than just talking to them without using their name. If you say, “Well, Sandra, thank you so much for coming today,” wow, you actually know who they are. Now you may have just glanced at the chart to see who they are, but feeling as if they’re more than their diagnosis, more than their chart number, more than the number of minutes you have to see them, but that they’re actually valued. How can I listen to you, believe you, and let you know that you are valued?
Listening to them carefully, and then asking a question, a follow-up question is a really good way of helping somebody to feel valued. If all you’re wanting to do is cut to the chase, make this a really quick visit, and get to the number four question on your chart, they’re not really going to feel heard. But if they talk about having a backache after pulling their son around in his wagon, and you say, “How old is your son?” Wow, they feel valued. They’re not just a number, you’re actually listening. You’re believing them, you’re hearing them, and now you’re helping them to feel valued.
The number four thing that patients need is to feel empowered in making the decisions. I know that often people give mixed messages in this, but it’s true. Even though, on one hand, many of you hear all the time, “Well doctor, just give me the prescription, or just give me the pill, or just fix it.” When you take that on and you just write the prescription, give the pill, tell them what to do, there is a way in which that is disempowering, and it gives you too much power, and then you’re the one to blame if everything goes horribly, and you’re the one that gets all the credit if everything goes well. That’s disempowering to the person.
If you’re the whole reason that they lost 100 pounds, they’re very likely to put on 120 the next time because they don’t feel like they did it themselves, or that they were a part of it. To help people feel empowered, you say, “We need to come up with a treatment plan here. I want to put my head together with you and come up with a plan that you can live with because you know yourself better than I even know you. How can we come up with a plan together? I have the science, I have the medical knowledge, but you know yourself. You have intuition. You have a sense of what you want for your life, and what your goals are, so let’s come up with that together.” Even though that takes more time, it will really, really, enhance your relationship and help them to cooperate with what you need, which is trusting you and following the treatment plan. In order to do that, they have to come up with a treatment plan with you, and feel empowered.
The fifth thing that patients need is to feel better, and have better health. The crazy part about this is that you would think as a physician that the number one reason somebody comes to you is to feel better, but that’s actually way down the list. They want to feel better, yes, but because as a human being and someone who is off and not feeling up to par, they need all these other things first. If they get those other things first, then they’re going to be able to corroborate, collaborate with you to find a plan that will help them feel better. But, absent those other needs being met, they almost always go away not feeling better. That is so frustrating to healthcare professionals who say, “I spend all this time with you. I told you what you needed to do and you must just not want to feel better.”
It’s not really true that they don’t want to feel better. It’s just that there’s a hierarchy of needs, and if they get those early needs met within the relationship, then they’re able to collaborate with someone to create better health. If those initial needs aren’t met then often they aren’t empowered enough to really work with you to create better health.
Ultimately, if you look at the list, it’s almost like they’re mirror images of each other, like they’re one pyramid up and one pyramid upside down, because the patient’s number five to feel better and have better health and the physician’s number five is to be seen as human. The patient’s number one is to be heard, which is a part of being that human, so the hierarchy of needs between the physician and the patient are different but they’re equally important.
As a healthcare professional, if you go in saying, “I have needs, and in order to make this relationship work, the number one thing I have to accomplish is meeting my needs, because I’m not going to be much of a nurse practitioner or physician if I’m not fulfilling my needs, so I need to make sure that I, early on in this relationship, feel validated, get an opportunity to get it right, feel like I’m making a difference, develop patient trust as evidenced by their following of the plan, and then be human and be seen as human. If I can meet all those needs, then I can make sure that I’m attending to the other side of the relationship, which is the patient needs, in helping them to meet their needs.”
To even say, “I know, today, what you need more than anything is to feel like I hear you, like I believe you, like you mean something to me, and are important to me, you want to participate with me in making your healthcare decisions, and you want to leave here feeling better, those are my goals too.” Let me tell you, to have that little 30-second conversation with the patient can make all the difference. “I want to be here and feel as if you can develop trust with me, know that I want to make a difference, get things right with you, and we’re going to leave this appointment today better human beings, and hopefully you’re going to feel better and be on the right track to better health.”
Pamela Wible: That’s really awesome.
Sydney Ashland: Having said all that, Pamela, what are some of your thoughts?
Pamela Wible: Well, I think it’s so important to have transparency in our needs. Sometimes when we are clueless about our own needs, we’re not able to participate fully in the relationship. and I think our own needs are often muddled. We don’t really know what our needs are. In medical school we’re taught to be self-neglectant—that the patient always comes first—and your needs are just not even relevant. I think that’s where the problem starts—in medical school? The whole idea of always putting patients first to your own detriment.
Sydney Ashland: Yes. Absolutely, and I think there are lots of places in life we can look at that and see models like that where it hasn’t worked. With parents, and parenting. Unless parents are having some of their needs met, and coming from a resourced place, they are not very good parents. That’s sort of putting the child first, while putting yourself last. It really doesn’t work because you end up so depleted and sick and tired, and out of sorts, and at your wit’s end, and on your last nerve, I mean we throw all those phrases, that’s from a parent that is not resourced, or a teacher who isn’t resourced. Well the same is true for physicians who do not resource themselves. Nurse practitioners and others.
Pamela Wible: I have a question, Sydney. Over time, do you feel like this relationship between patient and physician, or other health professionals, has evolved from the 1950’s? I remember sitting with some physicians older than myself who said something along the lines of what patients used to want is a sage from the stage, and now they want guide from the side, and that has made people uncomfortable who are more accustomed to being the sage versus a guide. I’m just curious. What’s your commentary on that and whether that has changed the basic needs, or do you think these needs have always existed and just never been vocalized?
