The art of making connections

By Allison Evans, Assistant Managing Editor, October 1, 2021

With increased demand for dermatologic care, dermatologists are being pressured to squeeze more patients into their schedules. While tweaking processes and interactions to keep patients flowing may optimize patient volume, it may come at a cost to the patient experience in that patients may perceive the physician to be rushed, uncaring, or ambivalent. 

While the topic of bedside manner often takes second stage to clinical training, studies have shown that the ability to communicate honestly and empathetically with patients has a powerful effect on the success of a medical practice. 

This month, dermatologists discuss what’s at stake in fostering strong physician-patient relationships and share how forging those connections can increase professional satisfaction, patient outcomes, and overall practice health.

Long waits, short visits

“How we interact with our patients is especially important for us as dermatologists because our visits are often so short,” said Indiana dermatologist Dara Spearman, MD, FAAD. “One of the top complaints against dermatologists is that we seem rushed,” she added. “We see a great deal of patients and we’re trying to get as many patients in as possible, but we still want them to feel that we’ve taken enough time.”

“A lot of times I can walk into a room and know immediately that it’s a seborrheic keratosis,” Dr. Spearman noted. “But even if I know that, I still ask them about the issue and let the patient talk about it. I may even use my dermatoscope to show that I’m taking time and effort into thinking about their care,” she said. 

“Someone once advised me to sit down with each patient as it helps them feel like I’ve taken more time with them. I’m not always able to do this because of the way our rooms are set up, although if I know I will be seeing a patient who really needs my time, I will sit. We also use scribes so that I can make eye contact and focus my attention directly on the patient,” she said.

Entering and exiting the room

“Sometimes physicians are so rushed that the art of the introduction is lost. When I walk into a room, I always address the patient by name and introduce myself,” Dr. Spearman said. “I also like to repeat back why they’ve come to see me so that they know I’ve looked at their chart.”

“Depending on how confident I feel about the patient’s name, I will specifically ask them about the pronunciation and preference of how they want to hear their name,” said Pennsylvania dermatologist Lisa Pawelski, MD, FAAD. “We write it phonetically at the top of our paper chart, so that when they hear their name, they feel welcomed.”

“Occasionally, we have days where patients experience longer wait times. If a patient has been waiting, I’ll always come into the room and apologize for the wait to diffuse angry people,” Dr. Spearman said. “I also let those patients know that I will ensure they have all the time they need.” Before leaving the room, she always asks if there are any other skin lesions that concern them. “I specifically avoid saying, ‘Is there anything else I can help you with today?’ to keep the visit focused and limited,” Dr. Spearman explained. 

Sometimes, dermatologists are faced with patients who have a long list of concerns that may deviate from the original complaint. According to Part I of a JAAD CME activity on compassionate care, when a patient has steered the conversation away from the focus of the visit for a prolonged time, it might be effective for the physician to tactfully ask, “Would it be okay if I interrupt you to ask some specific questions?” (2013 Mar;68(3):353.e1-8).

Dr. Pawelski credits pediatric dermatologist Neil Prose, MD, FAAD, at Duke University, for much of what she has learned about physician-patient relationships. “He taught us that even if you’re rushed and even if you’re an hour behind, never leave the room without saying, ‘Is there anything else that’s important for you to tell me or ask me today?’ It can be painful when you’re an hour behind, but I try never to leave the room without asking.”

Compassion, empathy, honesty

“Because of the visual nature of so much of what dermatologists treat, it’s not unusual for patients to cry in our office,” Dr. Spearman noted. The signs can be obvious or more subtle. “Sometimes we have to stop what we’re doing to reassure patients and offer them compassion. If you don’t pause every so often, you miss out on those key signs.”

Dr. Pawelski, who is a solo practitioner, views her job as a physician as a personal ministry more than a business operation. “This sometimes surprises people,” she said, “but you can be the smartest person in the world, making the rarest diagnosis, but if the patients we see feel uncared for, then we have failed.”

“I’m direct with my patients, as it helps them understand my expectations,” Dr. Spearman explained. “The physician-patient relationship is a two-way street. In the same way that patients have expectations of their physicians, we have expectations of our patients.”

“You never know what you might say to someone — or what they may say to you — that might make a difference down the line.”

It’s important to remain humble, admit uncertainty, and engage the patient in the treatment plan, Dr. Pawelski said. “Often, patients will say to me: ‘You just gave me three options. Which one should I do?’ I’ll say to the patient: ‘That’s because there’s not a clear right answer. Here are the pros and cons of these different approaches.’”

