S7E18: Building Trust and Connection in the Doctor-Patient Relationship

Austen: I'm just out here sharing patient stuff on accident.

Alizah: No. I'm doing the same too. I was like, "Oh, yeah, we're good." Okay, from the beginning. Take three.

Austen: Take three. Whichever one it is. Welcome back to the "Bundle of Hers." This is Austen, for those who haven't heard my voice in a while. I'm one of the co-hosts of the season. And joining me today, we have our other co-host, Alizah.

Alizah: Hello.

Austen: We are so excited for today's episode. We will be discussing kind of how we can foster and cultivate genuine relationships with people in general, but also with patients.

Well, first and foremost, everything that we discuss today is going to reflect our own personal views, not the views of the institution with which we are associated, whether that be through our medical training or our profession or our job, just to get that out of the way. These will all be our personal views.

This is a topic that I really wanted to cover just because I feel like so frequently in third-year, I've kind of been reminded of the personal aspect of medicine and how important that is and how much that aspect can impact care. And so I wanted to take an episode to really focus in on the humanity of medicine.

But also, we have a special guest on the episode today, Dr. Rana Jawish. She was my attending during my psych rotation, and she is also another one of these people who is super gifted with connecting with other people.

I feel like so frequently on the rotation, I would go in and talk to a patient and be like, "Man, hopefully what I said resonated." And then she would be there, and instantly, it was . . . Seriously instantaneously. She would go in, and she would talk to a patient, and they would connect, and you could tell that the patient felt cared for and understood.

So a little bit about Dr. Jawish. She is an assistant professor in the Department of Psychiatry and an adjunct assistant professor in the Division of Epidemiology, Department of Medicine, and the Department of Obstetrics and Gynecology at the University of Utah School of Medicine. She not only is such an amazing physician, but truly a powerhouse of a human being.

So thank you so much, Dr. Jawish, for coming on the episode and being willing to talk to us.

Dr. Jawish: Well, thank you very much, Austen, for this nice introduction. And I'm so delighted that you found me personable on the rotation. That's the goal when we try to teach and mentor medical students. Actually, part of our job is to teach you by communicating the knowledge, but also teaching medical students by modeling for them. So thank you very much. I'm honored.

Austen: I think what you talked about, Dr. Jawish, makes sense. And I feel like having learned from you, being your student for three weeks, that definitely came through. I feel like I am grateful that I had the chance to learn from you, directly observe you, see how you work, and learn that way. I think it was invaluable.

I also think it's really telling that one of the attendings that I most admire when it comes to cultivating genuine interest in other people, genuine patient-provider relationships, is a psychiatrist.

I feel like so often it's easy to make medicine overly clinical, to kind of separate the human aspect of the patient from the patient themselves. But I think it's a lot harder to do that in psych. And so I think it makes sense why this is something that, one, is so natural for you, and this is a field in which you thrive. And so I'm excited that you're here to join us for this conversation.

Well, I guess to kick off this discussion, I would love to get both of your inputs about just kind of making genuine connections with people you've just met in general.

While I do really care about other people, and I want that to come across, sometimes I feel like it can be tricky to get that point across really rapidly, right? Sometimes it may take a little bit longer to feel like you connect with someone and to get them to a place where they feel like they can trust you and rely on you.

And that's oftentimes not a luxury that's afforded to us in medicine, right? I mean, I know Alizah and I are new to this, but oftentimes you have to kind of build that therapeutic relationship really quickly so that you can work efficiently with your patients.

Alizah: It can be very intimidating because I think in healthcare, and especially as a medical student, you kind of walk into the space and you're like, "I am the least of these people." And these questions you've probably been asked before, and I have to go report back, and it can really be intimidating.

Because of that wall of maybe fear, there's this very natural inclination, I think, to lean inwards and kind of focus on, "Well, what things am I thinking about, and what do I want to present to my attending after this visit?"

And one thing that I've just defaulted to, to kind of get me out of that space, is I go in and I'm like, "Well, I'm just going to pretend this is a friend or a person or someone who I'm really close with that I would just chat about anything with." Even though I do need to go present this patient in about 10 minutes and I need to have a differential and a workup, I think about, "Okay, what can I do to make sure that this patient feels comfortable?"

