Practice

Ten practical steps towards healing consultations

phil-plus-robin

Many discoveries happen by accident. A chance meeting between two physician leaders led to a unified framework for healing consultations.

Phil Fischer is Professor of Pediatrics at the Mayo Clinic in Rochester, Minnesota, renowned for his success in treating function disorders in children and teenagers. Robin Youngson (the author) is an anaesthesiologist in New Zealand, recognised for his international leadership in compassionate healthcare. They met by chance when both were invited to be keynote speakers at the New Zealand Society of Paediatrics Conference in November 2016.

Phil gave an inspiring talk about his success in treating so-called ‘functional’ diseases in children – those conditions, causing serious illness or disability, where no structural cause can be found, despite extensive investigation. He began his talk with a story of a fifteen-year-old girl from Texas, who had difficult walking. During five weeks of inpatient hospital stay her condition steadily worsened. At the end of three weeks’ rehabilitation, she was now wheelchair dependent. Three days after her Mayo Clinic appointment, she was walking and running easily. Phil posed the question, ‘What’s going on? What am I doing differently?’

I sat in the audience, mesmerised by Phil’s inspiring talk. He outlined seven principles for his practice. As his talk progressed, I became excited – these were almost the exact same principles I had evolved over many years, in the care of patients who had been traumatised by previous hospital care. The example I immediately recalled is providing anaesthesia care for an elective C-Section patient, who arrives at the hospital fearful because of a distressing past experience of emergency C-Section.

In the coffee break Phil and I compared notes – the similarity of our approach was striking but we both gained new insights as we shared our experience.

 

You can’t teach compassion but you can teach what compassionate practitioners do

I’ve been campaigning and speaking about compassionate healthcare for more than a decade. In my book, TIME TO CARE, I write at length about what compassion is, how it can be developed in each individual, and what a profound difference it makes to patient outcomes. Until I heard Phil’s presentation I hadn’t thought to share exactly the steps I take, in a patient consultation, to bring that compassion to life and to create a healing connection. I teach it at the bedside but I’ve never written it down in detail.

One of the things that distinguishes our practice, Phil and I, is that we are both extremely mindful of how we conduct ourselves for every minutes of the consultation; there’s powerful intention behind our actions. To the casual observer, much of what we do might be invisible. This article has the purpose of sharing the exact steps we take and the principles that govern our consultations. I have taken the seven principles shared by Phil in his talk and expanded the ideas to create a generalised framework to guide any healing consultation.

 

Ten practical steps

1. Choose your attitude.

phil-with-kidPhil didn’t mention this principle, he just exemplified it in his presentation and his stories. Attitude is everything. A healing connection requires you to show compassion, which includes empathy, sympathy, an attitude of loving kindness, and a deep desire to relieve suffering. The other helpful attitudes that Phil displayed were a friendly and humorous approach to meeting each patient as a fellow human being, deep respect, humility, and joy in service. He comes with gratitude for each consultation; the patient feels his warmth and genuine pleasure in the encounter.

I’ve written and spoken a lot about ‘choosing to love your job‘. I regard my medical work as a privilege and I’m grateful to my patients.

 

2. Validate the patients concerns.

Phil meets patients who have been told by many doctors, ‘There’s nothing wrong! All the tests are normal.’ The first thing he does it acknowledge and validate the patient’s complaint: ‘This is a real illness,’ he tells them. ‘It’s not a structural disease that shows up on tests, it’s a functional illness, your nervous system function is screwed up.

I do the same with my patient presenting for C-Section. The scenario could be something like this: the labour and delivery of her first baby went badly. After 36 hours of agonising contractions, the obstetrician calls an emergency C-Section. The mother is exhausted, in severe pain, and frightened. She agrees to have spinal anaesthesia, so she’s awake for the surgery. The spinal anaesthetic drops her blood pressure so she feels suddenly horribly faint and nauseated, she thinks she’s going to die. The anaesthetist restores the blood pressure but fails to provide emotional support or reassurance. As the surgery progresses, the patient begins to feel pain. She’s completely immobilised, vulnerable and terrified. The anaesthetist is brusque and unsupportive, telling her, ‘It’s not pain, it’s just pressure.’ The patient’s husband at her side, sleep-deprived and stressed, has angry words with the anaesthetist who demands the husband be expelled from the OR. The patient shrinks to a state of silent suffering and terror. Ever since, she’s had nightmares about her experience in the OR.

All of the side-effects and discomforts my patient experienced are medically explainable. In past years, I used to explain away the patient concerns by saying they were just medical side-effects. You can imagine, this approach only heightened my patient’s fears! Now I take especial care to validate her experience. I tell her that I imagine this must have been a nightmare for her, a very traumatic experience. I ask about signs of post-traumatic stress and how she is feeling now. When she admits to being apprehensive, I validate that feeling. ‘It’s perfectly reasonable,’ I assure her, ‘anyone would feel that way.

 

3. Agree on common goals and outcomes, set intentions

Phil asks his patients, ‘Why have you come to see me?