“It’s helpful for patients when we can admit that we don’t know certain things,” Dr. Pawelski said. “There’s a lot we don’t know. It’s certainly less efficient to take this path, although efficiency shouldn’t be the end goal, even if that’s what is compensated the best.”

Dr. Pawelski maintains a social history for her patients that she reviews before each visit. “When I walk into a room, I know if it’s a professor that expects a high-level conversation or whether it’s a person who lost their spouse last year and may still be dealing with that. Maybe it’s a person struggling to take care of a partner with Alzheimer’s. Being aware of the patient’s social history colors how I’m going to start the conversation.”

Human connection

“I like people,” said Eliot Mostow, MD, MPH, FAAD, chair of the dermatology section at Northeast Ohio Medical University. “You never know what you might say to someone — or what they may say to you — that might make a difference down the line.”

“Sometimes my conversations do cause me to run behind, but I like to connect with people, and I think it’s important for the doctor-patient relationship,” he said. “I talk a lot about FISH! philosophy with my staff, which uses the Seattle fish market as a model for how to be happy and successful on the job. Their mantra is ‘have fun; attitude is everything, make their day and pay attention.’” 

From a customer service point of view, Dr. Mostow appreciates the part of FISH! philosophy that emphasizes making someone’s day. “Every encounter you have with somebody is a chance to make their day. Part of this is treating their acne or psoriasis, or finding and treating a skin cancer, but it’s also about noticing that the patient has a necklace with an anchor on it. I might ask that patient about boating. Or maybe I’ll comment on a patient’s Mickey Mouse watch, or whatever it might be,” Dr. Mostow explained. “It’s about paying attention to things around you.”

“Sometimes in the office when I’m running late and a patient is taking a lot of my time, I catch myself grabbing the doorknob,” Dr. Mostow said. “But I try to remember to notice these gestures and what they can convey to patients. There is an art to closing the conversation with patients in a reasonable way.”

“I’ve also empowered my staff to pull “‘the emergency brake,’” Dr. Mostow said. “If I walk out of the room and they realize that the patient may have more questions or may be dissatisfied, anyone has the right to pull the brake and bring me back into the room.”

Health outcomes

While most physicians are likely to agree that an empathetic and honest relationship with patients is beneficial, there are also data to support that it affects health outcomes. A review of 13 clinical trials published in PLOS One found that when doctors were given training to provide more empathetic and caring interactions, patients typically fared better in their efforts to lose weight, lower their blood pressure, or manage pain (2014 Apr 9;9(4):e94207). 

“Taking the time to understand our patients can make all the difference in their treatment. An African American patient may see a dermatologist about a scalp issue and receive a shampoo that’s prescribed daily,” Dr. Spearman said. “Well, we don’t wash our hair every day, and the patient may not feel comfortable saying that to the physician.” 

“Trust is a critical piece of patient compliance,” she added. “If your interaction with a patient causes distrust, the patient will not follow your directions, which will affect patient outcomes.”

According to a study in the British Journal of Dermatology, the likelihood of overall patient satisfaction was found to be significantly and independently increased by the physician’s ability to give explanations and show empathy for the patient’s condition. The lowest level of satisfaction was found among patients whose symptom-related quality of life was worse than the clinical severity rated by the dermatologist (2001 Oct;145(4):617-23). The study showed that improving a physician’s interpersonal skills can increase patient satisfaction, which is likely to have a positive effect on treatment adherence and health outcomes.

Knowing how to provide information and instructions that patients will understand and remember is also an important component of establishing trust and getting patients to comply. Authors of a JAAD patient education CME activity recommended saying the phrase, “What I’m about to tell you is very important,” which can improve patient recall and compliance (2013 Mar;68(3):364.e1-10).

Once a patient’s attention has been gained, the JAAD authors emphasize the importance of using clear and simple language and explanations. It can be helpful to assess patients’ baseline understanding of a condition or treatment plan by asking them what they already know so that the information can be tailored to the individual.

A COVID-19 shift

The COVID-19 pandemic has played a role in shaping how physicians interact and engage with patients. For Dr. Spearman, COVID-19 has impacted her use of physical touch. While a handshake may have taken place pre-pandemic, people are used to doing fist or elbow bumps now. “I warmly greet them with good eye contact,” she said. While handshakes may have faded to the background for some, this doesn’t mean physicians have to be distant from patients. “Human contact is nice, whether it’s a hand on their shoulder or gentle tap on the leg,” Dr. Spearman said. 

