How One Patient's Feedback Changed Practice

Laura Arenschield

October 16, 2019

Catherine van Montfrans, MD, thought she was good at communicating with her patients: She listened, she took time to get to know them, and she delivered diagnoses with empathy.

Or so she thought.

So when she asked one of her patients — a woman near her age diagnosed with melanoma and who also carried a genetic mutation causing familial atypical multiple mole melanoma syndrome — to join her in front of 350 medical students, she was embarrassed to hear the woman critique the way she had delivered the diagnosis.

"She would have liked for me to have asked her how she felt, or to say nothing and to wait with her while she absorbed the news," van Montfrans told Medscape Medical News.

Instead, at the time of diagnosis, van Montfrans left the room for a pamphlet, in part so the woman could absorb the information on her own, and in part to leave what was becoming an emotional situation.

I was taken aback that she felt that way. And I've never forgotten it.

"I was taken aback that she felt that way," van Montfrans said. "And I've never forgotten it."

That was in 2014. Now, van Montfrans chairs the European Academy of Dermatology and Venereology (EAVD) patient association working group, which advocates for patients, especially those with cutaneous or venereal diseases, and helps people advocate for themselves in clinics around the world.

van Montfrans led a panel discussion on patient advocacy — and on how to improve the way healthcare providers communicate with patients — at the EADV Congress in Madrid.

At its core, the message was about empathy. "Take some time to ask how patients are feeling," she said. "Or sit for a moment and say nothing, and see if they start to talk."

Other tips she offered: "Don't use too many words for explanations, and give a moment before you continue with what the next steps will be. Offer emotional reflection: 'I see that you are quiet,' or 'I see you are crying. How can I help?'"

Ask, Listen, Then Act

Gwen Darien, executive vice president for patient advocacy and engagement at the National Patient Advocate Foundation, suggested that healthcare providers take three steps when interacting with patients: Ask, listen, and then act.

"We all make assumptions about other people, but I think the basic tenets of patient advocacy and physician–patient communication is to not jump from one step to the other, but to take those three steps in order," Darien said.

"So ask the patient how they are feeling, and what you can do to be helpful in that moment. Some might want to sit with a diagnosis and think about it. Some might say, 'Please leave the room, I need some time to myself.' Everyone wants something different, and the only way you're going to know is by asking them, and by actually listening to them. And then you can act on it."

Those questions should also consider the cost of care, Darien said, and not just the financial cost.

"What does a treatment plan mean to patients in terms of their life flow? What does it mean that you have to go to radiation therapy every single day, what does it mean in terms of child care? What does it mean in terms of lost work time and lost opportunities?" she said.

Darien, herself a three-time cancer survivor, added that, often, the most basic, simple question can be the most enlightening.

"Ask your patients, 'What do you want your health for?'" she advised. "There are very basic questions like this that actually don't take very much time, but allow trusting relationships to be built on both sides and allow people to feel as if they can have those conversations."

Improved patient communication has been linked to better patient outcomes (Patient Educ Couns. 2010;78:350-356) and to greater patient satisfaction. But it can also help clinicians.

When physicians have better communications with their patients, the physicians are happier themselves, too.

"When physicians have better communication with their patients, the physicians are happier themselves, too," van Montfrans said.

Communication skills are something van Montfrans thinks can always be improved upon.

After that fateful public feedback, she invited another patient to critique her in front of her students. And while the patient had good things to say, she also mentioned that van Montfrans could appear stressed, that she sometimes sat on the edge of her chair, in a posture that indicated she hoped to leave soon. That, in turn, stressed the patient.

"It made sense to me — it is the end of the morning and my waiting time is increasing — but I wasn't aware of it," van Montfrans said. "I thought I was taking all the time with her."

That patient's father also joined them in the lecture hall, and at one point, he raised his hand to tell his daughter how guilty he felt about passing on a gene to her that made her susceptible to melanoma.

That crystallized another lesson about patient advocacy: It is also important to ask a patient's support person, or people, how they are handling a diagnosis or treatment.

"Communication with patients requires time," she said. "But if you invest in it, it will pay itself back."

28th European Academy of Dermatology and Venereology (EADV) Congress. Presented October 11, 2019.

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