When they reply, ‘Because I can’t walk!’ he challenges them again: ‘Why have you come to see me? Is it just to have a diagnosis, or to feel better, or to actually recover? I need to know.’

He wants to create a clear contract with his patients so that they will focus on recovery, he’s very clear about his intention.

I often tell my patients what my job is. Lots of people don’t know what an anaesthetist is, and they can’t even say or spell the word.

I tell them, ‘My job is to relieve pain and suffering, not cause it. I’m going to be with you every minute of the operation – watching over you, making sure you are safe, asleep (for a GA), and wake up feeling good at the end of the operation.’

For a C-Section patient I tell them, ‘My intention is that you are going to be completely relaxed, comfortable and smiling all the way through the operation. This is the birth of your baby, I want it to be a joyful experience.

 

4. Affirm the patient

Phil always affirms and commends his patients, he tells them that the problem is not their fault, he knows they have been trying hard. Then he empowers them to take recovery-oriented steps. He believes in their capacity for recovery.

When I first meet my frightened patients, their agitation is visible, they are ‘climbing the walls’ figuratively. Through the power of my calm presence, through validating their feelings and setting intention, I witness the patients become calm and grounded. I draw attention to the change, ‘See how you have managed to calm down and feel centred? That’s the strength you have,’ I say.

 

5. Help them understand

Phil takes trouble to explain to his patients the difference between structural disease and functional disease. Structural disease, he says, shows up on scans and tests. Functional disease, on the other hand, is like a bug in the app on your phone: the phone is structurally normal but the software has a bug. Functional illness is like that, he says, the instructions for the functioning of your nervous system have got screwed up but the hardware is normal. He validates their illness and gives them an explanation.

I do the same, I want to show my patients that their previous bad experience was real and can be explained. I’ll obtain the anaesthesia record from the previous C-Section and explain what I find: ‘See, here the blood pressure dropped, that’s when you would have felt very faint and nauseated. Here the anaesthetist give you an extra dose of painkiller, you must have been feeling pain during the surgery. You’re exactly right! What you said happened, is right here in the record.’

By making the experience explainable, I can recruit the patient in a strategy to prevent these side-effects from happening again. She can have confidence in the techniques I suggest.

 

6. Plan for recovery with specific steps

Phil creates a series of steps in the functional recovery of his patients, often with a timeframe. He advises, ‘Don’t overwhelm your patients, give them small do-able steps.’

I ease the burden on my anxious patients this way. ‘We’re going to break down the whole process into small steps, and at each step I’m going to check that you’re OK? You’re going to be in control of the whole process.’

I’m affirming that the patient is the most important person, I’m there to guide her through the steps, not impose medical control (unless for safety reasons).

 

7. Tell the patient, ‘You are not alone!’

Phil tells his patients that they have a whole team of professionals working together to ensure their recovery. In his interactions with the patient and his colleagues, he affirms his confidence in their ability and the way they work together.

I do the same. I tell my patient, ‘You’re lucky, you have the best surgeon to take care of you! If I had to choose a surgeon for my wife or my daughter, that’s who I’d choose. We have worked together as a team for many years. Not only is he a very experienced and skilled surgeon, he’s also really kind and gentle. He’s going to be very aware that you are awake during the surgery and he’ll be checking with me that you are doing OK.

I also explain the role of the anaesthesia technician and other OR staff.

 

8. Provide optimism

Phil tells his patient he has seen thousands like them and almost all of them get better. He will gladly use the prestige and reputation of the Mayo Clinic to reinforce the positive belief of the patient – but that’s not necessary, he says. The important factor is the belief the practitioner has in the patient. He lets his patients experience small improvements, with other patients and within themselves. He adds this as ‘proof’ of their progress towards recovery.

I support my patients in a similar way. I tell my patients that they are in my favourite category, that I get more pleasure from caring for traumatised patients and showing that they can have a safe, comfortable and joyful experience, than any other type of patient. My attitude conveys that I’m fully expecting a good experience for the patient, not a trauma.

Informed consent is a tricky issue, especially as patients are highly suggestible (see next section). I learned a nice idea from the Cleveland Clinic, which they called ‘informed hope’. Practitioners have a legal duty to inform patient of serious risk; for a spinal anaesthetic I’m obliged to warn the patient of the (very small) risk of nerve damage and paralysis, and the commoner complication of post-dural-puncture headache, which can be severe.

I follow this up with ‘informed hope’. I tell my patients that I have been doing spinal anaesthetics for twenty nine years and I have never seen a patient with a serious or permanent complication in my whole career. For the headache, instead of the 1% chance of he headache occurring I ask them to focus on the 99% chance of it NOT happening. ‘What you hold in your mind, is what often comes true in your body,‘ I say.

 

9. Use suggestion

Phil didn’t mention this strategy in his presentation but I’m pretty sure he’s doing it unconsciously, and powerfully.

