Building Rapport

Rapport is the feeling of trust and confidence an interviewer seeks to establish and maintain with respondents. It is essential in the doctor-patient relationship to build rapport to help facilitate the patient's treatment.

Introduction and Discussion
The main issue in this case is establishing communication and rapport with the patient. Physician/patient rapport provides the trust and confidence and encourages the patient to reveal more history and information. Allowing the patients to ask questions and to communicate will help to provide better health care by allowing them to disclose more information. The question here is how to establish a better connection and rapport with your patients which helps to provide a better and more efficient health care for them?

Discussion
The first video clip was an excellent example of how NOT to establish rapport with this young patient. Dr. Crane depersonalizes the patient by yelling things like "pregnancy test on urine in 5". This in addition to being rude and unpleasant for the patient is a real invasion of her privacy. Dr. Crane also gives off an unwelcoming body language -- bad eye contact, hiding behind the clipboard, turning away from the patient to yell things out into the hall. Dr. Crane also rushes out of the room at the end, leaving Tammy's questions unanswered. This approach to an encounter is really awful especially as this is one of Tammy's first experiences with OB/GYN. The 2nd Dr. Crane does a much better job of being respectful, sympathetic, a good listener, and shows better body language.

I think the 1st step is showing that you care and respect. Going back to the previous discussion dealing with Miguel, it cannot be overstated that having the desire to do good, do no harm, respecting the patient’s autonomy are essential in providing better and effective healthcare. When you genuinely care and focus on working with the patient and for their rights, then a solid connection and rapport will inevitably be established. I agree with what was said with regard to how Dr. Crane did a much better job of interacting with the young woman the second time around.

I agree with the statement about patient rapport and connection and would like to talk more about that. I think the most important thing a patient can have is someone who really does care about them and their health, someone who they trust, someone who does not get flustered when he or she might "act out" at them.


 * 1) Caring about the patient: this includes asking the patient about their health and more opened ended and follow up questions in that particular venue. When the patient refuses to answer a particular question, the doctor won't force him or her to answer that question and drops it. A caretaker is someone who should elicit patient information respectfully and not impinge on what is uncomfortable for the patient, provided this information is not life-changing towards the patient's health. In short, the doctor should be following the patient's lead, a core principle I learned from hospice work, where the hospice volunteer always follows the patient's lead.
 * 2) Someone who they trust: Initially, for example the first encounter with the patient, is hard to establish. Over time, the patient sees the care that he or she receives from the physician and is turned on/turned off by it while asking questions to themselves. Does the physician do all he or she can to help me out? Does it seem like the physician is hurrying and trying to get me out of the room because the patient backlog? Was the physician able to really help me today? I think a lot of times patients come into the office for one clinical problem but there really is a more important reason for their office visit i.e. suicidal ideations, domestic abuse, a concern for cancer, etc... I think this all comes with hearing out the patient and really understanding why they came in the first place.
 * 3) A physicians response when the patient acts out on them: This is another crucial aspect of developing patient rapport for establishing patient diagnoses. After a patient lashes out or is not very nice to a physician, assuming the doctor's positive response and also the individual patient, this could be a very big positive builder in strong patient rapport. I once had a hospice patient, Jim, who had ALS and was very sick. One weekend I came by to his house to hang out with him so that his wife could go grocery shop for the family. He couldn't talk anymore and communicated via the keyboard. When I first came, he wasn't being his usual cheery self. I didn't think anything of it so I continued to try to talk to him. The answers were short, he said he didn't want to talk, and then I proceeded to just be quiet; I didn't want to intrude into his. After 30 minutes, he started talking again and had said "thanks for bearing with me, I've had a tough day" and continued his usual calm and talkative demeanor. Was he more talkative because he felt bad that he wasn't talking to me? Was he more cheery because he felt better? It is a combination of all the above. I believe that part of the reason why he started talking again was because he felt that I wasn't intruding on his space or being all sad, emotional, and down about the situation despite his different demeanor. I know this is an extreme example of a patient "acting out" because he clearly wasn't, but it was my attitude and response throughout that lead to patient rapport.

I think in Tammy's case it is important that the physician is a female. Discussing such sensitive topics for the first time can be somewhat difficult and I think that the patient must be able to quickly connect with the doctor. I know this can’t always happen but we must keep our patients best interest in mind. I think you guys have listed excellent ideas about how to establish rapport, let’s keep those in mind when we are rushed in the office...

I think the above questions all deal with establishing patient trust. Asking questions about a patient’s sexual history can be awkward for a patient of any age due to the sensitive nature of the questions. This is especially true of teenagers who may have the additional concern of confidentiality. I think it is important to stress that the questions are being asked so that the doctor can better care for the patient and get a better idea of all of the factors which may be contributing to the illness. It is also important to reassure the patient that the information will be confidential and will not be discussed with anyone else, including the parents if the patient so chooses. By creating a trusting environment, patients are more likely to be forthcoming with information which may be embarrassing or difficult to talk about.

Building a trusting relationship with teenage patients can also allow them to ask questions and obtain accurate information that they may otherwise not get. Last year WIMSO organized a young women’s health day at a local high school. The girls had an opportunity to ask anonymous questions about sex and health issues. Some of the questions that they asked made me realize that sex education they receive in school does not really address crucial issues like contraception and STDs. It is important to not make assumptions that girls who are sexually active know about the risks involved with sex and about the options that they have to protect themselves. Assuring confidentiality and creating a safe environment in the physician’s office provides an opportunity for open discussion and education about sexual health.

If a patient has a humiliating experience when presenting with an STD, the experience is more likely to prevent her/him from seeking care for future STDs than it is to prevent her/him from having unprotected sex. You already have some good insights into ways to promote an experience in which a patient can learn and not feel humiliated. Any other ideas?

