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In this feature, we discuss a case which someone has shared with us.  We look at Agape in the context of that person's pain or joy. 





by Dr. Scott Diering

(Click here for a pdf download of this caseletter)

Is it what we do or how we do it?

OK, as you to read this month’s story, I would like you to think about the difference between quality of clinical care and quality of interpersonal interaction.  Do our patients perceive a difference?

 This story is from a woman whose fiancée has had a difficult hospital course.  In fact, at the time she wrote to us, he is still hospitalized.  Our family member writes:

 My fiancé underwent a radical prostatectomy on June 26, 2006, and his surgery was lengthy due to the aggressive and high grade nature of the tumor. There have since been multiple unanticipated complications, leading to an additional surgery as well as multiple procedures.  The projected hospital stay was 5-7 days, and we are now on day 29.

Throughout all of this, Dr. Blackwelder has provided exacting care, attentiveness and compassion.  He has been at the bedside during early mornings, late nights, weekends and holidays.  He consistently returns calls and responds to pages from nursing staff within minutes. 

Dr. Blackwelder has gone “above and beyond” in ensuring that we understood each arising circumstance and course of treatment, as well as involving us in the decision making.  He has made himself personally available to us. I have spent many hours at the hospital.  Dr. Blackwelder has been completely approachable, providing explanations and information to me, as well as allowing me to ask questions.  He is never abrupt and is consistently kind and patient in giving his time.  He has inspired confidence and made this ordeal bearable.  He has earned my admiration.

Dr. Blackwelder is genuine.   The consequences of the complications would have been disastrous if not for his attention to detail, immediate availability and commitment to patient care.  We feel blessed to have been under his care throughout these trials and tribulations.

 I hope and pray that this patient and his fiancée do well, despite their difficult time.   


Do you think our writer would have had the same response to the complications and prolonged hospital course if Dr. B had been aloof or unapproachable or (gulp!) arrogant?

 Usually, complications are a cause for upset and hostile families.  But this physician bucks the trend.   How does Dr. B earn high praise and commendations in such a minefield? 

 He’s a great provider; not only for his clinical skills, but because of the way he works with the patient (and family).  He scores maximum style points.  This letter was written by a grateful family member.  Not grateful for a bunch of complications, but grateful for a caring provider.


Actions speak louder than words.  Here are some of her words which jumped out at me:




“at the bedside”

“He consistently returns calls”

“ensuring that we understood”

“involving us in the decision making”

“completely approachable”

“providing explanations”

“allowing me to ask questions.”

“He is never abrupt”

“is consistently kind and patient”

“He has inspired confidence”

“Dr. Blackwelder is genuine”

“commitment to patient care”

And, among these examples of stellar behavior, the action words stand out.  “Ensuring,” “involving,” “providing,” “allowing,” etc prove that earning patient satisfaction is a dynamic, deliberate constellation of proactive behaviors.

Now, you might say, what kind of life does Dr. B have, being available to his patients all the time?  I’ll bet it’s a great life, doing as good a job as he is doing.  And, since he is putting a few extra minutes in with each patient each day, he does not spend time in depositions or courtrooms later.

Great interpersonal skills are a key part of great clinical skills

The quality of our clinical care is of paramount importance, and should never be compromised.  However, our patients’ perception of quality of care is not necessarily in terms of outcomes and results.  Our patients’ experience a gestalt*, a big picture.  How we behave with them is a crucial part of that big picture.

I believe that our patients see primarily our actions.  They do not discern the quality of their care as separate nor distinct from our interactions.

Patients and families judge, rate and score the quality of our clinical skills based on the quality of our interpersonal skills.

So, while you go about your clinical day, ask yourself,

What does it mean to you to be a “good doctor” or a “good nurse?"

To me, it’s not just about the quality of care.  It’s about how that care is ministered.

“Good” is not just be a measurement of clinical skills or outcomes.  Good is in the eye of the beholder. 

*gestalt : a configuration, pattern, or organized field having specific properties that cannot be derived from the summation of its component parts; a unified whole.


How is your practice?  Do you have any interesting concerns, stories, or anecdotes?  Any suggestions on making healthcare better? Let us know!

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June, 2006


Should we set limits on our multitasking?

For many of us, the hallmark of a talented clinician is completing many tasks.  How do we praise a talented multi-tasker?  “You do the work of three people!” or “If I could clone you, we’d never have to worry!”  For some of us, we’d be bored without three or four things to do at one time.

But yet, when is doing several tasks at once too many?   When do our patients deserve our undivided attention?  What are our limits?

Let’s look at the story which was sent to me by a remarkable woman, who donated one of her kidneys to her husband.


