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Communicating With Presence

Learning Objectives
1. Summarize strategies to “Prepare with Intention” including reviewing patient history and resetting before the visit
2. Discuss methods to “Listen Intently and Completely” including being thoughtful with body position and allowing your patient to finish their statements
3. Identify strategies to “Agree on What Matters Most” including making an agenda based on patient priorities and asking open ended questions
4. Engage using positive language for goals and asking about patient beliefs and attitudes by “Connecting to the Patient's Story”
5. Incorporate strategies to “Explore Emotional Cues” including validating patient emotions
0.25 Credit CME

Internet Enduring Material sponsored by Stanford University School of Medicine. Presented by Primary Care and Population Health at Stanford University School of Medicine.

Modern society has provided us with technological advantages but also barriers to connect with our patients in a meaningful way. This online module highlights the Stanford Presence 5 model, which is a framework for integrating humanism and effective communication as you interact with your patients.

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Activity Transcript

Speaker 1: This video covers strategies to foster humanism and meaningful connection during [inaudible] visits, as guided by the Presence 5 model.

Speaker 2: As clinicians, we may enter an exam room without knowing our patients as individuals. We have just a couple of minutes to learn about what matters most to our patients and to connect with them in a meaningful way. Most clinicians enter into medicine for this very moment. This ancient ritual. The ability to connect with and serve and heal a person in a moment of presence. Yet, in modern clinical settings, as technology advances, clinicians face more barriers to creating a place for these moments. The Stanford Presence 5 is a toolkit of simple evidence-based practices that can help clinicians forge meaningful connections with patients. The Presence 5 practices were identified through a two year study that included a comprehensive, systematic review of medical and social sciences literature, observations of clinicians in patients in three clinical settings and interviews with clinicians, patients, and non-medical professionals to identify strategies for effective communication and connection.

These formative research steps yielded 31 preliminary practices. After several iterations and additional literature review, 13 practices with supporting evidence were presented to a panel of clinicians, researchers, patients, and caregivers, and health system leaders. And a modified Delphi process was used to quantify their expert opinion and determine the final five practices. Prepare with intention, listen intently and completely, agree on what matters most, connect with the patient's story and explore emotional cues. We will now review each of these practices in greater detail, and we want to hear which strategies you use to connect with your patients.

The first practice is to prepare with intention. This practice is about creating a ritual to focus your attention before a visit and familiarizing yourself with the patient you are about to meet. Many clinicians have a brief amount of time to review a patient's chart before their visit. Conducting a brief chart review that focuses on key medical issues and a patient's social history can help you prepare for a meaningful encounter.

What types of details do you look for to prepare to connect with the person you are about to see? Performing a one-minute chart review of a patient's medical and social history has been shown to enhance the patient's experience, increased patient engagement and improved practice efficiency. Focusing on key information about the patient's social circumstances, their social support, living environment, occupation, or hobbies can be particularly helpful. In addition to physical preparation for the visit, psychological preparation can allow a clinician to focus their attention on the person they are about to see.

Studies have shown that engaging in meditative exercises can lead to improvements in clinician anxiety, depression, and stress. This can also reduce clinician burnout by decreasing emotional exhaustion and creating a greater sense of accomplishment. Some clinicians create a ritual to pause and refocus their attention before each visit. Taking three deep breaths before knocking on the door or reciting a mantra during hand washing can help you reset between appointments.

This can allow you to focus your attention on the patient you are about to meet. What strategy do you use to prepare with intention and recenter before a visit?

The second practice is to listen intently and completely. By exhibiting engaged body language and actively listening, clinicians give patients space to tell their stories. How do you position yourself in relation to your patient? Thoughtful clinician body positioning positively influences patient trust and satisfaction with treatment. Sit down and arrange your body to face the patient. If you have to reference or enter information into the computer, orient your lower body towards the patient and make eye contact when possible. The patient starts venting about frustration with their care, but is taking a while to express themself. How do you approach the situation? How long do you let them talk? Allow the patient to finish sharing their thoughts without interrupting them.

