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.