Sydney Ashland: Well, I think it’s sort of the classic story of moving from a life that’s focused on surviving versus thriving. When we were earlier in our evolution as a culture, there was a time when we were much more authoritarian and much more patriarchal, and in that world, there were many people who gave their power away or had no idea that they had any power, and other people who were programmed and educated to wield their power with compassion. That didn’t always happen. I think it’s really a commentary on our evolution as a world where more of the focus is on individuation and independence, and self discipline, and collaboration. There’s much less this authoritarian do-as-I-say-without-question sort of mentality.
Pamela Wible: One thing that I was discussing earlier with a physician in our group is that I believe the ideal physician or health professional is an empowered person who demonstrates (by example) personal empowerment for the patient. The whole idea that we create dependency with, “You always need me for labs or tests. You always are going to need these special supplements.” This whole placing the power outside of one’s self for healing is very dangerous, in my opinion.
Sydney Ashland: Right.
Pamela Wible: I think it’s absolutely essential that we remove so many of these unnecessary pieces so that the relationship itself can thrive and actually create healing between the two individuals in the room (using labs and tests minimally as needed, but not as the essential foundation of the relationship). I think that sometimes makes people nervous in practice because they haven’t really realized that they are the healer—the healing force in the room, you know?
Sydney Ashland: Right.
Pamela Wible: What do you think about that?
Sydney Ashland: Right. Well, at risk of going off into a little of my personal experience of late, I just want to say that I think that’s very true, that it’s easy to start relying on tests and labs, and not really listening to the patient, because we want to see what the numbers say. Unfortunately, when you don’t listen to the patient, you may miss a really important clue, and so you’re testing for the wrong thing. It’s actually better medicine to take a little longer to decide what tests you’re going to run, and really listen carefully, because then rather than just following the clinic protocol or the hospital protocol, you are putting yourself in a much safer position because you’re like, “Wait a minute, this piece doesn’t really fit, so maybe I need to run this test first.” I believe that that saves lives.
Pamela Wible: As they say, 85% of diagnosis can be made just by listening to the patient. Sydney, if you want to share what’s happened with you lately, and how to protect yourself as a healer, and then we can open up for discussion later, or we can do this during our discussion period, whatever you prefer.
Sydney Ashland: Sure. Well I think what I would say is, I have been guilty of many, many, many times over the years, not self-protecting. Because I’ve had a very strong constitution, and then a very type-A strong person. I’m always, “Oh, no problem. I’m fine. I’m good.” Just because you say it, even though I’m all for positive thinking, doesn’t mean that it’s true or that there’s not some denial going on. I think for years, not knowing my limits or always listening to my body, and taking fatigue seriously, I probably wouldn’t have gotten to a crisis point had I had little more of a reasonable schedule. Especially with patients in my office. When I work with patients by phone (at a distance) it’s much less energy that is taken from me than when I have a counseling session with someone in person.
To do that many times a day, for an hour and a half, sometimes 10 times a day, that’s a lot and it’s hard on the body. I was guilty of not being in balance. Loving my work so much, feeling so validated, like I’m making a difference. All those good things, but not listening. Then, when I started getting really sick and I started going to see the doctor, I had not developed a relationship with the doctor. The doctor didn’t even know me, and didn’t listen, and continued to run blood tests, send me to this specialist and that specialist. “Oh, it’s allergies, oh, it’s this, oh, it’s that,” when all my classic symptoms of coughing and bone-crushing fatigue, and fainting were being missed. Or “Oh, she must be being dramatic,” and I ended up stage three Atrioventricular Heart Block that was missed to the point where I was one second away from sudden death.
Luckily, at one point, my physician heard me and ordered that Holter Monitor, and that’s why I’m here today with a pacemaker. But the consequence for me is my life will never quite be the same. I am dependent on this wonderful little technology, and I (as a healer) wasn’t really listening to what my needs were, what my body was telling me. I really am even more burdened in my work with other healers to make sure that we’re not trying to save the world, that we’re having reasonable hours, that we are learning how to replenish, and resource, and refuel ourselves, stop when we get sick with a virus, not just keep going. All those things, so that others can learn from my mistakes, and from my lack of balance. That I can encourage, uplift, and inspire you all to do that for yourself.
Pamela Wible: In closing, I would say, that’s why it’s so important in medical education, when we have these hundreds of students listening in these lectures, and we orient them to medical school, to just encourage them to take care of themselves. If they don’t take care of themselves, they’re not able to care for others, and we literally can die prematurely and miss all sorts of clues in our own health and in our patient’s health. We’re not thinking clearly when we’re hypoglycemic or an AV Block.
Sydney Ashland: Exactly, yeah.
Pamela Wible: We absolutely need the same care as our patients. We need glucose—fuel for our brains. We need our hearts to be properly beating. We need our organs to be working to be doctors, including adequate sleep, meals, and bathroom breaks. This is just human nature, physiology. We need to take care of ourselves to take care of other people. I think the next generation of physicians is going to demand to have their human rights honored, and their physiologic needs honored, because it’s just not going to work any other way.
Sydney Ashland is an expert in physician psychology. Contact Sydney. Pamela Wible, M.D., is the author of Physician Suicide Letters—Answered. Her TEMED talk Why doctors kill themselves addresses the culture of abuse in medical training. Contact Dr. Wible.