When “Gloria,” a 60-year-old homeless woman with no family, was admitted to the University of New Mexico Hospital, Albuquerque, with laryngeal cancer, hospitalist Peter Barnett, FACP, had a hard time getting through to her. Gloria was extremely suspicious, dramatic, emotional and argumentative, although she had a good sense of humor and was obviously intelligent.
“It was difficult finding out who she was,” said Dr. Barnett.
Gaining the trust of new patients can be difficult for any physician, but for the hospitalist, it's a daily challenge. There's no preexisting relationship, and developing one can be more difficult when the process is interrupted by shiftwork. Acute illness causes stress and may compromise patients' awareness, problems that can be compounded by a lack of familiarity with the hospitalist and the hospital setting. Establishing the rapport necessary for an effective therapeutic relationship requires effort and finely honed interpersonal skills.
“The key is to recognize that these skills exist,” said Dr. Barnett. “It's not about being nice, although being nice helps. It's about clinical skills. I'd advise the hospitalist to engage each patient honestly, clearly, respectfully. Be patient, be genuine.”
Dr. Barnett guessed Gloria had difficulty trusting people. He asked her, “I know it's hard for you to trust people. How do I need to be for you to trust me?” Whenever she argued about treatment, Dr. Barnett responded with empathic questions: “What's your concern about this? You seem skeptical … what's most important to you right now?”
When Dr. Barnett transferred Gloria's care to another attending, he explained to the new care team what he was doing with his patient to gain and maintain her trust. “It worked,” said Dr. Barnett, “day by day, step by step.”
Bridging the gap
The skills required for building rapport are basically the same for hospitalists and office-based physicians seeing patients for the first time, but differences exist in how they're utilized and what issues are addressed. For example, although hospital stays may be short, hospitalists' visits with patients are daily and often lengthy—luxuries office-based physicians don't enjoy—providing ample opportunity for relationship building.
To start the process, when entering a patient's room, the hospitalist should pull up a chair and focus on the patient in an unhurried manner. Experts offered the following tips
- Be mindful of the patient's justifiable fears and anxiety;
- Explain the hospitalist's role as overseer of the patient's hospital care;
- Explain hospitalist scheduling and signoffs;
- Acknowledge both the patient's relationship and the hospitalist's collaboration with the primary care physician;
- Acknowledge communication with the hospitalist previously on duty;
- Emphasize hospitalists' availability to talk with family members and 24/7 availability to the patient;
- Carry conversations over from one daily visit to the next, addressing previously asked questions and information or instructions previously given; and
- Listen without interruption, then respond to explicit and implicit questions and fears.
“These skills can and should be modeled by attending physicians as they teach,” said Sunil Kripalani, ACP Member, chief of hospital medicine at Vanderbilt University in Nashville. “There's no reason why teaching rounds must be limited to discussion of pathophysiology. Comment and reflect on the interpersonal dynamic—what went well, what went poorly, what they could do better with the next patient. This takes only a few minutes, but can have a lasting effect on trainees.”
And Dr. Kripalani pointed out that basic courtesy and respect, such as asking permission before turning off the TV, or explaining what you're going to do before touching the patient, can go a surprisingly long way toward building rapport.
“Negotiating diagnosis and treatment is a matter of finding out what the patient believes, and what they think about what they've been told,” Dr. Barnett said.
Establishing rapport in the hospital setting aids these negotiations, experts said, because it makes patients more likely to trust the physician with information, ask questions and learn about their illness, and adhere to physician recommendations. Mounting evidence from the behavior change and health communication literature supports this, and further indicates that communication skills have a demonstrable effect on symptom and clinical outcomes.
Improved rapport also aids in navigating difficult situations (e.g., an unwanted outcome or a medical error) and decreases the chance of legal repercussions when something goes awry. Rapport-building techniques can positively impact relationships among interdisciplinary teams as well, said Dr. Barnett. Last but not least, experts said, improved rapport increases professional satisfaction for the hospitalist.
It's helpful to remember that sometimes it's the smallest personal connection that helps develop rapport. Adrienne Bennett, ACP Member, director of the division of hospital medicine at Ohio State University Medical Center in Columbus, cared for “Dan,” a 45-year-old man admitted with back pain after having visited several other EDs. Because no one had found an organic cause for his pain, he'd been treated as a drug-seeker.
Dr. Bennett had a difficult time establishing rapport with Dan, who was angry and mistrustful. Then his wife mentioned their cat, and Dr. Bennett told him she had a cat, too. “Tell me about your cat,” she said. That simple sentence changed the dynamic of the conversation.
“Dan settled down and gave me a chance, and I gave him a chance, too,” said Dr. Bennett. “Being able to build rapport helped me keep an open mind, and to pin down the source of his pain—a rare hematologic cancer localized in one vertebra.”