I think another way to elicit patient comfort and rapport when it comes to sexual history is to do the "patient-centered" and "assessed feelings" approach. In the patient-centered approach, you ask them what their feelings are on their sexual experiences/genital symptoms/what it might be in order to get an idea of what they think might be going on or what might be troubling them. I think this approach is strong as an initial springboard further into the topic because it tells the physician what he or she already knows and which may or may not be correct. It makes the patient feel more involved in their care also, if the physician has a positive, encouraging response.

In the "assessed feelings" technique, you ask the patient about how they "feel" about answering or talking about a particular subject, like their sexual history. Again, this is important to feel their emotions into the subject matter. Also, it gives the patient more of a "say" in their care, and makes them feel more important. This is core to developing patient rapport and thus, patient information.

The point that I wanted to talk about has already been brought up. That is, what are some good ways to breach sensitive subjects when the physician is the opposite sex from the patient? It seems especially from the male perspective that you are excluded from the room for sensitive exams or interviews at the patient's request on a weekly basis. I am perfectly alright with this because the patient has every right to be in control of that situation. However, what happens when that isn't an option? Say you are in a situation where there is no one else who can do that exam/interview (emergency, geographic location...), and your job is to make the patient comfortable and give them adequate care. What do you do then? And in this situation you have adequate ancillary staff for chaperoning of course.

I do not think it is insurmountable--I know there are many opposite sex providers who do great with this--partly because of their own comfort and experience with dealing with these situations. Most patients don't want an audience so that makes viewing role-modeling of this difficult. Has anyone seen this dynamic "done well?"

I understand the feeling that a same-sex provider would make one less uncomfortable, and yet the male physician I am working with actually does a fair amount of gynecology as part of his practice, and all of his patients seem quite comfortable with him (although not always with me shadowing him). obviously the key is trust and rapport, and in this community everyone seems to know everyone and many of them have been seeing the same doctor since they were a child (and their parents saw the doctor, and their siblings do, and their cousin does, etc...), which certainly is an advantage in building trust between doctor and patient. However, even when you are less familiar with the patient I don't think being of the opposite sex has to be a giant impediment to dealing with sensitive topics. The doctors I have seen do this well don’t seem rushed, do as much of the non-sensitive interview/exam as possible before moving to sensitive topics, and appear confident and competent with the exam or interview. I think one of the big things that make patients uncomfortable, whether their doctor is male or female, is when the medical staff seems uncomfortable or embarrassed with the exam/interview too...

I believe that key here again is building rapport with the patient and developing a patient-centered relationship where the physician and patient are a team in maintaining/bettering the patient's health. Conducting sexual histories and talking about STD's are very difficult but if we can assess what the stage a patient is at- whether he/she is denying/acknowledging that his/her lifestyle is a contributor to his/her STD, is ready to make a change in his/her life- and ask questions/make statements/listen to engage the patient in his/her healthcare, we may be able to see change in the patient's lifestyle that leads to better health. Whatever the health issue is, whether it is STD's, obesity smoking cessation, etc, the patient must come to a point where he/she believes that he/she is a active participant/leader in his/her own healthcare.

I have already had the privilege of some OB/Gyn related encounters during my rotation and therefore can really appreciate the difference between how the physician in the video approached Tammy and how I approached the older teen females in the office. This is what I have carried away from this interactions:


 * 1) It is important to not act awkward about the questions or exams that will take place. Patients pick up on this and feel ashamed and awkward themselves.
 * 2) Do not assume that young female that comes into the office is knowledgeable even about some of the most common forms of protection. I have used these opportunities as a means of sharing with them their options including spermicide, etc.
 * 3) Go over how to do a breast exam and what to look for with this age group. Today an 18 year old, married with a 3 y/o child came in today concerned about a lump and had never been taught how to do one. While examining her, I taught her this skill then provided her with take-home literature.
 * 4) Approaching them at their level while maintaining professionalism opens the means to greater communication. I am not sure if I felt that I was able to get more details because I was a younger female "doc" than the preceptor or because of my approach. Nonetheless, validating their feelings/concerns and all those skills we learned in FCM make for invaluable use.

I also think someone earlier brought up a really good point of asking the patient which sex practitioner they would prefer, if any. I had a similar situation come up when I worked in a women's health clinic. A patient wanted a woman practitioner and one of the nurses felt strongly that this was discrimination on the patient's part, and if she wanted the free health services she would have to see the available male practitioner. I'm not exactly sure why the patient couldn't have waited for a female, but it seemed wrong to me to make the patient uncomfortable - plenty of women request women practitioners especially for women's health. Then the nurse brought up an interesting argument - if the patient had requested a white practitioner, what then? This made us all uncomfortable, and if it were me on the phone with a patient requesting this I'd tell them we don't operate our clinic that way. I don't know how to rationalize that with complying with a patient's request for a female.

I cannot help but be reminded of a common complaint amongst my female classmates at William and Mary. The doctors at our campus health center, while well-intentioned, were notorious for strongly suggesting the possibility of pregnancy to every female patient, regardless of chief complaint (sprained ankle, etc.) I am happy to say that most found a lot of humor in this situation, but some women were truly offended and sought medical care elsewhere from that point on. I think that the situation at W&M highlights the importance of LISTENING to each patient and tailoring our interview style according to the patient's lead. Of course there is certain information that must be obtained from every patient, but the manner in which it is obtained should vary widely if we are really hearing what the patients say and not conducting a cookie-cutter interview.

Recommended Resources
The following link has an excellent article into the different techniques of interviewing and a small data collection on which types males and females respond to: http://archfami.ama-assn.org/cgi/reprint/8/3/218.pdf

From Wikipedia, the free encyclopedia: http://en.wikipedia.org/wiki/Rapport

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