#27 Its not Just What You Say…
A review of Its All in the Delivery by Anthony Orsini, DO
Those of us in the healing professions have the highest intentions for clear and thoughtful communications with our patients. Somewhere along the way, with time pressures, electronic medical records, rules about who can accompany a patient, and high emotions, many discussions go badly. I read and reviewed Anthony Orsini’s book: Its All in the Delivery which addresses many issues, provides suggestions and lays out how to simulate the conversations. Here is my review:
Most of us realize that we learn an incredible amount from our mentors. We model the way that they dress, how they speak and how they interact with their patients. Paradoxically, we sometimes learn what not to do. When young Anthony Orsini was a neonatology fellow, he witnessed a much-admired attending physician, deliver bad news to a patient’s father in the most blunt and insensitive way. The attending knew he botched it and Orsini realized, too, that there had to be a better way.
Such was the birth of a lifelong interest in improving the patient experience through conducting better communications. Orsini pulls together elements of a personal memoir with the communication teaching techniques he has developed into: Its all in the Delivery: Improving healthcare Starting with a Single Conversation. The result is a short but impactful read that should resonate with all physicians and healthcare professionals.
After recalling his own history as a child with a seizure disorder, Orsini offers his view of how physicians have become too emotionally detached from the patients they are treating. This approach was literally taught and modeled for us during the internship and residency years. The effect of sleep deprivation and the intrusion of computer screens between us and the patients seem to have detached us both physically and emotionally from our patients.
Orsini writes that empathy plus imagination equals compassion. We have to imagine what our patients must be going through. Regarding having difficult conversations with patients, he writes, “It is easy for us to get caught up in the rapid pace of the day and become task oriented. We can forget that we’re about to change a patient’s life forever, and to them, we are the most important person in the room. Before any meaningful conversations can take place, you must take a moment and place yourself in the patient’s shoes. Stop to take a breath and imagine. This is half the battle. By doing this, your non-verbal language will be consistent with your words and the patient will genuinely feel a connection with you.” Page 47
From the introduction of empathetic and connecting conversation, he introduces his approach to breaking bad news which he has honed through personal experience and devised a way to teach to the staff at his hospital. After learning of a training program using amateur, to play the role of patients so that prospective doctors could practice delivering bad news, Orsini went a step further, engaging professional actors and setting up realistic situations for training residents and senior physicians.
This facilitated the gradual design of The Orsini Way, also known as “Breaking Bad News: P.R.O.G.R.A.M.” The acronym stands for Plan/Position, Review, Observe, Gradual/Genuine, Relationship, Accountability, and Meet. These steps, illustrated in text and photographs, are based on three essential principles: the patient/family should feel that the medical practitioner understands and cares, that he or she is the expert and will lead them to the next steps, and that he or she will not abandon them. Orsini instituted this program for his own program and established a robust business conducting workshops for other organizations.
Orsini goes further with lessons for improved communications on day-to-day issues in the medical office or ward setting. He observed the excellent communication skills of his family doctor in Newark, NJ, and spent decades honing a friendly and collaborative approach. His five principles of communication for a positive patient experience are introduced with evidence of effectiveness in improving patient satisfaction scores, more positive patient perceptions and anecdotal illustrations. He even includes a section on the unwelcoming signage that appears in many of our waiting rooms and patient care areas. With a little empathy and imagination, simple messages meant to make requests or convey information could be worded in a much more effective way.
The final sections review what to do when something goes wrong because inevitably, it will. Better communications reduce errors and malpractice suits. The author reviews how to form relationships quickly and effectively, even under stressful circumstances. The circumstances of neonatal transports and rapid-fire emergency department interactions can all be refined and elevated in meaning and compassion.
The message of Orsini’s title that “It’s all in the Delivery” resonates with those of us who deal with patients under very emotionally charged circumstances. Osteopathic physicians will agree that, “It comes down to this most fundamental of tenets- how you say something is more important than what you say. Every word has both definition and a connotation that evokes a unique feeling to the person receiving it.” (p.143) Orsini advises getting away from scripts that sound insincere and trying to build genuine rapport with our patients or their parents.
For many young professionals, however, genuine rapport has never been modeled and they actually have to start with scripts that just might gradually, over the course of years, become second nature and honestly sincere. This book needs to be read and taught to the receptionists, the environmental services crew, the nurses, the residents, the attendings and the hospital administrators. As Dr. Orsini reminds us, “One bad encounter can negate many positives.” Everyone can learn how to do it better and Dr. Orsini lays out the blueprint with affection and candor.
As a neonatologist, Dr. Orsini speaks with a wealth of experience about the high emotions of the neonatal ICU. He speaks of the jarring experience of receiving worrisome news in an insensitive way from another physician about his own son’s health condition. All of us will find ourselves in the position of the patient or the family trying to make sense of a terrible diagnosis or incident that seemingly comes out of the blue. Some of the basic “rules” of effective communication are just not intuitive or obvious to us or our colleagues, particularly during times of stress. When that day comes for me, I hope my physicians and nurses will have read Dr. Orsini’s book. Because as he says, “This is where the real miracle of medicine happens.” (p. 191)
