A Relationship Built on Trust

A patient of Dr. T, an orthopedic surgeon, recently visited his office because the knee which he replaced seven months prior was still swelling and was painful at times. It was not like the first knee that he replaced for her, which was doing very well and was pain free. When she visited his office, he sat down near her at her level, as he has always done when she visits him in his office. He examined her knee and said that he sees that it is hot and swollen. He took an x-ray to make sure there is nothing wrong with the replacement knee. There was not. He then took a sample of the fluid on her knee, being sure that the knee is numb. He told her that he will have it sent to a lab for analysis. He will let her know what he finds. She is surprised when a few days later he personally called her with the results. He told her that there is no infection and goes on to explain that in his experience he has seen patients whose tissue near the surgery site stays tender for a while, causing swelling. He advised her that they should wait a while longer, a couple of months, as he thinks the issue will resolve itself by then. If not, he wants to see her again. She agreed because she trusts his judgement.

This is a real case. I use it here because it is a very good example of a physician being patient-centered and building trust with the patient. The patient responds positively to the physician because he has taken the time to build a positive, respectful relationship with her. He is empathetic with her situation.

This story is a very good illustration of the principle ‘Seek First to Understand, Then to Be Understood’, found in Stephen R. Covey’s classic business book, The 7 Habits of Highly Effective People. When Covey discusses this habit (Habit 5 in the book) he talks about empathetic listening, an important skill for any clinician and anyone else who provides a service to others. Covey relates that ‘communication is the most important skill in life.’ We communicate through reading and writing, speaking and listening. Each of you has spent hours in school learning to read, write and speak. There is little formal education for listening! To truly communicate with anyone we must be able to listen well. To be able to interact effectively with anyone requires understanding that person. Covey says that there are four levels of listening-ignoring, pretending, attentive and empathic. Ignoring listening is not really listening at all; it is just being present. When we pretend to listen we say ‘uh-huh’ and do not care what is being said. Attentive listening recognizes what is being said but does not internalize anything. Empathic listening involves listening with the intent to understand the other person. There is no judgement involved. You see the world as the other person sees it. This is the type of listening that the best clinicians use and which Dr. T uses.

Empathic listening builds trust in patients which is vital to engage them in their own care. You may reach this level of listening with your patients but the trust built can quickly be destroyed if you are careless when not in the patient’s presence. Consider the following incident.

As a licensed practical nurse for more than 20 years, Bob knew the importance of safeguarding a patient’s privacy and confidentiality. One day, he used his personal cell phone to take photos of Claire, a resident in the group home where he worked. Bob received permission from Claire’s brother to take the photo since she was unable to give consent due to her mental and physical condition. That evening, Bob ran into William, a former employee of the group home. While catching up, he showed William the photo of Claire and discussed her condition with him. The administrator of the group home later learned of Bob’s actions and terminated his employment for breach of confidentiality.

This incident is quoted from The Nurse’s Guide to the Use of Social Media. The guide, which can be found for free online, discusses the limits of using social media to share information about patients. It states that because of HIPAA a clinician cannot share information about a patient in social media where the patient can be identified. The only time any patient health information can be shared with another is when the other person is also caring for the patient or when there is a legal need to do so.

Consider another incident of misuse of identifiable patient data. A nurse was working at her station in a hospital. She received a phone call from her sister-in-law who said that she had just been admitted to the same hospital and would she visit her at her lunch time. The nurse agreed but forgot to take down the room number of her sister-in-law. When the nurse’s lunch time came she logged into the hospital’s computer system to find out the room of her sister-in-law. When she arrived at the room, she was met by hospital administrators who said that she had improperly accessed her sister-in-law’s patient information. The nurse said she only looked at the room number and the sister-in-law vouched for her that she did not mind. The administration proceeded to terminate her for breaching patient confidentiality.

The Guide goes further in cautioning about the use of social media to discuss patients. It may be that a clinician or healthcare employee posts an item in a blog or Facebook page which has been protected to allow only friends to see the posting. This seems safe enough. It is not. Friends may repost such patient information in a public forum. A posting of patient information may be removed quickly from a site. However, the information is still on the internet server and is discoverable by hackers or through legal means. The Guide goes on to say that no information about a patient which could be identified with the specific patient should be posted anywhere in a public forum or online. Only de-identified information may be used.

