From Consultation to Care Conversation: unlocking the power of conversation as a therapeutic tool for a post COVID world.
Article published by XPA Barcelona in the XPA & HEALTH COMMUNICATION Journal on 21st September 2020 (Links to English, Spanish and Catalan versions).
Conversations lie at the very heart of every doctor-patient relationship. A lady trying to articulate to her primary care doctor the reason behind her extreme fatigue, a surgeon welcoming a patient into a pre-operation room, a nurse giving the monthly prescription to an elderly man with diabetes or an oncologist listening to the daily struggles of a young family fighting leukemia. These are all intimate interactions surrounded by emotions and complexity. A dynamic, two-way relationship of trust that is dependent on the ability to engage with each other and strongly connected to patients’ health outcomes, satisfaction and experience (Angus et al. 2012) (Davis et al. 2008) (Ha and Longnecker 2010).
Since 2017, together with the Pain Unit team in Hospital Clínic de Barcelona, we have been exploring the power of conversation as a therapeutic tool in pain management and uncovering several key insights that support a new model of care. Chronic pain affects the everyday lives of both patients and family caregivers. It’s a subjective emotional state rather than just a sensorial experience, one that always comes with a personal story filled with emotions. And emotions can only be revealed and supported through a confident, safe, and compassionate conversation.
Yet the conversation between doctor and patient is often compromised, lacking a shared vocabulary with which to describe pain, or missing a common objective; the patient values sharing their story whilst the doctor is trained to listen for the facts with which they can diagnose and plan treatment. Chronic pain patients in particular benefit from a multimodal approach including psychological support and physical therapy alongside pharmacological treatment (Cheatle 2016). As with other chronic conditions, lifestyle and environment play a strong role in the experience of pain. Therefore effective care must involve continuity beyond the walls of the consultation room and into a patient’s daily life context and the neighbouring community. The conversation naturally then transforms from being paternalistic to one of empowerment, with the care team and patient working together to better manage their chronic pain.
These insights are driving a collaborative project with the Unit to redesign the space layout and service experience and introduce a new model of care that is built around the concept of conversations as a therapeutic tool. In the following article, we would like to explore the application of this idea further and reflect upon how COVID19 has set the stage for reframing every healthcare consultation as a care conversation.
Ingredients for a good Care Conversation.
To sustain a coherent and confident dialogue is not always an easy and smooth experience in life, but it’s especially challenging when dealing with the kind of complex topics that arise in healthcare encounters. Every doctor-patient interaction is wrapped up in emotions. One of the main drivers that form and inform the conversation on both sides is fear: a subconscious feeling coming from the anxiety to interact –will I be able to express what I need to say?–, the insecurity to assert –am I entitled to say this?– and the existential doubts about the inner self –will I be seen as ill forever?, if I’m wrong, will my professional identity be threatened? (Fischer and Ereaut 2012).
Having a good conversation that surfaces and overcomes these inner fears and blocks requires a set of general skills such as being present, being open to listen, understand and learn something new from the other, using open-ended questions, being humble and able to say “I don’t know” or not being condescending or boring (Headlee 2015). However, in a healthcare environment, a series of specific strategies are also required for an effective consultation. As for example, trying to adapt the verbal and non-verbal language used to the individual patient’s behavior, the use of clear language to ensure that they comprehend and engage, to give the opportunity for them to express their concerns and viewpoint, to create a safe space for emotional expression and to share the control of the conversation as two equal individuals (Angus et al. 2012). Likewise, there are some structures –such as the REDE model created by the Cleveland Clinic– that are proving to be effective ‘conversation anatomies’ with which to nurture meaningful relationships in care encounters (Windover et al. 2014).
Notwithstanding, healthcare settings are not always designed with the spatial and experiential qualities required to embrace a positive conversation, one that meets doctors' and patients' needs. Traditional space design in hospitals tends to be cold and functional, designed around medical tasks and processes rather than the experience. The context often looks and feels busy, which makes patients sense they don’t have the luxury of time to truly engage in the conversation (Chow and Hatala 2020) or to open up and express their deepest emotions the same way they would do sitting on a sofa next to warm light and with a coffee in front of them.