“Patients have been more distant as well, and many are expecting it,” she added. “I do, however, make sure to wash my hands right in front of the patient as soon as I come into the room, which, I think, helps them feel more comfortable.”

Masks are another potential barrier to connecting with patients, but they don’t have to be, Dr. Spearman said. “While masks can pose some communication issues, even behind the masks, if you’re smiling, people can hear it in your voice and see it in your eyes.”

Webside manner

“Webside” manner, the virtual equivalent of bedside manner, has become a point of focus for many physicians who have come to realize that good bedside manner doesn’t necessarily translate seamlessly to virtual visits. 

“Just as bedside manner encompasses much more than one’s appearance in person, webside manner transcends how one looks on camera,” said Neel Naik, MD, director of emergency medicine simulation education and an assistant professor of clinical emergency medicine at Weill Cornell Medicine during a webinar on virtual care. “It’s also about empathy and understanding the totality of the encounter.” 

Starting off

When Dr. Pawelski begins a virtual visit, she breaks down the staging of the visit. “I typically show patients that I’m in my office and then ask them where they are located and whether anyone else is in the room with them. This is a simple way to get the visit started and a good way to access information you may need to document.” 

Instead of the traditional, “What can I help you with today?” that might take place during an in-person encounter, a simple “Thank you for inviting me into your home today,” is another option for introductions that acknowledges the new format.

Some physicians prefer to begin virtual visits by acknowledging its limitations and asking about how the public health emergency has affected the lives of their patients. While this is a simple way to show empathy and care, it may also provide valuable clues to understanding a patient’s condition. 

Privacy

While virtual visits can take place outside of the physician’s office, the patient needs to feel that their privacy is being respected. For this reason, physicians may choose to conduct virtual appointments from the office. If the visit is conducted from home, it’s helpful for physicians to have a private, sound-proof or well-insulated space to avoid distracting background disturbances. To help keep the experience synonymous with a brick-and-mortar visit, physicians should consider dressing as they would in the office.

Technology

“One of the nicer aspects of virtual visits was that I didn’t have to wear a mask,” Dr. Pawelski said. On the flip side, a whole host of technical challenges could arise and alter a patient’s perception of the visit. “We had to learn to place the phone so that the microphone was positioned correctly. Also, I have to ensure I’m not backlit so patients can see my face.” 

If a patient is struggling with camera angles, lighting, or any part of the virtual setup, the physician should help guide patients through the troubleshooting process, knowing when to transition from a video visit to a telephone visit when needed, Dr. Mostow said.

Nonverbal communication

Eye contact is also important for virtual visits, although it’s easier to misstep in a virtual environment. While tempting to look at the patient’s eyes on the screen, physicians should practice staring directly into the camera. 

If a physician needs to look at another screen or look up information that would take attention away from the camera, be sure to communicate exactly what’s being done so the patient doesn’t misinterpret the lack of eye contact as disinterest. “Even for virtual appointments, I use scribes,” Dr. Spearman said, “so that I can provide the patient with my full attention.”

In addition to maintaining eye contact, the ability to express empathy through nonverbal communication is key to establishing a successful connection with patients. This may include nodding instead of saying “mmhmm,” leaning forward to show attention and concern, or placing a hand across your heart when the patient is expressing distress or sadness.

Patient education

“I always ask if the patient has a pencil and paper,” Dr. Pawelski added. “In the office I have bins and bins of patient handouts. For virtual visits, I may ask patients to write something down, like the name of their condition or the name of what I’m prescribing. I may draw diagrams and text them, like where a particular steroid is located in the steroid hierarchy and whether it can be used on their face and neck.” 

“I’m providing them with the same content that I would deliver in the office, but I sometimes have to put extra thought into how I’m going to relay this information to them,” she said. “Will the patient write it down? Am I going to text them a picture? Do I need to mail them a whole packet?”

Closing the visit

Knowing how to sign off from a virtual visit can be challenging. End every visit by making sure patients have a clear treatment plan and have no further questions. Also, it’s a good idea to give them a way to follow up if questions arise down the road. Lastly, a simple gesture like waving goodbye at the end of the visit can leave the patient with a more positive perception of the visit.

While some physicians have expressed concern about the impersonal nature of virtual visits, patients are generally satisfied with this type of visit. “Those of us who didn’t do telemedicine much before the pandemic learned that — even virtually — we could really help most people and connect with them at the same time,” Dr. Mostow said.

Additional DermWorld Resources