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Bill Gould talks to DrB
On engagement: An interview with William M Gould MD
William M Gould MD is a graduate of Yale Medical School
and has a dermatological practice in Palo Alto, California.
He is an Adjunct Clinical Professor at Stanford University,
and for many years has had a special interest in psychocutaneous medicine.
He is a founding member and former president of APMNA
- the Association for Psychocutaneous Medicine of North America
DrB: Bill, what is engagement?
WG: I think engagement has a lot to do with focus. With focus, in that moment, you are really in contact, visually and thoughtfully with the patient. That would be my definition of engagement.
DrB: Why is engagement important?
WG: I can imagine some instances of clinical work where it wouldn't be terribly important, I mean if a patient is coming to you to have some stitches removed, that's a kind of mechanical process and engagement doesn't play a big role. But otherwise, even a complaint that turns out to be a common condition, like a wart, or acne, these are things that bother the patient, and if, for example you as a practitioner, have your mind miles away, the patient will perceive it, will feel it and will resent it. For that patient it won't be a happy experience and the treatment prescribed is less likely to be successful.
DrB: What needs to be considered by the practitioner, and the patient, in order to achieve good rapport and engagement?
WG: Usually the patient comes to the office with a particular focus, that is, with motivation, and with a problem to discuss and seek advice about. In contrast, the practitioner may have a number of competing matters on his or her mind which have nothing directly to do with the patient at hand. These things might include, for example, recurring thoughts that remain about previous patients seen minutes or even hours earlier, or feelings of tension or pressure because the clinic has been overbooked and the doctor is running late. Such things can make it difficult for the physician to truly engage with the patient. Such engagement means allowing patients to tell their story without interruption, letting patients feel that the physician is listening and attentive.
DrB: So, the practitioner also needs to start with an appropriate focus.
WG: Yes. For example, in the first few minutes the experienced clinician needs to be alert for indications of the particular patient's expectations: whether the patient is at ease and accepting about coming to the office for advice, or perhaps is tense and on edge, or even is overtly hostile.
DrB: Do you have any tips for the patient to consider as the consultation starts?
WG: If the patient comes without a focus, or with several issues to ask about, it can be more difficult to engage with the practitioner. Some thoughtful preparation may at least allow the most important problem to be considered first.
DrB: Do you think it is useful sometimes for the patient to bring with them a written list?
WG: It can be. If this happens, the practitioner should ask to see the list, and actually take hold of it, and proceed to use it as an aid during the visit. At certain points he or she can then say something like "Okay, we've dealt with that. Now, let's move on to the next point you have here." This allows the doctor to follow the patient's agenda, and still keep within the time available.
DrB: We have considered what engagement is, and we think it's important. What should we generally do, and what should we beware of, in order to engage successfully with the different patients who consult us?
WG: It begins at the very first moment of meeting the patient: how you introduce yourself, whether you have a smile on your face, and anything you can do to make the patient feel comfortable, show your interest in them, looking at them in the eye, listening without interrupting, at least to begin with. The talkative patient will need interrupting - explaining that there are questions you need to ask: this will then be perceived as helpful, showing interest.
DrB: Can we judge whether or not we have successfully engaged with a patient?
WG: I think a lot of the time this is intuitive. Every patient is different. The patient wants to have the feeling he or she has been taken seriously. This is a continuous process: it includes the history taking, and also during the physical exam, when the physician is touching the patient. With this, the patient will be more likely to feel that the assessment has been complete, and not a rushed job. I think often you only know you have successfully engaged if you have a good feeling at the end of the interview.
DrB: What can we do when engagement is difficult?
WG: Let's consider an example. A teenage boy is in the ofﬁce with acne because his mother wants him to get treated. He doesnʼt like to admit the fact he has visible acne. He doesnʼt want to be bothered with the whole thing. Heʼd rather be out playing ball with his friends, having fun. Heʼs sitting there, sullen, and getting him to answer questions is like pulling teeth. This is going to be a battle rather than a helpful interview.
DrB: And with atopic eczema a teenager may have had the problem since infancy, but in adolescence he or she is characteristically much more concerned about his or her skin condition, yet they will resent being brought to you by their parent: there's an issue here around "whose skin is it, anyway?"
WG: Yes, sometimes it's better if the parent is not in the room during the consultation. I can recall a particular teenage atopic patient who always came with his mother, and he was very difﬁcult to treat. Then I lost track of him, and it was a while later that I saw his mother over another matter. I asked how her son was doing. It turned out he was doing just great, teaching English in Japan. Now, he could have just outgrown his eczema, but it occurred to me that the separation from his mother may have been beneﬁcial.
DrB: How do we deal with situations where engagement fails?
WG: It must happen some of the time, that a patient walks out and they are not satisfied with the visit. And it isn't always my fault! I don't think it is possible to be successful in every consultation. If a patient has also been seen by another physician, who gave them their opinion, and as you assess the patient you realize you are coming to the same opinion, and that you are going to be telling them the same thing: well, if the patient hears it a second time from you, maybe they'll begin to take it seriously and accept it, but maybe they won't, and they will then say "Oh you're just another doctor who doesn't understand what my problem is"...and thats the way it goes, I'm afraid.
DrB: Before we stop, Bill, how much, in your practice in California, do cultural attitude, beliefs and expectations influence the way engagement is achieved, or otherwise?
WG: What comes to mind is that it seems to me patients from certain cultural backgrounds can actually prefer the doctor to be authoritarian, and this can make me feel uncomfortable. My natural inclination is to try to have an agreement with the patient, who should actively participate in deciding on what the treatment will be, because I think the results will be better that way. Now, patients from our western cultural background are sometimes very much intoalternative medicine, and very early on in the interview they will let you know they would prefer a so-called natural treatment rather than a pharmaceutical agent.
DrB: And how do you accommodate this into your practice?
WG: As long as what they seem to want is not harmful, I do not object. But I have to explain that for certain skin diseases you really need also to use a particular pharmaceutical to achieve an effective treatment.
DrB: Their natural treatment preference should be complementary rather than alternative?
WG: That's absolutely right.
DrB: Thanks, Bill.
Engagement is a term describing the rapport or relationship that occurs between a practitioner and a patient. Engagement is an important subject in behavioural medicine, where successful health care is seen to depend not only on diagnosis and prescription, but also on belief and expectation.