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The Truth About Authenticity

      As a health care provider looking after mostly geriatric, or chronically or terminally ill patients, I have many opportunities for meaningful interactions with my patients and their families. And these interactions are a big part of the reason I love my work. I am blessed to have decent penmanship and work at nursing homes that still use paper charts, so I can sit and look patients and their families in the eye during most of our time together, instead of looking at a computer screen.
      I am not a perfect clinician. I can get distracted, for instance, if my Tessa bolts out of the room because she hears another dog. Or if my phone rings. But in general, I am engaged with my patients and I try to listen a lot more than speak (with varying degrees of success … as they say, “progress, not perfection”). My interactions with my patients are real. I care about them. I want to help them in the best way I can — to give them the care they want, and avoid treatments they don’t want — and help them make informed, individualized decisions.
      When I talk to my patients, I am not afraid to be spontaneous and transparent, even if I may not say the exact right thing that a textbook or website might recommend. (Or maybe I just have never developed the appropriate filter to stop me from, say, hitting the send button after writing that brilliant but very snarky e-mail.) I might even become a little annoyed with a patient sometimes, or more often a family member, although these days it takes a lot at the bedside to get me to that point. But even when I do, I am being authentic. I am having a real, human, feeling moment with my patient and family. And I think people appreciate the authenticity. I shouldn’t jinx myself, but I haven’t been named in a malpractice lawsuit in quite a few years now, and I think part of it is because I actually communicate with my patients and families, even in my imperfect and sometimes unfiltered, impulsive way.
      I have to admit that I have some biases. Perhaps because I have a hard time being inauthentic — or measured, or reticent, or whatever you want to call it — when I see this in others, I just don’t like it. When I see topic experts or motivational speakers or other gurus make presentations, sometimes they speak so slowly, making you wait several seconds for the next word, that I just want to slap it out of them. I suspect these folks went to some training course where they demonstrate how to gesticulate for maximal effect, how to say a certain phrase twice in a row in the middle of a sentence for emphasis, and how to rehearse in front of a mirror (or maybe even record themselves on a webcam? Is that a thing?), and other valuable communication tools. But to me, they are simply not being real.
      Don’t get me wrong — I try to listen for the message. And indeed, some of these speakers clearly have their hearts in the right place, so I try to step back from my judgment, put the biases aside, and give them a break. After all, they are simply trying to get an important message across. Although I can usually look beyond the overly scripted appearance, I still don’t care for the delivery.
      My personal speaking style is the opposite. I talk fast and want to cover as much ground as possible. I don’t rehearse my presentations when speaking in front of a group. (I know, you can tell. No need to bash me over the head with it.) I try to slow myself down a bit, but there is usually so much to be said! As with my patients, I assume the authenticity will buy me a few points, even if my spontaneity may be little more than an excuse for laziness. And I make a concerted effort not to speak too rapidly or use acronyms with my patients and their families — but I also don’t make them wait five seconds for the next word just because I think it’s an important one. I do use the “ask-tell-ask” technique when I remember to, and I try to spend more time listening than talking.
      I also believe in telling the truth. Call me old-fashioned, but I think the truth is important. Are there occasional compelling reasons not to tell the truth — for example, a lie of omission, or a lie to save someone’s feelings? I think probably so. But in dealing with seriously ill or dying patients, I think it’s a real disservice not to be truthful. After asking for and receiving permission to discuss potentially disturbing information, I try to share information in the most compassionate but direct way. People seem to appreciate it.
      But recent studies have shown that patients like doctors who give them good news, and don’t like doctors who give them bad news. In other words, the favorability rating of doctors who share bad news is lower. To some extent that makes sense; of course it’s human nature to associate positive feelings with a person who told you something you were glad to hear. With Press Ganey and other physician satisfaction rating systems playing heavily in some compensation structures, let’s just hope that we resist the inclination to paint things more optimistically than they are in the interest of getting better patient satisfaction scores or Yelp ratings.
      Patients like to feel as though their physician and other health care providers — all the way up to the certified nursing assistant at the bedside who spends the most face time with them in our facilities — really care about them. So, although the word “compassion” has been co-opted by proponents of physician aid-in-dying, our patients do want empathy and compassion from us. Most of us don’t choose to work in nursing homes unless we have a fair amount of empathy and compassion for the frail elderly, so we should be able to do this authentically and organically.
      However, for those to whom these attributes don’t come naturally, it seems that practicing and “acting as if” they care about patients can actually be effective. I am not talking about the scripted and dramatic saccharine politeness of some retail clerks, but rather a genuine effort to communicate caring. Sitting at the same level, making eye contact, not fidgeting, leaning forward, and all those kinds of things that come naturally to some people, can be learned and practiced — and they help. Medical students and residents get some training in these skills now (using actors called “standardized patients,” among other educational strategies), and that is a good thing. Patients, and usually their families, don’t tend to sue a doctor with whom they have had a good relationship, or a doctor they believe cares about them — even when the doctor makes an error. And patients feel better about their individual encounters, and about the therapeutic alliance between clinician and patient — as do the clinicians.
      So, to summarize: Care about your patients and their families, be real, and be truthful. Listen to what they are telling you. If you have to give them bad news, give it empathetically and graciously. When people are sick, they have a right to know how sick, if they want to know. I’m confident that Caring’s readers are already doing these things. But if you have a difficult time with these practices, consider some more formal courses or training in communication and interpersonal skills. With time and practice, these attributes will begin to become second nature.
      Dr. Steinberg, editor in chief of Caring for the Ages, is a multi-facility and hospice medical director, as well as chair of the Society’s Public Policy Committee. He may be reached at [email protected]