Earlier this week I went to a sit-down restaurant for lunch. I had to smile when the 20-something year old server said to me, “Have a good week, Hon,” as she left the bill on my table. This “Hon” phenomenon is a “thing” among wait staff and I’ve heard it dozens if not hundreds of times as the bill is presented to me. This is a piece of folklore handed down by generations of wait staff and sounds like it’s right out of the ‘50s. I mean, when was the last time you heard anyone being called “Hon” outside of a bar or restaurant? Wait staff do it because they believe it will increase their tip.
Nevertheless, despite this particular smile-inducing anachronism, I’ve learned many things from servers over my years of observing them that I’ve carried over into doctoring. In case you’re tempted to report me to professional regulation, let me quickly assure you I’ve never called a patient “Hon.”
Before I present what I’ve learned, let’s admit that these techniques wait staff use can be characterized as being manipulative; the person engaging in them has a goal of getting a better tip. My goal, on the other hand, is to help my patients get better in ways important to them and, as a means to that end, to increase their treatment adherence. There are several concrete ways of doing this – many of which I will not discuss today – and they include the things I’ve learned from servers.
I ask you to consider if any of the ways I present below feel right (or wrong) to you and that you can feel comfortable incorporating into your work with patients. My goal of sharing them with you is that in my residency training – which I think well of – no one ever spoke to us of how to talk to patients to improve treatment adherence or, as we called it then, treatment compliance. I was left to figure out this part of doctoring on my own. Also, in my work with residents over the years, I found many struggled figuring out what is appropriate to say to patients. When supervising in a room with a resident and patient, many times I found the resident not in the least inspiring in getting a patient on-board with the treatment they were recommending. I had more than one resident tell me explicitly they didn’t want to “manipulate the patient into doing something they didn’t want to do.”
So, I want to open a conversation with you on what you think is appropriate, or not, in terms of what we say to patients. I think the quote from the resident contains a misunderstanding: there is a big difference between inspiring a patient to engage in treatment and manipulating them to do something they don’t want to do. Inspiring change is the point of motivational interviewing, after all. In any case, I now present what I learned from restaurant servers. Haha!
How many times have you heard a server in a restaurant, or any sales person, tell you that whatever you’ve chosen, whether it’s the Chicken Vesuvio, or the particular leather trim on the new car you’re purchasing, is an “excellent choice.” The goal is to have you feel good about your decision and not waver and back out. I believe that it is my job to make my patients feel good about the treatment we’ve agreed on in order to help increase their medication adherence. As a rough rule of thumb, I know that about half of patients receiving psychiatric treatment do not adhere to medication treatment as prescribed through the course of treatment.
So, I start by asking the patient I’m with, let’s say a woman with depression, if she has been on any medications for depression before and, if yes, if any of them worked well for her. If yes, I next ask if she thinks it would be a good idea to get her back on that particular medication. If she agrees, then I say, “Great, it’s a very good medication, tried and true, and if it worked well for you in the past it’s likely to work well again now.” If my patient has not been on an antidepressant previously, I then say, “Many people educate themselves on medications through the Internet or from friends and family. Do you have any information about antidepressants you’d like to discuss with me?” It is fairly common that it is indeed the case that my patient has investigated med options and is happy to discuss their thoughts about them with me. It gives me an opportunity to correct misconceptions and fill in blanks.
It is not uncommon that I hear from a patient something like, “Well, my best friend, who’s also very depressed – she’s going through a divorce – has been taking Celexa. She says it works great for her.” I respond with – wait for it – “Celexa is an excellent medication. I don’t see any reason that prevents us from choosing it for you. So, if you’re on board, let me tell you more about it.” Recall that in MDD, response rates to placebo are 30-50%. This makes it hard for pharmaceutical companies to show that a new antidepressant under study is more effective than placebo. (Back in the day I was involved in a study of reboxetine, an antidepressant available in Europe and elsewhere but not in the U.S. It couldn’t separate from placebo and was never approved here.) My approach is that I want the placebo (and not the nocebo) effect working for me. (I’ll discuss the fascinating placebo effect some other time.)