And something that I also keep in mind is my attendings and my residents are entrusting me to talk to this patient, right? So I really want to honor that. And it doesn't fall past me that it's an honor to take care of patients that are not mine, to be trusted that way.

And so when I kind of enter or the patient encounter is started, I just really want the patient to know . . . and I try to express this through my body language and the way that I ask questions. It's like, "I am so excited that I get to be part of your day today, and I want to make sure that this is the best encounter you've had with me. I want you to feel like, 'Man, what a great person to interact with.'"

People come in with their own issues and their own problems, and I think we've all had experiences where the patient is not so excited to see us. That's a different conversation, I feel like. But you can always walk in, I think, with a sense of excitement to better someone's day or even just that moment to know that you care about them.

Austen: Definitely. I love that outlook, right? We have, first of all, the privilege to be part of someone's care. A lot of times when people are in the hospital, it's not the best day of their lives. It's generally a pretty bad day. But we have the opportunity to make them feel more comfortable, make them feel seen and heard, and to take those concerns seriously so that hopefully they are reassured that we're going to take care of them and that we're going to be an active part of a solution to whatever is going on. I love that.

Dr. Jawish: I like what Alizah said about your attitude when you start the encounter. The reality is, as a medical student yourself, you have a lot of pressure. The expectation from you is to get important information and kind of reformat this information in a way that you then produce a reasonable presentation and a differential diagnosis and, hopefully, an assessment and plan. And all these responsibilities and pressure for you serve as kind of an obstacle because you are consumed by the tasks that you want to do.

The important part that Alizah said is to reframe the situation, reframe the encounter, and your objective from the encounter. Yes, you are still required to collect data that will help formulate a differential diagnosis and assessment and plan. But the most important piece is the human being in that room.

And I think we sometimes forget in medical school and the teaching process the patient is a case, where it's not. It's a human being. I like the idea that you just reframe it, and this is an encounter that I'm going to try to enjoy and be part of the solution.

I totally agree that when we see a patient in the hospital or even in the clinic . . . Most of the time in the hospital, they are more in acute setting and they are not feeling well. And when they are in inpatient psych, they are there for a reason. Most of the time it's a crisis. Sometimes they are aware of what's going on, and sometimes they are unaware. They are in a mental state that they are not aware of what's going on.

So understanding the human side and this is an actual human being with a family, with people who care about them outside, and treating them with a humanity is very, very important piece to keep in your mind.

The other part of all of this is, I think, realizing the power dynamic also. You are a medical student. You think that, "Oh, I'm low level here," but you are coming to this encounter, and believe me, the patient is receiving a power dynamic. They are feeling that you somehow have some authority over them. And it's more real with the attending.

Austen, when I go in as the attending, to this day, there is a huge power dynamic. So, immediately, I try to address that by being genuine, being humble, without saying it, telling the patient that we are partners in this, and try to alleviate that kind of gap in the power dynamic.

In reality, especially in mental health, you are going to make decisions for the patient sometimes, especially if there is a safety concern, if there is a specific medical or mental health need. We sometimes have power over these people's life and that's . . . Imagine yourself in that position.

So keeping in mind that there is a power dynamic will help you manage the situation and actually help the provider and medical student realize, "Oh, let's not get frustrated, because there is the situation here that the patient probably is feeling that and reacting to it."

It's very delicate. Just go back to the human, that this is a human being. It's not a case. It's not just a case in my day so I can learn, or I can move on in my career. This is someone's life. I find this always grounding for me. And even in the most challenging cases, it helps me stay calm, stay collected, and be able always to reset.

Alizah: Wow, that's so powerful. I especially am just taken aback by the idea of partnership in this healthcare, partnership in taking care of you, where this is a team effort. I'm curious what that looks like for, I guess, both of you, Austen and Dr. Jawish. Of course, you said it, and that, I think, almost eliminates any sense of power dynamic. But how does that look like with boots-on-the-ground type of . . .