My husband recently died in January from liver cancer after I gave him a kidney in 2002. His physician, Dr. A, referred me to a physician, Dr. X, that he felt was very good.

     I took his recommendation and the first appointment was a disaster when Dr. X  did not even read the top line of the 4 page history I filled out (This was where I had written "WIDOW  1/30/2006,"  since no option was given for my  marital status.)

So when she entered the examining room and said "Well let's get acquainted; are you married?" I immediately burst into tears in frustration AND also because I had been fasting since the night before and was hungry, AND she was running 1 1/4 hours late. THEN she asked me if I was thinking of harming myself when I mumbled that I should not have come to this appointment because nothing mattered. I cried more and harder. THEN she asked if I was thinking about harming anyone else. At this point I was sobbing and my heart was beating a mile a minute and she said "OK, let's do your EKG". I said: "Lady, I will be in the Cardiac Unit if you do it now and probably on the heart transplant list by suppertime, can't you see that I am upset?" Bottom line: She said to get my blood drawn and make another appointment for the following week. I did get my blood drawn and then I phoned Dr.A’s office to tell his nurse about my experience since I knew that Dr. A would want to know what happened.

Dear Dr. Diering, Thanks again for the encouragement. I hope that sharing my experience will enlighten and educate. I wanted to add this postscript:  Today I received a call from Dr X’s office asking me when I was going to schedule the rest of my first visit. I had to chuckle, after this length of time and they are calling NOW?

If there had been any concern it would have been long overdue. I told the caller that my first visit was my last and why. She obviously was just the messenger for Dr. X who may have felt embarrassed after being given such a high recommendation by the head of the hospital's transplant clinic and then dropping the ball.

Anyway, I have an appointment with a doctor in town who may be what some call a "concierge" or "boutique" doctor. His $1500 yearly fee, that is beyond my insurance payments, will be worth the peace of mind and personal dignity I think I deserve.


Now, you might say this patient is over reacting.  Or, you might say this physician made one tiny mistake which was blown out of proportion.  Or you could say, “That’ll never happen to me! I am a better multitasker!” These may be true, but they do not alter the fundamental reality that this clinician missed an essential part of this patient’s history, which was written down, and caused her to lose this patient forever.

How did this clinician overlook that this patient was a widow?  I think she was multitasking.  This physician (and it could easily have been a nurse or technician or any one of us) was behind schedule.  She did not take time to read the chart (or the referral letter) before she went in the room…I picture her scanning this four-page history as she began the encounter.  She then asked a question.  She was trying to read and talk at the same time.

Our human minds cannot actually do two complex cognitive tasks at once.  We can switch back and forth rapidly between several tasks, holding information in short or intermediate term memory, but this is not quite doing two things at once.  We can shift some tasks to motor or cerebellar memory, such as when we talk and drive at the same time, but this is risky, as more and more accidents are caused by “inattention blindness.”

I suspect that is what happened in this encounter.  Our clinician suffered “inattention blindness” to our patient’s history because she was multitasking. 

How can we avoid “inattention blindness” and multitasking blunders?  When is “multi” too many?

We must set limits on ourselves.  We all must decide where and when we can multitask, and where and when we cannot.

I absolutely must set limits on my multi tasking.  (I learned this after being confronted by enraged patients who took time to fill out forms which I overlooked.)  I do this by:

·                                              I make sure I know something that’s new or different about my patients before I see them.  I take the extra few seconds to look over their chart before I walk in.

·                                              I follow the 5 second-rule.  When I enter a room, I dedicate the first 5 seconds to directly observing my patients.  I make eye contact, look at their posture and demeanor, and begin my assessment.  Only after this dedicated attention for at least 5 seconds do I begin to take notes, or look at their injury or their IV or other things. 

·                                              I try to start with open ended questions.  I like to let my patients choose what is important.

We all multitask.  It’s part of modern healthcare.  But, we can prevent misunderstandings and catastrophes by limiting our multitasking.  We can dedicate some of our time with every patient to undivided attention. 

If you want to leave your patient with a memory of you that will resonate forever, give them your time.  Your undivided, single-tasking time is a wonderful gift.  Your patients will appreciate your compassionate attention.  And we'll be better clinicians because of it.

Let’s try to set limits on our multitasking.  When we try to do everything, it is difficult to do anything well.

Take home message:  Greatness is measured by how well you do each task, not by how many tasks you get done. 


How is your practice?  Do you have any interesting concerns, stories, or anecdotes?  Any suggestions on making healthcare better? Let us know!

Caseletter! Is published bi-monthly by Dr. Diering and Love Your Patients!