In order to achieve the best outcomes with patients it is necessary to be authentically engaged in listening to them, as Stephen Covey points out. Such engagement leads to a building of trust. This trust must be safeguarded at all times. It only takes acts of carelessness or thoughtlessness to destroy such trust, as illustrated in the careless use of social media by caregivers or by the improper access to patient information by a clinician. Trust needs to be built and protected to have the best results. The best action for any caregiver or any service provider is to never share any personally identifiable information with any other unless it is necessary for the care of the patient or improvement of service for the client.

Practical Steps In Improving One’s Health

Health is the general condition of the body and the mind. A healthy lifestyle is a manner or way of living that enables one to develop a general condition of the body and mind that is free of sickness and disease. Every activity that the individual undertakes and the decisions that he/she makes affects his/her lifestyle either positively or negatively. Therefore, there is the need for every individual to plan his activities and make sound decisions that would affect his/her health positively.

There are some activities that can tremendously improve the healthy lifestyle of an individual. These activities have been time-tested and have proved beyond all reasonable doubt to affect one’s health positively. To assist in remembering them easily, we would rather use an acronym ‘SPARKLE’ to stand for all of those activities. Each of these initials stands for a vital activity in life that prolongs one’s lifespan and improves the health condition of a person.

S – Sleep
P – Plan every day
A – Anticipate less
R – Relax
K – Keep your temper under control
L – Laugh more
E – Exercise regularly

• Sleep

Sleep has been recommended as the best antidote to restore the body organs to work more effectively and efficiently. Our bodies are like machines that need to be halted or stopped for a considerable time. Doing this helps all the organs of the body to renew their strengths. It also prevents us from overworking our bodies which usually result in a breakdown which may be evident through sickness or even death.

It is recommended that the body should take a nap for not less than eight hours a day to help its organs to work well. It is wrong to strain the body if it gives signals that it needs to rest and it would even be a death blow if we try to induce our bodies to work an extra mile by taking in hard and unhealthy drugs and liquors like ‘Caffeine’ etc. just to stay awake all day. Let’s allow the body to take its natural course of rest and allow it to rest since this would positively affect our health.

• Plan Everyday

Many sicknesses especially heartaches are as a result of poor or no planning of activities that one wants to undertake in a day. The Bible even admonishes that ‘the shrewd one considers or plans his steps (activities)’. If you fail to plan for your activities every day you put a strain on the brain and you push it to adjust to new activities without prior consultations. It also results in overworking of the body which can cause high fevers and headaches. Therefore, it is advisable to plan your activities for a particular day the night before the day. Though unforeseen events may arise, yet we can minimize it considerably and improve our health if we plan.

• Anticipate Less

Imperfect as we all are, there is the great tendency to anticipate the unfolding of events and the outcomes of our decisions. However, it would also be wrong to anticipate too much of the future. This puts unnecessary pressure on the body and negatively affects the heart especially in situations where the matter at stake affects us and our business directly. It can also negatively affect our activities we need to do for the day. Experience has shown that some businessmen commit serious arithmetic mistakes as a result of extreme anticipation of past business transactions of which they have paid dearly. Others who work on machines in the industry have even lost control and endangered their lives. The candid truth is that our extreme anticipation cannot overturn situations or results of our decisions. Think or anticipate less and leave matters to God and move on with the planned activities for the day.

• Relax

Relaxation is one of the activities that set the body in its right and perfect tone. If we relax our bodies by engaging in a recreational activity such as listening to music, watching a video or sport, sightseeing etc. refreshes our bodies. It will be as if we have charged our body ‘batteries’ new. It gives us a new ‘spirit’ or energy to work. As artists, we gain are able to brainstorm and generates a lot of creative ideas for the production of functional artifacts. Remember the old maxim that says ‘All work and no play make Jack a dull boy’. Don’t be too engross or busy in your work, relax and engage in a wholesome recreation to keep your body healthy always.

• Keep Your Temper under Control

Anger is like fire. If not kept under control can burn a whole house as it were. Therefore when tempers are high, exercise self-control or engage in activities that can calm your tempers down. Such activities include taking a walk off the scene, talking about the matter with a trusted friend or engaging in your favorite hobby such as drawing, painting or listening to music. In fact, if tempers are kept unchecked, they can cause serious health problems such as heartaches and other diseases related to the lungs. Also, because the victim is not thinking straight, he/she may take wrong decisions and act unwisely. It is advisable not to act in a provoked situation, just take your leave and remember that we all err against one another. Not making an issue out of what ensued between you and the one who angered you or harboring resentment will improve your health greatly.

