Rana Awdish, a critical care doctor, published an essay about her inpatient experience when she had a life-threatening illness. She praises the clinicians whose skills saved her life, and also recalls instances in which some clinicians’ words unintentionally caused her emotional suffering: “When I overheard a physician describe me as ‘trying to die on us,’ I was horrified. I was not trying to die on anyone.”
Dr. Awdish’s powerful essay reinforced for me the importance of IHI President and CEO Derek Feeley’s keynote presentation at the 2016 National Forum. He discussed the need to move from a narrow definition of medical harm that concerns only physical injury to a broader one that includes emotional harm. “The absence of dignity is harm,” Feeley stated. Yes, it is — and Feeley framed it perfectly.
In my career as a service quality researcher, I‘ve written and spoken about how service organizations must more effectively manage the “clues” embedded in all customer/patient service experiences. The goal: to evoke positive feelings, such as trust and hope, about the service. After all, with services, we generally make the decision to buy them before we experience them — there are no “tires to kick” before the purchase, so we pay for a promise of how the service will be performed.
A service’s clues tell its narrative. Functional clues signal the service’s technical quality. For example, a well-designed online appointment system is a positive functional clue; missing medical records is a negative one. Mechanic clues are associated with tangibles in the service experience, such as facility design and cleanliness. Humanic clues come from people — their choice of words, body language, tone of voice, willingness to help, and appearance.
The more important, variable, complex, and personal a service is, the more clue-sensitive customers are likely to be. Because virtually no service is more important, variable, complex, and personal than health care, patients tend to be ultra clue-sensitive. What may seem an insignificant or minor detail to a clinician, can make a huge impression on a patient.
Dr. Awdish’s story and Derek Feeley’s reframing of medical harm strongly resonated with me because both elucidated the importance of humanic clues in health care. It is not enough for clinicians to perform well with their hands and their minds; they must also perform well with their words and other forms of communication. “Doctoring for your soul, not just your body” is a phrase I learned from Maureen Bisognano, IHI President Emerita. I have observed many clinicians do just that with their patients in my years studying health care.
Most recently, I’ve been investigating service improvement in cancer care in my role as an IHI Senior Fellow. One of many “lightbulb” moments for me in this research was when Dr. Peter Eisenberg, founder of Marin Cancer Care, said: “I would never tell a patient there is nothing left for us to do. Patients may have incurable disease, but there is always something to do. I tell them that even though we are not treating with aggressive therapy, he or she is still my patient . . . Patients need to know they are not being abandoned.”
Dr. Eisenberg got me thinking about the humanic clues of “never words” in cancer care, and I began asking clinicians in interviews to identify certain words or phrases they would never use with a cancer patient. Every clinician I asked this question had at least one. Here are some examples:
“Let’s not concern ourselves about that now.”
“Just” (as in “We can continue treatment or we can just do supportive care.”)
“This is a bad cancer.”
“Why did you wait so long to come in?”
“You are lucky it is only stage 2.”
“You failed chemo.”
A hospice social worker I interviewed told me, “Cancer strips people of self-confidence; they lose what they once were.” An oncologist offered this wisdom: “Healing conversations are part of the healing process.” Clinicians’ words are high-potency humanic clues. Too often, clinicians unintentionally use words with patients that harm rather than heal, that evoke distress rather than trust. Investing time within clinical groups to discuss their “never” words and to commit to banishing their use is an investment worth making if we are really serious about reducing emotional harm. Beth Israel Deaconess Medical Center (BIDMC) in Boston tracks and analyzes emotional harm events and documents them in its quarterly preventable harm scorecard that also includes physical harm events. Disrespectful communication is the category of emotional harm most frequently reported. Kudos to BIDMC for recognizing that preventable medical harm extends to humanics and doing something about it.
Leonard Berry, PhD, is a professor at the Mays Business School, Texas A&M University. He also is an IHI Senior Fellow.
You may also find of interest:
A View from the Edge — Creating a Culture of Caring by Rana L.A. Awdish, MD
Video: IHI President and CEO Derek Feeley’s full keynote from IHI's 28th Annual National Forum