Building rapport with patients – the foundation of shared decision making
Author: Laurie Proulx
I have spent a lifetime interacting with the health care system beginning with a diagnosis of Juvenile Idiopathic Arthritis at the age of 14. I remember many of the interactions I have had with clinicians, many were routine, some were difficult, while others were heart-breaking. Let us start with an example of an exchange between a patient and a clinician.
A patient with Juvenile Idiopathic Arthritis enters a physician’s office to discuss her severe pain. It is affecting her school, her friendships, and her concentration. She limps into the office and the physician asks some questions. Her physician is short of time and recommends steroid injections. The appointment lasts 10 minutes with limited time for discussion of options, goals, and risks. The steroid injections temporarily help with joint pain, and she continues struggling.
This patient is me. I was 15 years old and suffering tremendously with Juvenile Idiopathic Arthritis. In hindsight, I see this appointment as a missed opportunity. Not only was I incapable of conveying my needs in a way the physician could understand, but the physician missed an opportunity to make a difference and to relate to me in a meaningful way.
Shared decision making might have changed this scenario. It is a process in which clinicians and patients work together to make decisions and select tests, treatments, and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values. As a patient, I see tremendous potential for shared decision making - it has been described as synonymous with patient-centred decision making.
I know what shared decision-making looks and feels like. It means that I am seen as a person with a life, goals, and things that matter to me. I am intelligent, able, and more than the ‘severe joint deformities’ labelled by healthcare providers. I feel respected and heard. Clinicians believe and trust me. In return, I trust them and willingly share more information knowing that our interactions are safe and free of judgement. I leave the office feeling like I can follow through with the treatment plan. There is no regret and little uncertainty. The result is a feasible plan and I can put it into action.
Theory and reality however can be two different things. Those ‘joint deformities’ are especially significant to me – I trained on the piano for ten years. This is an important context if a clinician wants to build rapport and trust with a patient – they need to see me as more than my condition and use appropriate language that sees me as more than the terminology in a medical textbook. Without this trust and rapport, the foundations of shared decision making cannot be laid. When I ask a question, they should see a person who wants to learn more about their health, not an annoyance or bother. The clinician could address many of my problems by counselling and helping me learn about treatment options. Without information and mutual respect, there is no trust.
In practice, however, shared decision making is often elusive. The right incentives are not in place to allow the time for building rapport with patients. Clinicians often are not trained in communicating with patients from diverse backgrounds. Efforts are underway to address this including a recent group of medical students at the University of Ottawa who are leading the way in improving communication skills training in medical schools.
Knowing what we now know about shared decision making, lets re-create the scenario from the start of this article. A patient limps into a physician’s office. They start to talk. Then the physician pauses and asks, “How are you really doing?” She bursts into tears and is consoled by the physician. After a few minutes, he asks “I can see you really aren’t doing well. Can I bring your parents in here so we can have a long chat about how to help you?”. Through her sobs, she nods.
A long conversation is held about the state of the patient’s health, options, and next steps. With agreement of the patient, she is hospitalised and starts on intensive treatment for two weeks to get her health back on track. (Note to readers: This patient is also me but several months later with different physician)
We all recognise the important of practising evidence-based medicine. Patient-clinician interactions deserve just as much attention. But as a patient, I feel this is one of the most important but overlooked part of research and healthcare delivery. In the thirty years of lived experience as a patient, the interactions I have with clinicians have had an enormous influence on how safe I feel and the state of my health. It means that I feel like clinicians will ‘have my back’ when I cannot advocate for myself - an inevitable reality for many patients. Healthcare institutions need to heed this call by focusing research, quality improvement, and medical education on outcomes that are important to patients. This means that patients need to be embedded in health research teams and institutions.
A final note to healthcare professionals doing their best day to day: take the time to have that next important discussion with patients and build high-quality and impactful relationships with them. Not only are you setting the foundation for shared decision making, you are also supporting the patient’s journey to better health.
Laurie Proulx is 2nd vice president of the Canadian Arthritis Patient Alliance, a patient run, volunteer-based organization whose activities are largely supported by independent grants from pharmaceutical companies.
Laurie Proulx has received speaking fees of less than $500 from a pharmaceutical company.
Many thanks to Dr. Karine Toupin April for reviewing a draft of this article and providing valuable feedback.