More Questions: Improving the Patient Care Experience
- pietruszkaraye
- Jan 7
- 6 min read
Updated: Jan 8
I want to highlight a question that a doctor recently asked at the beginning of a patient's visit. This blog post is an open letter to thank all healthcare providers who ask this question and I will also use this as an opportunity to extend our learning as we constantly strive to improve healthcare experiences (for patients, their families and even for ourselves, as healthcare professionals).
"So, how was the last treatment?", the doctor asked.
To share a little background, it is important to know that the word "last" meant "previous" in this context and it was actually the "first" treatment with this doctor. This type of treatment (likewise, we can consider the words: procedure, medical visit) was not new to this patient and like others, these treatments range from uncomfortable to very painful. It's also important to know that the doctor likely did not grasp the severity of the patient's pain during the last treatment just by observing the patient's behaviors (ie: midway through it started and persisted through the remaining 15 minutes, a continuous stream of tears and the tensing of muscles). In certain settings, this patient is very quiet, will answer questions but will not initiate discussion, and often does not verbalize physical pain (or emotional pain) to healthcare professionals. This patient presents themselves as "everything is great" and "nothing is going on here" during very painful moments. This patient is tough and to many of us, this patient is a common patient, well known to parents and healthcare providers. Some reading this might even be thinking, that sounds like me. I know many patients, many adults and even a maxilliofacial surgeon who is "this patient".
Why is this question important for healthcare providers to ask?
It starts the dialogue, demonstrates importance to you and gives them a voice: Here is the important piece - how do you think this patient answered this doctor's question? ... ... ... ... Think for a minute on what I have already shared ... ... ... ... True to character and temperament, this patient did not choose to share their full experience - they simply verbalized, "it was fine" and got into the usual position for another treatment, body tensing up in anticipation of pain. What the doctor did not hear after the last treatment, and well out of this particular clinic area, is, "that was the most painful treatment so far". Likewise, as we prepared for this 2nd treatment, the doctor did not hear the patient say, "don't tell [them] anything", "no", and "we'll just see how this goes" to my questions, "would you like me to help you share that the last treatment was painful?" and "would you like me to ask if there are any pain measures [they] can offer?". So while this question is still very important and begins the dialogue (and may be successful in getting an honest response), this particular patient would benefit from follow up questions or statements that validate the patients experience. Read on for tips!
To reduce further trauma and support emotional safety: While this blog post was prompted by a true lived experience by myself and a patient - it highlights common fears and experiences many children and adults share: fear of sharing pain or "weakness" and fear of "disrespecting" or "challenging" or "critiquing" an authority figure. I am a firm believer that no one is an expert (and certainly not all the time) and there is always room for improvement. These questions ensure that we are digging deeper into the psychosocial, emotional and pain experiences to reduce the risks associated with trauma and adverse childhood events (ACE).
Observed behavior alone is not adequate for assessing pain: Of course pain scales are helpful tools to use for patients of all ages and abilities but when you get to the bottom of things, no one can determine someone else's pain experience and these don't paint the full picture, pain is not an isolated event. What matters most, is that you exhaust ALL avenues and resources to continuously assess pain and give options for treating pain (or stress). This means we simply have to ask more questions and dialogue.
To build resilience and healthy coping: This question allows reflection for all people involved. It offers an opportunity to improve the overall situation and experience. This question opens a doorway for patients and providers to work together to improve the next similar experience or the next "last treatment". This question leads to discussions and insight into what worked, what didn't work, what caused stress, what helped reduce stress, what might have been missing, and what could have been said or done to improve the situation. The answers to this question can spark individualized care that is essential in building healthy coping skills and an added bonus: they can spark larger system wide change that improve the healthcare experience for all.
"The more reflective you are, the more effective you are." - Hall and Simeral
So, why did I omit gender, specific age, the treatment type and other details here?
While all of these aspects matter in our general assessments, as a veteran child life specialist and experienced healthcare educator, I believe we should be asking this question, questions like this, and even the follow up questions much more often, routinely. Certainly, this question could be helpful for any healthcare visit that involves an ongoing course of "treatment" or even routine healthcare events that are potentially stressful and painful. Let's face it! How many times in your experience (as a parent or provider) do you observe or take on an attitude of "it's to be expected, they'll cry through it". It is a healthcare norm amongst parents and healthcare providers that I think we all need to work to change. The answers we obtain by exploring these questions provide the building blocks and drivers of the patient care experience. These questions, when asked, or not asked, can affect lifelong coping. We want newborns to grow up equipped with knowledge, skills, and confidence to meet their healthcare needs. We want newborns to grow up with trust in their healthcare teams and systems, feeling secure that their providers will do everything to make experiences less painful, less stressful and easier than the visit before. Regardless of the identifiers above, the answers to these questions drive success.
TIPS FOR NEXT TIME:
Prepare for a patient's dismissive responses. Even when doctors ask this question, some patients may need to build more trust to answer honestly. Follow up with statements like, "I know these treatments can be uncomfortable but I'm going to need your help to tell me if things feel worse than uncomfortable. We can take a break and find ways to make this easier."
Make sure you are documenting patient responses to pain (behaviors / words, not only pain scores), your interventions to address the pain, and refresh before your next visit. Managing pain (perceived pain AND STRESS) is a huge part of your care plan regardless of the invasiveness of the procedure or event. This helps to improve future visits.
Don't overlook the benefits of documenting pain and stress for "less invasive" procedures / events. Example: for a toddler , pain responses - "patient cried, arched back, and pulled away during head circumference". Intervention - "Provided anticipatory guidance to prepare for next visit. Gave mom measuring tape to increase familiarization and comfort. Provided suggestions on how to use it during supervised play at home and just before the next well visit. Encouraged mom to bring a favorite stuffed animal for the next visit." Next visit: In preparation, let the child hold it, see it and use it with their stuffed animal before using it on them. These early experience shape lifelong coping.
After refreshing yourself on the previous visit, start out with statements like, "I wrote in my notes last time that you quietly cried and tensed your muscles, you did a great job getting through something hard. If something feels too much or too hard to get through, I want you to tell me or raise your hand" and discuss options to manage the pain.
Always offer non-pharmacological options for any procedure / event that is associated with discomfort or pain. Plan ahead for using pharmacological options to ensure the proper resources are available and ready for immediate needs.
As a certified child life specialist it is my role to help children, teens, and caregivers develop the skills to advocate on their own, to support their sense of control over their own experience, and to promote a sense of independence and autonomy in their healthcare journey. It is also my role to provide training and educational opportunities to support healthcare providers as they aim to provide exceptional care to ensure emotional safety and to promote positive healthcare experiences despite potential and known stress and pain.
Why didn't I write a personal thank you note or intervene to advocate?
It would "out" the patient. It is important to honor the patient's wishes and control over their own healthcare experience, this patient is practicing the skill of going it alone - it is my job to prepare them well enough so they don't need me or their parent. I will definitely write an anonymous thank you letter to the doctor himself and to the patient relations department. Parent's, we need to do this more often.
Healthcare providers, my HUGE THANK YOU goes out to you!
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