Gaffney Joanne - Relationship power in health care: science of behavior change, decision making, and clinician self-care

It was during the polio epidemic of 1955. On one ward were dozens of men and women lined up and paralyzed from the neck down, in iron lung machines, unable to breathe on their own or to speak. But they could hear just fine. Even as a second-year medical student, I realized before long that many of the doctors and nurses, including me, were saying things about our patients that they could hear. The adventitious comments in earshot of patients, like, These infections are stubborn! were taken personally and increased their suffering and sense of hopelessness. Our talking was mostly designed to relieve our stress, not to help our patients. Months later, much to my remorse, the survivors told me how the unconnected, seemingly critical comments from the mouths of clinicians only increased their sense of despair. Even though it was inadvertent, I felt badly about my part in it.

For years afterward, while making solo evening rounds as a trainee in pediatric surgery, my focus on what we say that we wish our patients hadnt heard was strengthened. Clinical comments like, Lets cut out his penicillin, said on group rounds within a childs earshot got transformed by the mind of one 5-year-old into terrifying words like, Lets cut out his penis. Before the penicillin was stopped, that child developed his first fever spike in a week. The possible impact on patient outcome of the clinicianpatient relationship began to pique my curiosity. Research was emerging, also, that diabetes II onset in teenagers correlated with a recent divorce or death in their family. I realized that unprocessed emotions and out-of-tune comments in earshot of patients were the tip of an iceberg of out-of-sync patient care that needed attention.

My interest in tracking and understanding relational processes in patient care piqued again seven years later during my first year as faculty in child and adolescent psychiatry. I discovered a whole collection of parents who had shopped among many clinicians for answers about their childrenwhich was both expensive and wasteful. My first hypothesis was that a more integrative approach would fix it. Fortunately, I knew a pediatrician/neurologist who was conversant with child emotional development, a child psychologist who used testing flexibly, and a trusted clinical social worker who respected the role of parents and pediatricians. We started an experimental diagnostic clinic that integrated our four disciplines. Having learned that what clinicians describe they have said and done with their patients is significantly different from what a mentor or the same clinician might directly observe, we included a technology for observing our work in real time. A lot gets lost in the translation that is significant, especially for trainees. I recommended that we build a one-way mirror suite to observe each others interviews and to integrate our process and findings. We called it Team Clinic for Children and evaluated one child and parent(s) in a condensed 3-hour-long session in a single morning. Even the insurance companies liked it and gave us a unique procedure code.

The clinic became a teaching center for students and trainees from each of our four disciplines and for nurses. The total clinical and teaching impact was greater than the simple sum of the parts. The questions of why parents shopped from clinic to clinic kept us focused on parental alliance-building. I thought, What is the point of obtaining accurate diagnoses of children if the communication with and engagement of their parents lagged behind? Team Clinic became a last-stop child evaluation clinic, not mostly by increasing accuracy of child diagnosis but by making advances in parent engagement and communication of evidence-based information (Livingstone, 1968). The fix for costly parental shoppingwhile the childs symptoms became entrenchedturned out to include the integration of disciplines and the enhancement of the parentclinician relationship.