On the other hand, there are other elements at the system level that influence these healthcare interactions. The classical power asymmetry between doctors and patients perpetuates a paternalistic approach to the conversation, or the lack of transparency in the consultation process itself makes patients feel clumsy and disempowered during their conversations. Also, the fact that this exchange may take place in a fragmented and disconnected way across multiple touchpoints, with various providers (including primary care and social care) and at different moments in time, results in negative emotional consequences, gaps in clinical insights, and diminished patient engagement and satisfaction. At the same time, the absence of conversation skills training or specific governance or evaluation processes around the consultation leaves professionals powerless to improve the quality of the relationships they can build with their patients and caregivers (Fischer and Ereaut 2012).
Accordingly, we can state that Care Conversations are strongly influenced by the level of awareness, skills, and strategies of their participants, but also the different layers and characteristics of the context in which they occur.
Right now, no one can deny that the COVID19 outbreak has completely shaken the foundations beneath the majority of healthcare interactions, activating some underused telecare tools that already existed. As stated by the Medical Futurist, over the past three months, telehealth usage in the US has tripled. In Catalunya, teleconsultations in Primary Care have increased over 460% (Sust et al. 2020) and, in the Pain Unit of Hospital Clínic de Barcelona 90% of their consultations have been remote since the lockdown began there on March 15th, 2020.
Care Conversations in the time of COVID19.
In light of the recent crisis context, we decided to interview Dr. Dürsteler, Head of the Pain Unit in Hospital Clínic de Barcelona, and Jordi Piera, Chief of the Digital Health Strategy Office at the Catalan Health Service (CatSalut) to reflect together upon the influence of the pandemic in the Care Conversations of today, and tomorrow.
From them, we learned that teleconsultation –including email exchanges, phone calls, and video calls– despite being a sudden and disruptive change to the system, has been in some ways also a blessing. Patients have felt secure and continuously cared for, and professionals –although having gone through some sharp adaptation processes– have been able to support them despite the challenging pandemic circumstances. In terms of patient experience, reducing the traveling and waiting intervals has resulted in a great time optimization for both patients and professionals. Allowing more informal, frank and insightful conversations, simplifying the patient and caregiver journeys, and providing more quality time for doctors and nurses that, in the future, can hopefully be invested in other valuable activities such as research, team training, or patient engagement programming. This has come with an additional level of comfort for patients and caregivers because not having to move from home (especially beneficial for patients in pain) they didn’t need to stop their lives in order to interact with the health system. Moreover, the broader social situation during confinement increased everyone’s sense of being part of one system; a feeling of solidarity connecting patients and professionals which has been translated into a more trustworthy relationship and a greater consideration towards the preciousness of every minute of time being able to talk to each other.
In contrast, virtual consultations during COVID19 have also raised some challenges in terms of patient-professional experience. With the lack of physical contact, the use of body language as a strategy for professionals to support patients in dealing with their emotions has been eroded; also, natural pauses in conversation have been more difficult to fill over a digital void and the doctor-patient-caregiver interaction has been fractured –either losing the caregiver’s spontaneous reactions and point-of-view or hearing only their voice and not that of the patient. In this sense, video calls have been more reassuring than a phone call or mail, especially for patients with heightened anxiety and in conversations where non-verbal communication is key for dealing with emotions (Greenhalgh et al. 2020).
On the other hand, some ethical and ontological debates have arisen.The majority of professionals have had to deal with the insecurity of giving a diagnosis or treatment plan without even seeing or physically examining their patients. Doing so without knowing the implications in terms of personal liability, and whilst feeling a loss of control over this new virtual context that feels far less secure in terms of privacy compared to their consultation rooms, where they easily close the door and can be alone with their patients. This, together with the fear of being accessible to patients 24/7 via telecare channels and hence more exposed and pressured to respond, added one more layer of anxiety to each interaction and a lot of stress amongst care teams. In this sense, digital platforms like Emento in Copenhagen or supporting toolkits designed by Public Healthcare Agencies such as CatSalut in Spain or the NHS in the UK, have helped reassuring professionals in their decisions and improving the quality of their digital conversations.
better video consultation experience published by CatSalut (Public Healthcare Agency in Catalonia).
All in all, there is no doubt that the enormous spike of teleconsultations triggered by the COVID19 outbreak has brought us to a new paradigm of the doctor-patient relationship.
The experts we interviewed hope that more than 30% of all patient interactions will be via telemedicine solutions in the future. According to a survey among patients in the Pain Unit in Hospital Clínic de Barcelona, 57% of them would like to keep the consultations by phone and 59% of them would like to have them as video calls. In the same hospital, 78% of patients with chronic cephalea would also like to use teleconsultation for forthcoming visits and follow-ups. On the horizon, telecare will further establish itself and with it, the power of the conversation as a therapeutic tool and as a catalyst for building relationships of trust in healthcare will sharpen. A great opportunity to consolidate all the positive experiences resulting from these last months of crisis and to overcome the challenges that have emerged.