• Laugh More

Laughter is a major tool that improves one’s health. Studies have revealed that people who laugh always live long more than those who harbor resentments. Laughing helps in relaxing the muscles causing them to work more effectively. Health experts like clinical psychologists use laughing as a therapy in treating individuals with depression to help restore their emotional state. Therefore, laugh more and don’t frown or always put on a serious look. This would improve your health.

• Exercise Regularly

Exercise is the activity of exerting one’s muscles in various ways to keep fit. Exercise helps in strengthening the joints, muscles, and tissues of the body while improving on one’s heart condition. It assists greatly in the circulation of blood throughout the entire body. Exercising on a regular basis can help in avoiding stroke, a disease caused by a sudden loss of consciousness resulting when the rupture or occlusion of a blood vessel leads to oxygen lack in the brain. It is advised that a thirty minutes exercise on a daily basis can significantly improve one’s health. Doctors even recommend exercise as a cure to thousands of ailments. Therefore, make time every morning to exercise your body and make sure you do it daily to improve your health condition.

Community Needs Health Assessment

In 2012 the Internal Revenue Service mandated that all non-profit hospitals undertake a community health needs assessment (CHNA) that year and every three years thereafter. Further, these hospitals need to file a report every year thereafter detailing the progress that the community is making towards meeting the indicated needs. This type of assessment is a prime example of primary prevention strategy in population health management. Primary prevention strategies focus on preventing the occurrence of diseases or strengthen the resistance to diseases by focusing on environmental factors generally.

I believe that it is very fortunate that non-profit hospitals are carrying out this activity in their communities. By assessing the needs of the community and by working with community groups to improve the health of the community great strides can be made in improving public health, a key determinant of one’s overall health. As stated on the Institute for Healthcare Improvement’s Blue Shirt Blog (CHNAs and Beyond: Hospitals and Community Health Improvement), “There is growing recognition that the social determinants of health – where we live, work, and play, the food we eat, the opportunities we have to work and exercise and live in safety – drive health outcomes. Of course, there is a large role for health care to play in delivering health care services, but it is indisputable that the foundation of a healthy life lies within the community. To manage true population health – that is, the health of a community – hospitals and health systems must partner with a broad spectrum of stakeholders who share ownership for improving health in our communities.” I believe that these types of community involvement will become increasingly important as reimbursement is driven by value.

Historically, healthcare providers have managed the health of individuals and local health departments have managed the community environment to promote healthy lives. Now, with the IRS requirement, the work of the two are beginning to overlap. Added to the recent connection of the two are local coalitions and community organizations, such as religious organizations.

The community in which I live provides an excellent example of the new interconnections of various organizations to collectively improve the health of the community. In 2014 nine non-profits, including three hospitals, in Kent County, Michigan conducted a CHNA of the county to assess the strengths and weaknesses of health in the county and to assess the community’s perceptions of the pressing health needs. The assessment concluded that the key areas of focus for improving the health of the community are:

· Mental health issues

· Poor nutrition and obesity

· Substance abuse

· Violence and safety

At this time the Kent County Health Department has begun developing a strategic plan for the community to address these issues. A wide variety of community groups have begun meeting monthly to form this strategic plan. There are four work groups, one for each of the key areas of focus. I am involved in the Substance Abuse workgroup as a representative of one of my clients, Kent Intermediate School District. Other members include a substance abuse prevention coalition, a Federally qualified health center, a substance abuse treatment center and the local YMCA, among others. The local hospitals are involved in other workgroups. One of the treatment group representatives is a co-chair of our group. The health department wants to be sure that the strategic plan is community driven.

At the first meeting the health department leadership stated that the strategic plan must be community driven. This is so in order that the various agencies in the community will buy into the strategic plan and will work cooperatively to provide the most effective prevention and treatment services without overlap. The dollars spent on services will be more effective if the various agencies work to enhance each others’ work, to the extent possible.

At this time the Substance Abuse work group is examining relevant data from the 2014 CHNA survey and from other local resources. The epidemiologist at the health department is reviewing relevant data with the group so that any decisions about the goals of the strategic plan will be data driven. Using data to make decisions is one of the keystones of the group’s operating principles. All objectives in the strategic plan will be specific, measurable, achievable, realistic and time-bound (SMART).

Once the strategic plan is finished, the groups will continue with implementation of the plan, evaluating the outcomes of the implementation and adjusting the plan as needed in light of evaluation. As one can see, the workgroups of the CHNA are following the classic Plan-Do-Check-Act process. This process has been shown time and again in many settings-healthcare, business, manufacturing, et al-to produce excellent outcomes when properly followed.