The Impact of Communication Skills on Patient Outcomes: Part 2
My first time I had to open a treatment door by myself, walk in and treat a patient, I was so nervous I was shaking. I felt like a total fraud. “What did I know?”
“What possible benefit could I provide to this other human being waiting on the other side of the door?” “Who was this other person and what would they think about me?” All these thoughts were racing through my head. So I did what I had to and I faked it! I pretended I thought I knew what I was doing, even though I was convinced I didn’t know anything. I acted with confidence. I pretended that I believed that what I was suggesting the patient do would help, even though I had no idea of whether I’d be successful or not. As I acted in this confident way that was contrary to how I felt, the feeling of insecurity vanished. It turned out that first new patient, a stranger to me, was nice, interested in what I had to say and had confidence in me (which I thought had no foundation whatsoever) and so my career was launched in a rickety, awkward way.
Now when I open that treatment door, after treating thousands of patients and training hundreds of doctors, I’m confident. I realize now that it’s okay to not know everything and to be honest with the patient about what I’ve seen and done in the past with other patients. The confidence is real because it’s based on my personal experience.
Confidence in the patient communication context often means faking it because in all honesty, we’re not sure how well things are going to go. Maybe confidence itself is remaining confident when you’re not confident, having a sense of purpose and knowing things will work out even when you’re not sure what the final outcome will be. I built my confidence in my first five years of practice 100% on the backs of my teachers. I’d watch Dr. Frieder design and implement a clinical nutrition program with an autoimmune case, observe the patient return in a month much improved and think, “Okay, I can do that, it worked for his patient, should work for mine”. Eventually I realized that most of what Frieder did worked and I just became confident in everything he recommended. In turn, that allowed me to be confident in everything I recommended, even though I didn’t have his depth of experience yet. I just mimicked him until I got it.
When I met Dr. Bill Timmins, I thought, okay, here’s an old guy, been practicing for decades doing these functional medicine labs—he must know what he’s doing. So I just copied him. Lab for lab, B6 milligram for B6 milligram, I did what Dr. Timmins did, confident in his skills and that what he did would work with my patients. Eventually, the transference process was complete and by year five of my practice I had confidence in myself because I’d had so many hundreds of success stories. I finally not only believed in functional medicine, but I had experience in functional medicine, based on my own successful cases. Since that point confidence has never been an issue.
Part of why I spend so much time now teaching is to lead by example and show doctors coming into the area of functional medicine that this stuff really works better than you could imagine. It’s not that hard to figure out how to do it if you have someone good to copy.
Simple Explanation of Complex Issues
In the early 1990’s, when I first learned about cytochrome P-450 issues, I was enthralled. I studied Jeff Bland’s lectures and read everything I could on the subject. I thought it was one of the most interesting things I’d learned. By the time I was face to face with a patient and had to explain why they needed to complete a liver detoxification program and follow this elimination diet for 30 days, I thought, I’ll just tell them about cytochrome P-450 and maybe I’ll mix in a little on DNA adducts and boom, they are going to be super excited too. Have you ever been lost, stopped to ask for directions and have the person helping you tell you exactly what you need to know so quickly and in such a confusing way that the directions were of no help? That’s what I was doing to patients. I was telling them about what I found interesting and focusing on the science and research aspects of the work we do. For me, when I understand the science behind a subject, it motivates me to pursue that area. However, what we find interesting may or may not be relevant to that patient at that moment.
Patient personalities vary. Some people really enjoy learning about the complexities of the science behind cytochrome P-450 and some people really don’t care. Some patients will do better with a simple story or analogy. Many patients have no interest in any of the details and focus in on what exactly they need to do to get better. Understanding the process isn’t important to them. As we attempt to explain the complex subject of functional medicine in a simple way, the focus is, as always, on patient communication skills development and being sure that our message is getting through to that individual, that we are speaking that person’s language.
I ask patients right away if they are interested in learning the details behind the labs and if so, to what level. I’ll see if they are in a hurry and just want to get their protocol set up so they can start right away. Finding that right mix of education makes all the difference in getting off on the right foot with a patient program.
There are also FAQs of practice. There are frequently asked questions that almost every patient will ask and if they don’t ask you, be assured they are wondering about these issues to some degree. In order to cover the FAQs of FM, I’ve developed scripts or frequently given dialogues that I use with almost every patient. I’ve found it best to answer questions early in the process, often before the patient even asks them. Here are some examples of questions we should all be prepared to answer with examples of how I answer them.