When patients are anxious, they are highly suggestible. An example is the way I do informed consent about potential side-effects of anaesthesia. Doctors with a defensive practice will tell a C-Section patient that they may feel nauseated or vomit, develop severe shivering, get very itchy, and they may feel pain during surgery. It’s not the best way to make your patient feel relaxed and confident!

So I do it this way: ‘There are some discomforts and side effects you may experience during anaesthesia and surgery. The important thing is that we stay in close communication and you let me know if anything is bothering you. We have some really good remedies for side-effects and I’m going to have those sitting there on the side, ready to use. But my intention is that you will be relaxed, comfortable and smiling throughout the procedure and at the end, the remedies will still be sitting there, unused.’

I am being very deliberate in painting a picture to enhance the power of suggestion. In fact, by the time I’ve completed my pre-op consultation with the patient, we’ve created the perfect C-Section in our minds together – so it already exists. ‘The job in the OR will be easy!’ I say.

 

10. Use the power of personal presence

Phil didn’t mention this in his list of principles but his powerful presence was felt by all in the conference hall.

The trick to bringing your presence to each consultation is to be deeply mindful, conscious, present, and purposeful. This last point verges into the realm of spirituality – that deeper sense of identity, connection and purpose. I don’t equate spirituality with religious faith or practice – I have no religious affiliation – but I do think my work with patients is sacred.

I was grateful to receive this unexpected letter from a patient, many months after her surgery:

We met many months ago, you in the role of anaesthetist, me as patient…

Thank you, thank you, thank you for the all-encompassing experience of being fully met – Presence, level eye contact, pace, tone of voice, physical touch ….I could go on and on. The experience is beyond words. I cannot underestimate the importance of being received in that way at that time ..and then the flow into the operating theatre …feeling so totally safe and at ease.

I cannot help but wonder what impact that has on all present, the surgery itself and post-surgical recovery and beyond. That experience resonates within still.”

Scientific research tells us that this kind of compassionate presence directly affects the patient’s physiology and stimulates a wide range of healing mechanisms that lead to better clinical outcomes (see our info-graphic for a summary). We rarely have the privilege of knowing just how much this healing presence means to our patients on an emotional level. I was so touched to receive this letter from my patient – who was not someone I remember, just a ‘routine’ case in the OR many months before.

 

Summary

So there you have it, ten practical steps on the way to a healing consultation:

1. Choose your attitude
2. Validate the patient’s concerns
3. Agree on common goals and outcomes, set intentions
4. Affirm the patient
5. Help them understand
6. Plan for recovery with specific steps
7. Tell the patient, ‘You are not alone!’
8. Provide optimism
9. Use suggestion
10. Use the power of personal presence

I’m grateful to Phil for his inspiration and I must say meeting the man was a pleasurable and fun experience. I’ve no doubt his patients love him! You can learn more about his work here.

We’d love to hear, in the Comments section below, how people apply these principles in their own field of practice. Our belief is that they are universal.

 

7 Responses to “Ten practical steps towards healing consultations”

  1. Cecilia Wood says:

    Thank you for the informative article illustrating important communication techniques that everyone in health care should be taught in their respective curriculums. Motivational Interviewing by Miller & Rollnick teach many of the same principles to engage and prepare people for change. People are engaged and supported as they are assisted to develop their own plans to meaningful change any facet of their life but particularly related to chronic disease management and behavioral health. Integrative Medicine has adopted these principles and it is my hope that all health care practitioners will seek to incorporate them into their practice.

  2. Phil Fischer says:

    I am very grateful to Robin for documenting and expanding on my comments. I love what he is suggesting! And, this blog has inspired lots of good discussion in the United States – with more suggested steps toward success with patients with “functional” disorders. Someone suggested “be real” – clearly, we must be genuine in working with patients and must not seem simply to be applying techniques to them. Another person has suggested “use humor” as another key step to helping people. I look forward to reading more good comments from others of you.

  3. Patricia says:

    These points together with a demonstration of each would make a great video!
    Thx Robin!

  4. Janet Peters says:

    This is great work!
    It would be great to include such concepts in work on Adverse Childhood Experiences with children
    Janet

  5. Dear Robin,
    I’ve read this blog with great interest and much appreciation. It ought to be read by every practising doctor. The contrast you provide with the all too common ‘norm’ is illuminating and astonishing.

    Keep up the good work. What you are doing really is having a wonderful effect.

    Love.
    Dad.

    • Robin says:

      Thanks Dad! I’m hoping the widespread interest in this article will result in an academic paper based on the same framework, for publication in a peer-review journal 🙂

  6. Kim Evans says:

    Thank you for succinctly describing a holistic, integrative medicine visit! I love it! I’ve always taught the nurses that come to shadow me that intention (which is an energy) is an intervention – one of the most powerful that they can use! Thanks for articulating it so clearly!
    Love,
    Kim

    PS. Ellie just told me that she’s coming to New Zealand for her honeymoon. What a wonderful experience for all of you!!! I was so excited for all of you.

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