Austen: I feel like I've had, like I've mentioned before, what I consider the privilege to learn from Dr. Jawish, and I would literally see her . . . We would go in to talk to a patient, and she would say, "We are partners in your care. I am not here to tell you what to do, to boss you around. I am here to help you get better. I am here as your partner to help you get better."

And I think I learned so much from that example. Really just explicitly saying, "We are partners. I'm not someone that you should feel like you need to fight or you need to defend yourself to. I'm really just here to help." And so I think that's been super helpful.

Something that I've been trying to implement recently is . . . Right now, I'm on adolescent psych, which has been fun, and I feel like adolescents are fun because everything they feel is heightened. Being a teenager as my own self was hard enough, but then a lot of these teenagers are inpatient psych, they are hospitalized away from friends, away from everything that they know, and so everything they feel is 10 times more.

And so I have similarly tried to establish that rapport with patients. Oftentimes, over the last couple of weeks, I've asked patients what their goals are. Most of them are like, "Oh, I just want to get out of here," or whatever. And typically, whatever they say, I try to validate, but then also be like, "You know what? I've got the same goal. We are on the same side. My goal is also for you to get out of here. I just want to make sure you're safe before that happens."

And so I think, for me, that's kind of my own way of saying that, "We're partners in this. Your goals are shared with the rest of your team." It's not like we're plotting against them. We truly do want them to be healthy. We want them to be safe.

I think once you establish a shared goal with a patient, that is a way to take away some of what can seem like a barrier of a power dynamic, right? It's no longer the patient versus their treatment team. It's like, "Okay, we're all on the same team. And even if the members of the treatment team have more power, they're helping me. They're working for me. We are working together."

Hopefully, that's something that the patients have found helpful. I feel like it's been cool to implement that, and I think it really does kind of shift that dynamic when you have a patient interaction. It feels more genuine, and I feel like the patients are typically more willing to kind of meet you where you're at as well.

Dr. Jawish: Well, I'm so proud of you, Austen. I think one thing also is, believe it or not, all these techniques that I use are grounded in science and literature. Yes, we are all supposed to be genuine, human, humble in medical field, and I would assume that that's the case. There are a lot of literature and interviewing techniques, and that's why I told Austen that it's technique. You start practicing it, and then it becomes natural. And I would argue that these techniques and skills are essential for any patient interaction.

One of my mentors, he's an OB/GYN. He jokes with me sometimes. He says, "Oh, psychiatry is just 50 years ahead of all other medical specialties, because in other medical specialties, we practice psychiatry even without knowing it."

Talking to a patient in a therapeutic way is psychiatry. There are a lot of validation techniques that we use every day that anyone can learn. Motivational interviewing is a very useful tool that as an addiction psychiatrist, I practiced. I was taught by my attending. And actually, you can use motivational interviewing on everyone, even your partner, if you want to get something out of it.

So these skills are . . . there is a science behind them. So it's not just, "Dr. Jawish is being nice." No, there is technique and skills that we can teach to all medical students.

Eliminating "but" between sentences is a very powerful tool. And I got taught this from a patient early in my residency. I was talking to the patient, and I said a sentence, and I then said, "Oh, but you are doing better." And the patient told me, "See, you said 'but.' You just canceled the previous sentence, just to let you know." And that was a very powerful lesson from a patient that actually taught me a lesson early in my career.

Since that time, I try every time not to use "but" in my interaction with patients. So if I say, "I care about you, but I'm going to keep you today in the hospital against your will," compare it to, "I care about you, and I think staying in the hospital one more day might be helpful."

The other technique is repeating the exact same words that the patient said. It shows the patient that, "I'm hearing you." That is very powerful and you can immediately see the patient deescalating. I'm telling them without telling them, "I heard you. Your words matter."

So these techniques are simple and easy to learn, and they make a huge difference. And I would argue that once you practice them, they become part of your communication profile. Without effort, it becomes you.

