Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 5.

Another recommendation in the informal curriculum is to regularly acknowledge patient strengths.

Physicians are specifically trained to look for problems. The purpose of diagnosis is to identify what is wrong with a patient’s health. As a consequence, we spend a lot of time thinking and talking about what is ill, incorrect, out of order, defective. Our worldview can shift so that we overlook what is healthy, robust, flourishing, hopeful.

Patients, like all people, like to hear what they are doing well. None of us like the experience of receiving only negative feedback, particularly when we are doing the best that we can. Acknowledging patient strengths explicitly recognizes the contributions patients make towards improving their health. We want them to continue to do those beneficial things.

Physicians are in positions of authority and power. Taking the time to comment on what a patient is doing well can strengthen the relationship between patient and physician. Furthermore, this positive feedback can encourage patients to continue their efforts in improving or maintaining their health status. (Positive reinforcement[1. Positive reinforcement is an active intervention that increases the likelihood that a specific event will happen. Example: A woman wears an orange blouse to work. People tell her that the orange blouse looks great on her (intervention). As a result, she wears the blouse more often.] is often more effective than negative reinforcement[2. Negative reinforcement is the removal of something unpleasant that increases the likelihood that a specific event will happen. Example: A woman wears a green blouse to work. People incessantly whine that she looks better in an orange blouse. She wants the whining to stop (i.e. removal of something unpleasant). As a result, she might wear an orange blouse more often.] or punishment[3. Punishment is an active intervention that is meant to increase the likelihood that a behavior will stop. Example: A woman wears a green blouse to work. People spit at her because she is wearing that blouse. She learns not to wear the green blouse… but note that she does not know what the desired behavior is. Compare this with negative reinforcement.] in changing behavior.)

Acknowledging patient strengths need not be saccharine. Simple observations can serve as encouragement:

  • You’re checking your blood sugars regularly.
  • I see you’ve gotten out of bed three times already today.
  • You’re keeping a record of how much alcohol you’re drinking.

These observations may ostensibly appear neutral. However, patients know that doctors pay attention to those things that we find important. This attention is often highly valued currency. Patients may find themselves attending to and doing these desired behaviors more often as a result.

How often do you explicitly point out what people are doing well? Do you find yourself commenting more on problems?

  1. ”Tell me what you think helped keep your blood sugars within this healthy range on this day.” or “A lot of your blood sugars are too high.”
  2. ”You’ve helped your body recover by getting out of bed.” or “You should get out of bed more often.”
  3. ”What’s helped you limit your alcohol use to a bottle of wine on that night?” or “On most nights you’re still drinking two bottles of wine. This is a problem.”

Of course, there are occasions when we must discuss problems and focus on what is wrong. This is not a call to willfully disregard what is out of order. This is a reminder to balance what we say.

And lest these suggestions seem foolish, consider your own experiences with your supervisors. We like it when people recognize and praise the work that we do. It’s a drag when we only hear about our lack of productivity, patient complaints, or the urgency to discharge patients from the hospital. Most people want recognition and encouragement for their efforts.

Patients are no different.