In light of this, the question is unavoidable: how might we approach designing the qualities of conversations that bring the doctor-patient relationship to a deeper level of engagement and effectiveness?
Why Design Thinking matters now.
Design Thinking is a human-centered innovation methodology that has become increasingly applied in healthcare product, service, and system innovation over the last several years (Kim, Myers & Allen 2017). Its starting point is a deep understanding of human needs — patients, caregivers, and professionals — followed by idea generation, rapid prototyping, and iterative testing towards a final solution.
In a post-COVID reality and considering the pandemic to provide a testbed environment for innovation, the methodology can have particular relevance and value. Rapid prototyping and iterative testing fit the urgent pace of adaptation that COVID19 has demanded of many health systems and services. Healthcare professionals have had to adapt overnight to be comfortable and confident to ‘work in beta’. Yet this also highlighted some disparities in participation. We’ve observed some teams naturally implementing changes and improvements to make teleconsultation tools work better for them, whilst others felt they had no power or capability to intervene and adjust.
The participatory nature of Design Thinking enables organisations to co-create solutions, offering tools and techniques that encourage multidisciplinary collaboration between patients, families, and care professionals. Participation combined with a sense of personal agency are both essential ingredients to drive the buy-in and uptake required to reach robust and sustainable solutions.
Furthermore, Design Thinking can help with the systemic change needed to build the healthcare systems of tomorrow, resilient enough, and capable of confronting future challenges such as COVID19. Intervening on multiple levels of services and organizations: shifting attitudes and organizational culture, prompting new behaviors and practices, creating new tools and care delivery strategies as well as revealing new models of engagement blending online and presential experiences.
Let’s talk about the New Normal.
As mentioned before, there is now a shared appetite and intention amongst patients and healthcare professionals to maintain open these digital communication channels as we move into the so-called New Normal. But what might it mean for Care Conversations?
The creative use of digital, physical as well as hybrid or mixed formats for doctors to keep caring for their patients during the pandemic has built renewed confidence, openness, and a sense of urgency to implement digital transformation strategies in healthcare systems.
But, how might we shape these digital spaces to create more intimate and spontaneous therapeutic conversations between patients and professionals?
Digital transformation also facilitates a push for more personalized care, better use of doctor’s time to improve care quality, and for better care coordination, training, and integration between health and social care services.
How might we design flexible protocols that combine analogue and digital interactions to offer a variety of conversations according to changing needs and contexts — from hospital to home and even within the community?
In all this, technology remains just one key enabler for a better Care Conversation; a tool to enhance the interactions between patients, families, and professionals. As such, even with effective digital infrastructure and capabilities built into our care systems, and the intention and collective desire for change, we still lack the necessary conversation skills and expertise amongst professionals, citizens and patients alike in order to forge these new relationships.
So, how might we support healthcare professionals to develop their communication skills by redesigning medical school programmes and curricula? How might we equip citizens, patients, and their caregivers with the capabilities, tools, and confidence to develop their health literacy for a better Care Conversation online and offline?
The Patient Revolution in collaboration with the Knowledge and Encounter Research Unit (KER Unit) at Mayo Clinic in the United States is creating shared decision-making tools that help patients and families with conditions like diabetes and depression have more personalized Care Conversations with their healthcare providers. Here in Barcelona, the Catalan Agency for Quality and Assessment (AQuAS) offers health literacy tools like Essencial to improve communication and understanding between doctors and their patients. However, the challenge remains in how to spread, scale, and embed such approaches throughout an entire healthcare system.
So, the real opportunity lies in driving a culture change towards a more equitable, compassionate, and proactive model of care. The Care Conversation lies at the heart of this shift. The way we communicate with one another fundamentally changes our behaviors and ultimately can improve our experiences of care in a most direct way.
COVID19 may have shaken our care systems, but it has also left us more resilient, flexible, and open to change. Now is the time to reflect upon our past experiences, move forward from outdated archetypes, learn from our most recent experiments, and translate best practices into sustainable solutions that can make a good Care Conversation the new normal.
Acknowledgments:
Thanks to Christian Dürsteler, Head of the Pain Unit in Hospital Clínic de Barcelona and Jordi Piera, Chief of the Digital Health Strategy Office at the Catalan Health Service.
References:
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