Austen: Yeah, definitely. I loved how you even almost offhandedly made that joke and were like, "Oh, you could use this with your partner." I feel like so many of the skills that you mentioned and so many of the skills that I feel like I've been able to learn while on my psych rotation, I can use in basically any facet of my life.

It's been so cool being on psych and seeing that so much of how we connect to other humans has been studied, which means that we have a lot of information about how we can more effectively connect with others, how we can more effectively communicate with others. And I feel like that helps you no matter where you end up in medicine and in life. So thank you for bringing that up. That was awesome.

And it reminds me of a patient encounter that we had. We went to go see a patient who did not agree with the treatment team's decision on how to proceed, how to manage what was going on. We went in, and through having an open, honest conversation, the patient ended up agreeing with the treatment team and the plan, and we were able to proceed from there.

That sounds maybe a little vague, but I feel like the most important thing was seeing Dr. Jawish interact with this patient, making sure that they were on the same physical level, sitting eye to eye, making sure that she took the time to explain details to them, give them the reassurance that they needed, and really treat them as a person who was dealing with something.

That's what's happening at the hospital or at clinic or wherever you're seeing your provider. You're there because you're dealing with something, and you're probably scared and you don't know what to do. She took the time to give them reassurance, to make sure that they felt seen and heard, and ultimately come to a decision together.

Dr. Jawish: One thing that Austen mentioned is mirroring patient's attitude, body language, communicating to patient at that point, especially when there is disagreement on the treatment plan. That's the time to show the patient that you are on the same page and to communicate verbally and non-verbally that you care about them and you see and hear them.

So sitting in a position that matches their sitting position. If they are sitting, I'm sitting. If they are standing, I'm standing. Matching their voice tone, matching their attitude. It's not reasonable when the patient is angry or upset that the provider is speaking with a, "Oh, yeah." The provider should be showing the patient that, "I see you're anxious, you are not happy with the decision."

So you address the patient in all appropriate ways verbally, non-verbally, body position, your sound, your tone. All of this actually is skills that are part of the validation and communication skills.

The other part is the education. Education is very important. At that time, it's one of the ways to tell the patient, "We are partners in this," is to share your knowledge and to let the patient know exactly the evidence base, what knowledge you have to make that decision. It's very important to communicate clearly in a simple language, based on the patient education level, where they are at this moment.

I firmly believe that all patients have the right to understand their condition in the same way that we understand it. There is no reason to abbreviate the encounter into two sentences. "Well, you have a problem in your heart. Yeah, we need to do a couple of testing." What is the problem? What are you going to do? Explain to the patient in a very thorough . . .

This is your main focus in this encounter with patient. And it's very fascinating to me that in medicine sometimes you spend an hour with two consultants on the phone, like the psychiatrist, the cardiologist, the GI talking about this case. And then when we present it to the patient, it's a five-minute discussion where the patient is being told just a summary.

Some patients, they don't want to know, and that's fine. Then we respect that.

And when there are consequences, I find it very important to educate the patient. I always educate my patients on medication, even options. Just by educating them, they feel valued, and you can see immediately that they are, "Well, now I understand."

So educating the patient is a huge part of what could be done differently to gain more trust. How can they trust you if you don't provide the full picture?

Austen: And I think that was part of why I wanted to do this episode, right? At the beginning, I stated so much of our interactions with our patients dictates their care, and that is something that I have seen time and time again through third-year. I feel like if I learn anything third-year, that's probably going to be the biggest thing.

I think people are aware of what's going on around them. People know if they are having a genuine interaction with someone or if they're just kind of like a checklist on someone's to-do list.

Being a human is a good thing in medicine. Being a human is a good thing always, but it can add humanity back into medicine. Ultimately, that leads to better health outcomes, right? That leads to better patient care. That leads to increased patient trust in the medical system as a whole.

There is so much mistrust in the medical system, whether that be mistrust in larger systems like hospital systems, mistrust in pharmaceutical companies, but also mistrust in providers. There are patients who don't trust their providers. And one of the things that impacts patient trust in providers the most is feeling like a provider actually cares about them as a human being, having a good relationship with your provider.

We are in the business of healing humans, so it feels like a good place to learn how to care for humans and how to show humans that you care for them.

