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January 28, 2019

Nice doctors really do finish first. (At least on patient outcomes.)

Daily Briefing

    Editor's note: This popular story from the Daily Briefing's archives was republished on Dec. 19, 2019.

    Read Advisory Board's take: This study shows why we need to bring the 'art' back to medicine.

    "The simple things a doctor says and does to connect with patients can make a difference for health outcomes," Lauren Howe and Kari Leibowitz, social psychologists at Stanford University, write in the New York Times' "Well."

    What the research says

    First, Howe and Leibowitz point to a study conducted at Stanford, in which Leibowitz and colleagues compared patient outcomes between a doctor who was reassuring and a doctor who was not.

    In the study, for which the authors recruited 76 participants, researchers pricked participants' forearms with histamine, to induce an itchy reaction.

    One group of patients was seen by a doctor who "examined them without saying much," Leibowitz and Howe write. The other group of patients saw a doctor who told them, "From this point forward, your allergic reaction will start to diminish, and your rash and irritation will go away."

    According to Leibowitz and Howe, the study highlighted the power of a physician's words to ease a patient's symptoms, as those seen by the latter doctor "report[ed] that their reactions were less itchy."

    But even still, Howe and Leibowitz note, "as anyone who has been on the receiving end of a terse 'You're fine' knows, it's not just what you say, it's how you say it.'"

    To speak to that point, Howe and Leibowitz cite a study conducted by Howe that "assessed whether the same words from a doctor influence patients differently depending on how warm or competent the doctor seemed."

    In this study, too, researchers gave participants a histamine skin prick, to induce itchiness.

    One group of patients saw a doctor who was "glued to the computer screen" and "didn't bother introducing herself." This doctor "stumbled through some of the procedures" and had a "messy exam room." Another group of participants saw a doctor who had a clean office and "acted both warm and competent," Howe and Leibowitz writes. The doctor smiled, chatted, made eye contact, and referred to the patient by name.

    Doctors in both groups gave the participants an unscented hand lotion that they said was an antihistamine to reduce the itching. "Decades of robust literature on placebo effects demonstrate that, even without any active ingredients, this cream should reduce the allergic reaction," Howe and Leibowitz write. 

    However, the study found "the placebo cream reduced participants' allergic reactions only when the provider projected warmth and competence."

    To better understand how competency played into the equation, the researchers had another group of patients see "a provider who seemed highly competent but remained businesslike and distant." These patients, Howe and Leibowitz write, "did not respond to the placebo cream as much as when the provider acted warm and competent."

    Howe and Leibowitz note, "All of this research suggests that doctors who don't connect with their patients may risk undermining a treatment's success." They add, "Doctor-patient rapport is not just a fluffy, feel-good bonus that boosts Yelp reviews, but a component of medical care that has important effects on a patient's physical health."

    How time-crunched doctors can connect with patients

    While some doctors may feel too busy to build individual relationships with each patient, Howe and Leibowitz note that direct eye contact and asking the patient their names are effective ways to foster the doctor-patient relationship without adding minutes to the exam.

    "We often think the only parts of medical care that really matter are the 'active' ingredients of medicine: the diagnosis, prognosis and treatment," Howe and Leibowitz write. "But focusing only on these ingredients leaves important components of care underappreciated and underutilized. To really help people flourish, health care works better when it includes caring" (Howe/Leibowitz, "Well," New York Times, 1/22).

    Advisory Board's take

    Veena Lanka, MD, Research Partner

    The findings of this research come at a time when the notion of delivering a positive 'patient experience' has become a much maligned phrase among providers. To be fair, patient experience, as it is measured today for regulatory purposes, does have significant shortcomings (as physician perspectives reveal here and here). But this begs the question: Does improving patient experience actually benefit the patient's health, or does it simply placate them just enough to ensure they don't go shopping for care elsewhere?

    “'Patient experience' has become a much maligned phrase among providers”

    This study adds to a growing body of research that makes the case for patient experience being a critical consideration for patient health and a worthy area of aspiration for all providers. Patients don't simply define a positive healthcare experience as the availability of amenities, speed of service, and the other comforts we've come to expect from hospitality industries such as restaurants, hotels, and (dare I say!) airlines. While these hospitality measures certainly help smooth an otherwise difficult stay and perhaps add a measure of dignity to the whole visit, they are simply icing on the cake.

    Rather, the actual "cake" patients are looking for lies in the conversation with their care team and, in particular, with the physician they perceive as in charge of the critical decisions about their care. That is, patients are looking for more than amenities, or even whether the physician had the best surgical technique that ensured rapid post-op recovery. They are scanning to assess whether physicians demonstrate care and concern for their wellbeing beyond the current interaction or episode– by assessing the verbal and physical cues we humans view as indicators of warmth, concern and competence. The physician's role, then, is a dual one: To provide the best evidence-based treatment possible and act as 'influencer-in chief,' building confidence in that treatment plan and preparing the patient for potential obstacles and questions that could arise downstream. As Dr. William Osler more succinctly said: "The good physician treats the disease; the great physician treats the patient who has the disease."

    “We need new language, tactics and tools for providers to bring more of the 'art' back into their practice.”

    This is not a new concept by any means, as the age-old emphasis on 'bedside manner' which is drilled into medical students reveals. But perhaps in the age of digital documentation, automated predictive care algorithms, and evidence-based medicine, where the 'science' portion of art and science of medicine is over-emphasized, we need new language, tactics and tools for providers to bring more of the 'art' back into their practice. Physicians themselves would likely welcome this shift, as many attribute growing burnout among physicians to the lack of time and autonomy to practice the 'art' and 'joy' of medicine more.

    Download the slide deck from our recent webinar to learn how your peer organizations are sharing this message with providers—and how you can re-engage physicians in your system's efforts to create a positive patient experience.

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