Pediatrics: For exceptional patient and family perceptions, think theater, not service

As our pediatrics focus month continues, Fred Lee shares his experiences as both a senior vice president of a major medical center and a cast member at Disney to look at how physician communication can influence patient perceptions.

When I was a boy in the fifties I was bitten by a rabid dog. We were living in Taiwan at the time because my parents were American missionaries. The Chinese pediatrician gave me my first gigantic rabies shot. It was quite painful, and I was to get one every day for two weeks. I cried going into the doctor's office the next day and begged him to let my mother give me the shot. The doctor knew my mother was a nurse and said it was all right. Even though I knew it would still hurt, it was significantly less painful than the previous one. Her soothing voice and gentle touch, her willingness to slow down when I winced, made it bearable. She gave me all the rest of my injections, and as I grew up I never wanted anyone else to give me a shot or stich up my cuts. Thankfully all the doctors I knew growing up let her do it.

Looking back through the lens of current understandings of neurology and psychology, I believe that the placebo response to my mother's touch in a painful and stressful moment demonstrated the power of perceived empathy to reduce fear, pain and anxiety in the patient's experience.

The book, The Experience Economy by Pine and Gilmore provided a paradigm shift I adopted for my own book, If Disney Ran Your Hospital — 9 ½ Things You Would Do Differently. These two economists set out to prove that there is a fourth economic offering, distinctly different than the currently held three-sector paradigm — commodities, goods, and services. They call this fourth sector the experience economy.

"Disney's mission could be stated as: meeting the emotional needs of a family having fun together. Not exactly a mission that fits our industry."

Audiences don't come out of an opera or a movie saying, "Great service". They say something like, "Great experience". The difference is in the emotional content. A service, by contrast, like cooking my meal, washing my window, changing the oil in my car, or dry cleaning my suit, is simply labor performed for me that I would otherwise have to do for myself. On the other hand, when I purchase a ticket for an experience that is staged for me, I am hoping it engages me at an emotional level. The expectation of an emotional experience is what leads me to purchase a ticket. Depending on what I am expecting, it needs to satisfy my desire to experience something internally that is funny, scary, romantic, or sad.

Disney's mission could be stated as: meeting the emotional needs of a family having fun together. Not exactly a mission that fits our industry. Theater, however, is not only about comedy and fun. It is also about tragedy, and every human emotion in between. Tom Hanks makes a movie as the voice of Woody in a Disney feature film, Toy Story, which is fun and entertaining. But when Tom Hanks makes a movie about a man dying of Aids, Philadelphia, he doesn't get it made at Disney because making a tragedy does not fit Disney's mission.

A pediatric clinic deals with children and their parents every day. Having Disney characters on the wall will certainly appeal to children. However, fun and happiness are not the key emotions the staff will be dealing with. In contrast to Disney's mission, theirs might be stated as: meeting the emotional needs of a family going through pain, fear and distress together.

"...75% of all malpractice lawsuits could have been avoided by better physician communication."

The most appropriate response to pain and distress is empathy, and its many synonyms such as caring, compassion, sympathy, kindness, and comfort.

Statistics from the insurance industry show that 75% of all malpractice lawsuits could have been avoided by better physician communication. In fact, there is only one predictor of the physician on a hospital staff most likely to be sued — the number of patient complaints. And the most common complaints are that the physician did not seem to care, was rushed, or did not explain things clearly.

According to research done by Bayer, physician loyalty is built by practicing four behaviors in addition to the normal physical assessment and diagnosis. They are: "Engage the patient; Empathize with the patient; Educate the patient in the patient's own vocabulary; Enlist the patient's cooperation in the healing process".

The Program in Placebo Studies and the Therapeutic Encounter was founded in July 2011 at Harvard Medical School. Its mission statement reads:

"Its purpose is to bring together researchers who are examining the placebo response and the impact of medical ritual, the patient-physician relationship and the power of imagination, hope, trust, persuasion, compassion and empathic witnessing in the healing process."

We are not surprised by how important "compassion and empathic witnessing" are in the healing experience. We all know that emotional distress affects immune function. When the patient or family perceives that a physician "really cares about my child", the response can actually be measured by immune system markers in a clinical study on something as ordinary as the common cold. (See, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720820/ where the response to physician empathy could be measured by the prevalence of Interleukin 8 and reduced severity in symptoms and duration.)

"We all know that emotional distress affects immune function."

As for physician loyalty, just circle the words used by grateful patients in their fan mail. Notice how often it is words like, caring and compassion.

The service industry can give the right scripts to use when we greet them and introduce ourselves and ask for information. But it cannot teach us much about compassion, since they do not deal with pain and suffering. So service training does not suffice. When it comes to responding to another person's emotional state, theater provides much better training. In the reference given above on the common cold, physician empathy made a significant difference. However, for empathy training, they turned to an acting coach, where like an actor, they learned how to engage a child like a sympathetic parent would.

Like my own mother giving me a shot with tenderness and love.

About the author:

Fred Lee has the enviable distinction of having been both a senior vice president of a major medical center and a cast member at Disney. At Disney he helped develop and facilitate Disney's healthcare version of its 3-day seminar, "Disney's Approach to Quality Service" and its additional seminar on "Customer Loyalty". Using an insider's experience and a keen eye for cultural comparisons, he authored the healthcare all-time best seller, IF DISNEY RAN YOUR HOSPITAL: 9 1/2 Things You Would Do Differently, which was awarded the ACHE 2005 Book of the Year. Disney recruited him because of his expertise in helping hospitals achieve a culture that inspires patient and employee loyalty. He now shares his insights with healthcare groups all over the world.

How can we improve the engagement between physicians and patients?