Alizah: What if we all had a Dr. Jawish? Can you imagine?

Austen: The world would be better, honestly.

Alizah: Everybody would be healed. How exciting. I can say I'm sappy, right? These concepts of motivational interviewing and these techniques are not sappy at all. They're interdisciplinary pillars, because that is what this is. This is care, this is humanity, and that's why these techniques work so well across the board.

I feel so sappy about that just because of the recent climate we're in, that someone felt cared for. Even in a professional setting, I think that's so touching. How do we demonstrate concern and care for our patients outside of just, "This is my duty. This is my profession"?

Something that I am guilty of is I love to talk to patients about their social life. I'm so interested in knowing, "Oh my gosh, this town is bigger than when you grew up in it? Tell me more about that." And then they'll go into how the lumber economy came in, and then the oil company came in, and I'm like, "Oh my. Wow." And these are things I never would have known because you can't read up on the history of a small rural town in Utah. No one is going to know that except for right here in this room.

Allowing the patient to lead the conversation is something that I really enjoy and find meaning in, but I also find that it's so effective, right? They will present their most chief concern. I can't speak from years of experience. I can speak from two weeks, right? But I feel like they come in and they almost have the diagnosis right off the bat, and they know why, and they know what their family history is. And so really just letting them take the driver's seat and me getting to go along for the ride. And of course, my attending is really doing the heavy lifting.

What I like to think of is saying, "I have genuine concern and care for you, and I do care about literally you as a whole. Tell me about your 17 dogs, and I'd like to know their names and pictures, please."

Austen: I think that's awesome. No, I think that totally makes sense. When you show genuine interest about a person, I think that comes through, especially if you, one, let them guide the discussion. I loved how you mentioned that. Not just assuming that something is their concern.

What's important to you might not be important to me, and vice versa. And so letting the patient decide what's important to them and what they need help with, I think, is a great tool to show a patient, "Hey, this is your thing. I'm here to help you and support you as best as I can. Tell me how I can do that." Giving them that autonomy back, I think, is such a powerful tool.

What this boils down to, this discussion, to me, is we get the chance to figure out what kind of providers we want to be. We get the chance to decide and explore the kind of people we want to be. This discussion and the themes of this discussion are kind of at the foundation of that, right?

There are tons and tons of doctors, and I truly believe that doctors care about their patients. All doctors, on some level, care about their patients. But I think it takes truly exceptional doctors who implement some of these techniques and some of these skills that we've talked about. It takes these kinds of skills to help transform a good doctor into an exceptional doctor, a good doctor into someone that people can trust, someone that people will go to with their problems, someone that people will be vulnerable with.

I mean, we touched on psychiatry especially being a sector of medicine where patients are so incredibly vulnerable with providers. And so we have so much opportunity to do good and to effect good in people's lives. Showing them that we care and that we're concerned about them is a great way to start.

Dr. Jawish: One last comment about the provider you want. I think thinking about that, what keeps you going when you wake up in the morning? You are going to do medicine for the rest of your life, hopefully. Ask yourself, "What will keep me going? What will keep me doing this for the rest of my life?"

And for me, I figured out it's making a difference. Just making a difference in people's lives. Waking up every day convinced that I'm going to make a difference today in someone's life, that's my source of satisfaction in my career.

Each one of us in this field needs to find a motivator. What motivates you every day? And it better be focused on patient care, on making a difference in people's lives, in knowledge, in the literature, in treatments, in access for patients, serving the underserved.

Whatever is your passion, focus on it, and then you'll find yourself working hard because it's not just giving the patient satisfaction. It's giving you satisfaction, and you will do great.

So thank you. Thank you for your nice words. Thank you for working with me. Thank you for all your hard work. Thank you for inviting me to this cool podcast, "Bundle of Hers."

Austen: "Bundle of Hers." Well, thank you both for contributing tonight to this episode of "Bundle of Hers." And thank you, listeners, for joining us. Remember that you can find us anywhere you podcast. We're @bundleofhers. We hope you join us on the next one.