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What are the most promising practices to foster physician presence and connection with patients?
This mixed-methods study identified 5 practices that may enhance physician presence and meaningful connection with patients in the clinical encounter: (1) prepare with intention; (2) listen intently and completely; (3) agree on what matters most; (4) connect with the patient’s story; and (5) explore emotional cues.
For busy clinicians with multiple demands and distractions, 5 recommended practices have the potential to facilitate meaningful interactions with patients.
Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.
To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.
Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (−4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their “top 5” practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.
The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient’s story (consider life circumstances that influence the patient’s health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient’s emotions).
Conclusions and Relevance
This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.
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Corresponding Author: Donna M. Zulman, MD, MS, Stanford University School of Medicine, Division of Primary Care and Population Health, Medical School Office Building (MSOB), 1265 Welch Rd, MC 5411, Stanford, CA 94305 (firstname.lastname@example.org).
Accepted for Publication: November 5, 2019.
Correction: This article was corrected on March 17, 2020, for typographical errors.
Author Contributions: Dr Zulman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Zulman, Haverfield, Shaw, Brown-Johnson, Schwartz, Tierney, Zionts, Safaeinili, Thadaney Israni, Asch, Verghese.
Acquisition, analysis, or interpretation of data: Zulman, Haverfield, Shaw, Brown-Johnson, Schwartz, Tierney, Zionts, Safaeinili, Fischer, Asch.
Drafting of the manuscript: Zulman, Haverfield, Schwartz, Fischer, Verghese.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Zulman, Tierney, Zionts.
Obtained funding: Zulman, Thadaney Israni, Verghese.
Administrative, technical, or material support: Zulman, Haverfield, Shaw, Brown-Johnson, Tierney, Zionts, Safaeinili, Fischer, Asch, Verghese.
Supervision: Zulman, Brown-Johnson, Safaeinili, Asch, Verghese.
Conflict of Interest Disclosures: Ms Thadaney Israni reported serving on the boards of Scients.org and the Society of Bedside Medicine; both roles are unpaid. Dr Verghese reported receiving royalties from Knopf, Harper Collins, and Simon and Schuster and honoraria from the Leigh speaker’s bureau and serving on the health policy advisory board for Gilead. No other disclosures were reported.
Funding/Support: This study was supported by grant 6382 from the Gordon & Betty Moore Foundation (to Drs Zulman and Verghese, principal investigators) and by a VA Office of Academic Affairs Advanced Fellowship (to Drs Haverfield and Schwartz).
Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Additional Contributions: We appreciate the valuable contributions of the experts who participated in the Delphi panel: William Branch Jr, MD (Emory University School of Medicine), Arleen Brown, MD, PhD (University of California, Los Angeles), Calvin Chou, MD, PhD (University of California, San Francisco), Richard M. Frankel, PhD (Indiana University School of Medicine), Judith A. Hall, PhD (Northeastern University), Manny Hernandez, MEng (American Diabetes Association), Rumana Hussain, MBA, MPH (Alameda Health System), Lucy Kalanithi, MD (Stanford University School of Medicine), Eliseo J. Pérez-Stable, MD (National Institutes of Health), Bill Polonsky, PhD, CDE (University of California, San Diego), Helen Riess, MD (Harvard Medical School), David Sobel, MD, MPH (Stanford University School of Medicine), Ian Tong, MD (Doctor on Demand), and Elaine Wittenberg, PhD (California State University, Los Angeles). All panelists received $500 honoraria and travel cost reimbursements. Ally Hinson (Stanford University), Muzzammil Muhammad Shittu, MS (Stanford University School of Medicine), Derek Chen (Stanford University), and Shreyas Bharadwaj, MS (Stanford University School of Medicine) contributed to evidence synthesis and development of the expert panel booklet and received compensation through the study grant. Other research assistants who contributed to the literature review and received compensation through the study grant included Isabella Romero (Palo Alto University) and Gabriella Piccininni and Theodore Miclau, MS (Stanford University School of Medicine). Michelle Bass, PhD, MSI contributed to the systematic literature review in her role as research librarian for Stanford University School of Medicine, Lane Medical Library. Megan Mahoney, MD (Stanford University School of Medicine), Marcie Levine, MD (Stanford University School of Medicine), Lars Osterberg, MD, MPH (Stanford University School of Medicine; VA Palo Alto Health Care System), Christophe Gimmler, MD, LMFT (Stanford University School of Medicine; VA Palo Alto Health Care System), and Jaime Chavarria, MD (Ravenswood Family Health Center) served as clinical advisors and liaisons to partner sites during formative research and did not receive compensation for their roles. Chaplain Bruce Feldstein, MD, BCC (Stanford University School of Medicine), Alan Glaseroff, MD (Stanford University School of Medicine), John Kugler, MD (Stanford University School of Medicine), Sheila Lahijani, MD (Stanford University School of Medicine), Karl Lorenz, MD, MSHS (Stanford University School of Medicine, VA Palo Alto Health Care System), Amrapali Maitra, MD, PhD (Brigham and Women’s Hospital, Harvard Medical School), Kelley Skeff, MD, PhD (Stanford University School of Medicine), and Andrew Elder, MD (University of Edinburgh), provided additional clinical and content expertise during the development of the preliminary presence practices and did not receive compensation for their roles. Additional research contributors who received compensation through the study grant include Marcy Winget, PhD, MHS (director, Evaluation Sciences Unit, Stanford University School of Medicine), Farzad Azimpour, MD (Stanford University School of Medicine), Lucie Richter, MA, and Svava Atladóttir, MS (Future Medical Systems; Human-Centered Design Consultants), Laura Jacobson, MPH (OHSU-PSU School of Public Health; research consultant), and Jaime Dice, PhD, MSc (Dice Writing LLC; ethnography consultant). We greatly appreciate the contributions of study participants, including physicians and patients from Stanford Primary Care and Family Medicine Clinics, VA Palo Alto General Medicine Clinic, and Ravenswood Family Health Center.
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