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Physician Patient Rapport, Part II
The need for building relationships has never been more important to the physician than it is today. Faced with the threat of malpractice, the demand for efficiency in the office, and the growing trends of HMO's to measure and reward physicians with high patient satisfaction scores, learning the skills to construct a sturdy doctor-patient relationship can positively impact critical areas of your practice. Relationship building can be broken down into 3 simple steps.
- Establish and nurture doctor-patient rapport.
- Define mutually satisfying goals for each patient encounter
- Produce positive feelings whenever possible.
My belief is that the creation of rapport is the single most important element in relationship building and is therefore the very first step. That this key piece has been left out of nearly every modern treatise on the doctor-patient relationship is a serious oversight. Typically authors have talked about the value of empathy and medical schools have taught interviewing skills, but the core process of establishing rapport has not always been included or explained.
The Oxford English Dictionary provides one simple definition of rapport as merely a "connexion". A connection in modern English. The computer metaphor is very appropriate for an article on the internet and it just so happens to work perfectly well. Imagine if your computer keyboard was unconnected to your CPU. All the lights would come on, but you could not store or retrieve a single bit of information. Has this ever happened to you in a patient encounter? If you've failed to establish or retrieve rapport somewhere in the relationship, the answer must be yes.
So how does one develop rapid rapport? How can it be tested? How can it quickly be retrieved from one visit to the next? What if rapport is lost, how can it be reestablished? Doctors typically wonder what they have to say in order to establish rapport. The answer is surprising in that the initial steps in establishing rapport require no conversation at all! We all have a natural ability to establish rapport and we are in and out of rapport with people many times during the day. The easiest way of thinking about it is to loosely define the process as….becoming similar.
The technique of becoming similar in order to gain rapport is often referred to as matching, mirroring, or pacing. Now there is a clear distinction here between matching and mimicking because in matching the goal is to slowly and unobtrusively approximate the other persons behavior. You can match nearly any behavior that you can observe and the elements of powerful matching can include such things as posture, rate of breathing, facial expression, and some gesturing. Also voice tones, volume, pitch, and rate of speech, can be used as powerful rapport builders. Once rapport building comes naturally, it gives the physician the ability to "plug-in" to the patient's world. It will facilitate other communication with the patient and you will feel and understand what it is like to be that person at that moment in time. The patient feels more connected as well, and she is more likely to provide both verbal and non-verbal clues as to her condition or problem.
Think about what you do when you first go in to see a patient in an exam room. Is she dressed or undressed when you first meet? Is she seated in a chair, sitting on top of the exam table, lying down, or pacing the room? However you find her, what do you normally do? What is the first thing you say? Where do you usually sit or stand and what do you have the patient do? Is there another person with you in the room? If so, how do you arrange the group for adequate communication? Every bit of information you can gather about the first moments of your encounter can help you to reengineer this critical step in gaining patient rapport.
My strategy in nearly every patient encounter is to reach out my hand for a brief handshake and a greeting. This is such a universal human gesture that it cannot be forgotten under any circumstance or you will create an immediately odd moment that can delay rapport building. Right away after the greeting, the next step is to get into a similar posture as your patient. If she is seated in the chair, pull up a stool and try and match her posture. If she is upright, then sit up equally as straight. If she slouches, then be equally as relaxed. If her legs are crossed, then you might want to cross yours as well, although perhaps not at the same point or in exactly the same manner. Is she gesturing as she speaks? If so, match her gestures in size and style. As your conversation begins, maintaining eye contact at a similar level gives an added non-verbal cue of "seeing eye-to-eye". Beginning to notice and match the voice qualities of the patient will help to maintain rapport as you move the conversation around the room or over to another setting.
If the patient is lying down on an exam table but does not immediately sit up when you walk in, a simple touch on the top of the shoulder with your greeting can substitute for a handshake. You can then bend down and help her to sit up as you begin your interview. If the patient is walking around the room, it may be better to do a walking handshake and greeting, taking a few steps in the same direction as the patient. In this way you are "sharing the same space" and "heading in the same direction" rather than "squaring-off". These body-language cues are important as you begin to move your conversation into a specific direction. Occasionally it is helpful to purposefully and momentarily break rapport by mismatching the patient, in order to see what loss of rapport would feel like. It is then usually easy to reestablish rapport by realigning oneself with the patient.
If the patient is in an obvious problem state, such as with a painful condition, or in an emotional upheaval, it is often more effective to align yourself with that emotional state and attempt to match the same feeling in a positive and sincere way. You know how irritating it can be in an angry conversation when the other person never acknowledges your emotion but merely remains cool, calm, and collected. The patient feels the same way if the doctor seems detached from the situation in the beginning. The correct approach is to initially pace and acknowledge the emotional content, and then say, "Look, in order for me to really help you we must get back to some basic medical questions." Then you can really begin the process of soliciting meaningful medical history with a much more confident and cooperative patient.
So the concept of matching is the key to building and maintaining rapport. When rapport is established, it is then easy to go on to develop mutually satisfying goals and a well-formed outcome for the patient encounter. Finally, the creation of positive feelings and the attachment of those feelings with your presence is the last step in developing a strong doctor-patient relationship. Ultimately, whenever your patient returns, that first handshake, will automatically set the stage for another productive patient encounter that will be remembered and appreciated.
Also see Physician Patient Rapport, Part I
Douglas J. Krell MD FACOG
Galisteo OB/GYN Associates PC
Santa Fe, New Mexico
OBGYN.net State Representative, New Mexico
douglas.krell@nsionline.com
