Sunday, April 2, 2017

What is your doctor's Relationship Quotient?

Relationship Intelligence is NOT the same as 
Emotional Intelligence


What do I say to a patient who tells me about childhood memories of assault, or sexual abuse, or a traumatic experience?  


What do I say to (or do for) a patient who tells me about their (shameful) addiction to drugs, or alcohol, or pornography, or eating, etc.?

What do I say to a patient who reveals being in a cycle of abusive relationships?


To have or to be open to having an emotionally authentic conversation yet alone a relationship with any of these people is to open one’s heart to the human condition in ways that are out of the ordinary.  With any new person, we begin at a comfortable distance, and then when we hear their story, we have some automatic, reflexive reaction which may include adjusting that figurative or emotional distance (increasing or decreasing).  We may unconsciously erect some protective barrier, or we may possibly embrace the pain and woundedness in our presence.  We would like to think we can remain objective, non-judgmental, non-blaming and very self aware, but no matter how often we have heard these stories, it's difficult not to have some reaction.  What about our (unknown or unnamed) biases?  What attracts us to one individual?  What repels us from others?  Do we even know what’s happening inside ourselves when it is happening?



 What is it about some people that make them interesting to us?  What is it about some others that make it more difficult for us to connect with and be more understanding?

How do I ask questions that are on topics that may be very sensitive to ask and complex to delve into - like sexuality, drug and/or alcohol use, abuse experience?

How do I establish an agreement / contract with my patient about trust, safety, privacy, availability, shared responsibility?


    There is a significant body of literature supporting the primacy of the relationship between therapist and patient or physician and patient over the particular treatment method or approach of the professional.  Simply stated, the most important factor in patient care is the nature of the relationship between the doctor and the patient!  Technique is secondary.   Physician time spent establishing a relationship is never wasted time!  And yet, professionals will argue back and forth about the merits of different techniques or approaches, and they pay less attention to relationship building processes.  Research has measured the time it takes some physicians to interrupt a patient’s story in seconds!  Interruptions may get us to the core of the symptoms more quickly, but we bypass the patient in the process.

     As early as 1957, Michael Balint wrote about “… the doctor as drug,” suggesting that the physician’s impact on the patient can be akin to the impact (or side effect) of a pharmaceutical agent.   With pharmaceutical agents, the side effect is almost always negative.  Once in a while, a medicine is chosen because a known side effect is a desirable one for a particular patient.  If we think about “the doctor as drug,” it is an opportunity to have NO negative side effects.  In fact, the relationship that is developed can be a multiplier of the purely medical treatment regimin.  But this is dependent on the physician’s Relationship Intelligence or their Relationship Quotient!

So, a natural question to ask is what are the components of Relationship Intelligence and how does one develop such a skill?   It is clear that emotional intelligence is a necessary component - necessary, but not sufficient - especially in the form of listening to self and to others.  

Why is listening such a challenge?

     Emotion trumps Logic: I often think about a Maya Angelou quote: "I may not remember what you did for me, but I will always remember how you made me feel."  It is so ironic because so many physicians will first remember what they did for the patient and only when probed might recall the emotion in the encounter.  This is an example of how there can be such a dichotomy between the patient experience and the physician experience.   The patient may be sitting with emotionally and physically painful secrets they have never shared - until today.  The physician is prepared to ask a few diagnostic questions, chose among several medications they will prescribe and smoothly leave with encouragement and a plan for the next appointment.  Doctors are prepared to open the door to the examining room, but maybe not prepared to open the door to the patient's life.

 Listening as a billable code: Part of physician's training is to think about how to code this visit to justify billing the insurance company. It's not the first thing on the doctor's mind, 
but they are quick to know that this is a Level 2 or Level 3 visit, for example. They also need 
to be clear about documenting all of their findings in order to justify the medical diagnosis 
and the codes for treatments - especially procedures. Doing a procedure or sending a 
prescription to the patient's pharmacy feels like I'm doing something. "Just" listening does 
not feel like I'm doing something - no matter what the patient says.  

I wonder if we are teaching the subtleties of listening well enough!

     Emotional Arithmetic:  When we share good or exciting events in our lives with people who care, the joy gets multiplied.  When we share sad or bad events that we experience in our lives, the pain is divided.  Sharing our experiences is always a positive - primarily for the sharer.  Good things get better; sad or painful things get lessened by virtue of their being shared.  However, the experience is different depending on whether we are sharing or we are listening.  To fully listen and only listen is a gift!  It is like saying (silently): "Let me help carry that load."  And to fully listen is to acknowledge the story and to validate the emotions.
  
One challenge is to avoid several traps.  One is the trap of trying to fix it - it's in our DNA!  We are helpers, fixers.  We get some of our goodies by relieving pain and suffering.  It is easy to forget that really listening, uninterrupted, helps!  Another trap is to try to reframe it or put it in a more palatable context - another form of fixing it.  Another trap is sharing our marginally similar experience as a way of saying "I know how that feels." which we probably could never know.  It is a helpless feeling to "just" listen, yet it is such a gift!

     The Patient vs. The Schedule (all the other patients):  When the visit I thought would be routine becomes a drama, my schedule flashes before me and I think about all the other patients I will be seeing and to whom I will have to apologize for being so late.  It is so unfortunate that physician's schedules have to be so tightly booked that there is little time for even one drama to pop out and require adequate time.  it is unfair to patients as well as to doctors.  And the only remedy the way schedules are set up is to make everyone who follows a bit later than they planned or expected.  No wonder listening is so challenging.

     Balance Content with Process - Paying attention to what is said in addition to how it is said is crucial in understanding the complexities in what is being communicated.  Recognizing a patient’s reluctance or their anxiety or the tension with which they share information adds to the meaning that sharing may have; it may help to recognize or uncover additional layers of information crucial to understanding that patient 's story.  Sometimes, patients do not have the emotional vocabulary to fully express how they are feeling.  Sometimes, the best they can do is to demonstrate the anxiety by being anxious or the tension by showing us their tension.  It is our task to identify those emotions, to provide the emotional vocabulary.  It is another subtlety of listening.

The Role of the Physician in the Community?

This emphasis on relationship seems in marked contrast to current trends in health care which emphasize efficiency, cost containment and the bottom line, patient improvement as measured by laboratory test results, and patient satisfaction measured by a brief questionnaire.  In contrast to more highly valuing healing relationships, this emphasis on efficiency and patient (customer?) satisfaction is more of a focus on the business of medicine.   I have wondered how good the Press-Ganey scores would be for Shamanic healers.



Balint groups are such a reminder of what components are essential for developing relationships that can be healing.  Maybe Balint's impact is to help physicians develop better Relationship Intelligence which leads to better connections with patients and ultimately better care!  Part of the process may be revealing or uncovering blind spots.  Another way to think about this is that Balint group participation helps physicians to integrate their  professional role with their human role.  It helps us to listen to ourselves as well as to listen to our patients.  We both need to be acknowledged and to be validated!