Look Your Patient in the Eye
Another lesson I’ve incorporated from wait staff is to look my patients in the eye, especially when I’m explaining the treatment to them. I want to make sure they have the impression that I am totally behind the treatment. Imagine someone recommending something important to you and not looking directly at you, perhaps filling out paperwork and such? Such lack of eye contact inspires hesitation on the listener’s part.
What some servers do is they squat down next to the table to be at the customers’ eye level when speaking to them, rather than looking down at them, because they receive bigger tips as a result – research by the restaurant industry bears this out. People like and trust others who are “at their level” and looking directly at them.
Give Your Patient a Transitional Object
With e-Prescribing, many doctors no longer hand the patient a paper prescription. This removes an opportunity to leave your patient with a tangible “takeaway” as they leave the office. This is OK because there are other and better “transitional objects” a doctor can give a patient. The easiest one is to give your patients a medication info sheet when you prescribe a new med. Its function is not only to educate but also to provide the patient something that reminds them of their interaction with you – a memento. Business cards are good, too, as long as you, and not your receptionist, hands it to the patient. Another better one is to give your patient, one who gets into crises, a “safety plan” printout. What I’ve done at times is to type a safety plan (with narrow page margins) as the patient and I develop a step-by-step safety plan in the office. I print it out and cut out the narrow area of print so it easily fits in their wallet or purse and give it to the patient. At times, I’ve recorded the safety plan or other message to the patient on their phone so they can listen to it when in crisis. It provides a more direct connection to me to a person who may be struggling with inadequate internalized supportive objects. This is an example of not being afraid to use “the power of me” to help patients navigate through difficult times.
This is a bit of a stretch, but I notice that servers in restaurants also like to give out things, like discount and announcement cards. In the old days people would take a matchbook on their way out. It’s designed to form a longer lasting connection with that establishment.
Another thing that sales people are often trained to do is to lightly touch their prospect on the outer arm or elbow – very briefly. They know that touch is powerful in forming a connection between people. This connection can be both good and bad. Touch does two things: many people, like some of our older patients living alone, are starved for touch. Touch can be very therapeutic for them. Second, once a person allows themselves to be touched, even if they did not seek it, it becomes a self-communication to themselves that the person who touched them is not to be thought of as an enemy or aggressor.
Touching patients in psychiatric care is tricky, no doubt. I tend not to proffer a handshake at the beginning of a first intake evaluation. But, if I feel the patient is open to it, I proffer my hand as a farewell at the end. With older patients, I sometimes hold the handshake for longer, as I talk to them, sometimes cupping my second hand over their hand.
Of course, whether or not to touch has so many aspects that must be considered. It differs based on the gender of the physician, the gender of the patient, the age of the patient, the cultural background of both doctor and patient, and the patient’s behavior and feelings toward the doctor. I can’t tell you how many women doctors have told me that patients sexually come on to them – this is most certainly a topic we need to discuss more. Establishing touch as part of that type of fraught relationship is clearly a bad idea. The approach there is for the physician to maintain as formal a professional relationship as possible, establish and maintain clear boundaries and explicit rules of acceptable behavior.
I’d be happy to hear your thoughts on these topics. What do you find manipulative? What is helpful and acceptable? What “rules” do you follow when talking (and perhaps touching) patients? How do you use the “power of you?” What do you do to maintain a safe environment from patients seeking to break boundaries? Important questions, all. Let’s keep exploring.
Until next time,
“In time, in time they tell me, I’ll not feel so bad. I don’t want time to heal me. There’s a reason I’m like this. I want time to set me ugly and knotted with loss of you, marking me. I won’t smooth you away. I can’t say goodbye.”
– China Mieville
“Do not look for healing at the feet of those who broke you.”
– Rupi Kaur
“We cannot live only for ourselves. A thousand fibers connect us with our fellow men; and among those fibers, as sympathetic threads, our actions run as causes, and they come back to us as effects.”
– Herman Melville