When clinicians listen attentively and avoid interruption during patient histories, patients communicate more medical information and report greater satisfaction. The third practice is to agree on what matters most. This is where you can discover what your patient cares about and incorporate these priorities into the visit agenda. You can agree on what is important and craft a plan together. The patient doesn't appear to have an organized plan for today's visit and has more multiple health issues that you feel you need to address. How do you set an agenda with your patient to address these concerns? Use open-ended questions to elicit the concerns your patient would like to prioritize for the visit. Collaborate with the patient to set an agenda based on their priorities to enhance patient satisfaction and communication. Based on the time allotted for the visit, determine which topics to cover and schedule a follow-up appointment to address the rest. Before the visit ends, invite your patient to voice final thoughts by asking, “Is there something else you want to address in the visit today?”

The fourth practice is to connect with the patient's story. Consider the circumstances that influence your patient's health. Acknowledge your patient's efforts and celebrate their successes. Your patient is relatively quiet and appears slightly uncomfortable throughout his visit. How do you engage with the patient? Be curious about the patient's life and circumstances when identifying personal, historical or contextual details. Avoid negative assumptions about race, ethnicity, gender, culture, or social and economic circumstances. Engage in perspective getting where you ask the patient about their thoughts, beliefs, or attitudes.

Comment on personal details that the patient mentioned previously. For example, family news, travel plans, or a change in job. Connecting with your patient's story can lead to improved patient satisfaction and outcomes and can reduce the role of biases in clinical interactions and healthcare delivery. In prior visits, you and your patient have set a joint goal to reduce his blood pressure by a certain amount. During your visit, your patient's blood pressure did not quite decrease to the goal you established together. But he mentions that he has been trying really hard to maintain a healthier diet and exercise.

How do you respond? Use positive language to celebrate the patient's successes and acknowledge their efforts. Positive affirmation statements improve patient treatment adherence, behavior change, and overall wellbeing. Use words of encouragement. For example, “I believe you can do it,” or, “Even a little improvement is great.”

The fifth practice is to explore emotional cues. This is about noticing, naming and validating your patient's emotions to become a trusted partner. A patient starts yelling at you, but you are not sure if the outburst is the result of anger, frustration, sadness, or something else. It is clear that based on tone and body language, something else is going on with her. How do you proceed? Reflect, validate, and confirm your perceptions of your patient's emotion. For example, “That sounds very difficult.” Or, “I can see that this is affecting you deeply.” Work to understand your patient's emotions. Studies have shown that for certain clinical situations like the common cold, when clinicians acknowledge a patient's emotions, they are more likely to experience a shorter and less severe illness.

Acknowledging emotions is also associated with higher patient satisfaction and greater understanding of conveyed information. The end of the visit presents an opportunity to further build trust and solidify the diagnosis and treatment plan by asking for patient teach back. Closure of a visit can include a reference to the patient's family, health and social concerns and priorities. In this way, clinicians convey to the patient that they listened fully and want to provide care that is aligned with a patient's circumstances and goals. The Presence 5 practices can help clinicians foster meaningful connections with patients during clinical encounters. Integrating human principles into medicine will help enhance the connection between patients and clinicians.

Activity Information

All Rights Reserved. The content of this activity is protected by U.S. and International copyright laws. Reproduction and distribution of its content without written permission of its creator(s) is prohibited.

Financial Support Disclosure Statement: Stanford Medicine adheres to the Standards for Integrity and Independence in Accredited Continuing Education.

The content of this activity is not related to products or the business lines of an ACCME-defined ineligible company. Hence, there are no relevant financial relationships with an ACCME-defined ineligible company for anyone who was in control of the content of this activity.

Donna M Zulman, MD

Assistant Professor of Medicine (General Medical Disciplines)

Stanford University School of Medicine

Course Director, Faculty

Juliana Baratta, MS

Project Manager

Stanford University School of Medicine

Faculty, Planner Disclosure Information

Sonoo Thadaney Israni, MBA

Executive Director

Stanford University Presence and The Program in Beside Medicine

Faculty, Planner

Abraham Verghese, MD

Linda R. Meler and Joan F. Lane Provostial Professor of Medicine and Vice-President of Education

Stanford University School of Medicine

Faculty, Planner

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In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation
Stanford Medicine designates this Enduring Material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.


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