“Why did I get sick in the first place?”
“How long will this take, how much will this cost, do I have to take these supplements forever?”
“Why Did I Get Sick In the First Place?
This is an opportunity to present a clear, cohesive model of functional medicine. We all need a “philosophy” of functional medicine. A belief system. A structure. A well- this-is-the-way-things-work speech. I like mine and you’re welcome to copy part or all of it if you don’t have one of your own yet. I copied someone else for about eight years until I came up with this on my own.
Let’s call the patient Dorothy. Dorothy, in functional medicine, we look at illness as a result of a failure of body systems. We don’t look at individual symptoms and treat them in isolation. So for example, if you have high blood pressure, of course we want your blood pressure to normalize. But we also want to understand what is the underlying cause of the problem and work from there. We look at three body systems: the neuro-endocrine system (that means your brain and your hormones), the digestive system, and the detoxification system. Most often, someone becomes stressed due to emotional or spiritual disconnection; perhaps a divorce or death in the family is a trigger or 10 years at a job that they hate. That stress damages the neuro-endocrine system; stress hormones like cortisol increase while thyroid hormones and sex hormone levels drop. Many people experience a depletion or burnout of neurotransmitters, which are the chemicals in the brain that keep us happy and motivated. As a part of the stress response, the digestive tract tends to weaken and we develop “leaky gut”, food reactions and sometimes even digestive tract infections with bacteria, parasites or yeast overgrowth. If this goes on for long enough, the detoxification system falters and we accumulate a large burden of toxic chemicals and dangerous heavy metals in the body.
And, Dorothy, by the way, we have a test for each one of these body systems. I will test your neuro-endocrine system, your digestive system and your detoxification system so we can determine where your specific problem is coming from and develop a comprehensive plan to correct each body system. What we find is that when all three body systems are working properly, the symptoms you are experiencing clear up.
From a patient education and patient sales perspective, we are wrapping the explanation of the clinical model in with the three body systems, which matches the three labs tests we want them to purchase. This is how to dovetail education with sales to create the motivation for the patient to buy all the necessary labs. Later, the same technique is repeated for supplements
Relevance and Urgency to Act
How do we create relevance and generate a strong sense of urgency to act? How do you take someone who has struggled to make changes and get them to move beyond their past failures? When I am able to do something I see my patients are able to do as well, they learn through transference. I find that 100% of my credibility in asking a patient to start meditating rests on the fact that I meditate for two hours most every day. Patients find that inspiring and I set the pace as the role model so that when I ask them to meditate for five or 10 minutes every day, all of a sudden it seems doable to them. Similarly with alcohol and caffeine, I can only ask a patient to stop all alcohol for three months or to get off caffeine if I’ve lived that way and been able to do this myself.
So it starts with our own personal habits. Once we have these mastered, we can then follow some basic sales and motivation techniques to get patients enrolled in what we are already doing ourselves.
Although I do the same lab work-ups (hormones, GI and Organic Acids) on every new patient, the reasons for testing vary. In order to establish relevance and a sense of urgency to act to purchase a lab kit, we have to explain in an easy-to-understand way why this specific test makes sense for this specific patient. So, for example, if someone’s chief complaint is fatigue, I’ll explain how hormone imbalance, neurotransmitter deficiencies and mitochondrial energy problems can all, in and of themselves, create extreme fatigue. The kicker here as I speak to the patient is that I’m not sure what is the exact problem for them, so we’ll need to do all the testing to figure out exactly what’s wrong so we can fix it. If someone has a primary problem with depression or anxiety, it’s again the same testing, but in this case for different reasons, since we consistently find hormone imbalances and poor neurotransmitter function due to stress causing depression. Yet, we also see many patients with gut inflammation who end up depressed as a direct result of the GI tract tissue damage and of course, we often see neurotoxins triggering anxiety or depression so again, we need to test all three body systems to determine the root cause of the problems. While the protocols are individualized and specific to that patients particular labs, the actual lab work-up I order remains the same 90% of the time.
Dan Kalish, DC
Dr. Dan Kalish has developed his own model
of Functional Medicine founded on 25 years
of successful clinical results. Through The
Kalish Institute he has trained over 1,000
practitioners worldwide in The Kalish Method,
which solves patient challenges through
a lab-based approach.