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April, 2006

Patients are not objects!  Part I

 A really smart doctor I know told me, “I cannot endorse the teachings of Love Your Patients.  I’m afraid clinicians who practice this way will lose their objectivity.”

 As I thought about what he said, I realized, “Yes!  I do want to lose my objectivity!  I want all of us to lose our objectivity!  Patients are not objects!  Patients are not problems, cases, chief complaints, diagnoses nor issues.  Patients are people.  They are not objects!”

 This brings us to a concerning set of notes I received from a patient.  Despite appropriate patient-ing skills, she was dismissed from her doctor’s practice.  She relates this story to us:


It was my fourth appointment with a new PCP Internal Medicine doctor (female).  When I scheduled my appointment, I asked that I have the 1st appointment of the day because I needed to get to work (I worked for another doctor then). I was taken to the exam room on time and discussed with the nurse the reason for my appointment.

1. Follow up

2. Time to schedule mammogram (I've had several that have required follow up ultrasounds).

3. I had developed a new problem of bruising easily.

4. To make the doctor aware of the results of my CT myelogram ordered by my neurologist.

5. Refills (nurse wrote down what I needed when she worked me up for the exam).


After waiting 28 minutes, she was late and saw another scheduled patient before me, she came into the exam room and appeared to be rushed.


Each problem I addressed was addressed quickly.


Bruising-I was told to stop taking Vitamin E. I told her that I had been taking Vitamin E for several years and I hadn't bruised so easily before. NO COMMENT. She could have at least ordered a protime.

Abnormal result of CT myelogram-not her area of expertise, but she was the one prescribing the pain meds for the lower leg radiculopathy.

Mammogram-not scheduled

Refills-none written.


She was gone in 5 minutes.


When I got to work, I asked my employer (a doctor) how to express my dissatisfaction with the visit. She advised me to write the doctor a letter expressing my concerns.

I wrote a very appropriate letter of concern.


A week later, I received a hand written response on a 4X10" card stock stating that it was obvious that she could not meet my expectations of a doctor and she dismissed me as a patient.


Kicked out for providing feedback!

This interchange is very telling.  And very helpful for those of us who want to make healthcare better.

What do you think?  If you were this concerned patient’s provider, how would you have treated her?

For me, her story brings out several points:

  1. Patients are not objects! 

Þ       They are not tasks, slots in a schedule, jobs, chores nor problems! 

Þ       We absolutely, unequivocally must never view any patient as merely something we’ve got to get done! 

Þ       We should never dismiss, belittle nor ignore any concerns.

  1. We can never appear rushed.  (Providers who are sued often seemed in a hurry.)  If there just is not enough time, say so!  Then, apologize and tell you patient when you will have time for them.  Being in a hurry is a non-verbal way of saying, “You are not important to me.”  Please, never say this!
  2. We should minimize loose ends.  We can make every effort to be certain that there is nothing we have missed, forgotten, left out or omitted.  When we are unsure, ask! 

©      “Is there is anything else I can do for you?”

©      “Do you need something else?”

©      “Have I forgotten anything?”

©      “Is that everything?”

  1. We should always thank our patients for feedback they provide.


This patient did everything correctly.  When her care did not meet her expectations, she provided feedback.  And, she was punished for providing this feedback. 

We should never punish our patients for providing feedback, no matter what form in which it arrives.  Even when feedback is in the form of complaints or poor satisfaction scores, we must thank our patients for providing that feedback.

I am glad she left this physician’s practice.  This patient deserves better.  As do all our patients.


How is your practice?  Do you have any interesting concerns, stories, or anecdotes?  Any suggestions on making healthcare better? Let us know!

Unsubscribe?  Just reply to this email with “unsubscribe” in the subject line, please.


Love Your Patients! CaseLetter #1:

 A patient sent me his story:


I recently had to go for a colonoscopy and endoscopic exam due to digestive problems.   Prior to the procedure I was interviewed by the pre-op nurse. Once she began to ask questions, she noticed I was having both procedures done; at that point she giggled a bit and continued to ask questions. I asked her, "What is so funny"? She would not answer. However in my mind, I knew she was laughing at me for what I was about to go through.

   For me, this procedure is both humiliating and embarrassing. It did not help me one bit when she giggled. In fact, I was ready to cancel due to the embarrassment just from her giggling. I told her that this was not funny, I knew what she was laughing at and that this was very difficult for me to even discuss. She told me it was no big deal and that they do this procedure all the time. That is a big part of the problem itself. They do this so routinely that they become immune to the fact the people have different feelings about this kind of procedure. For me, this is not routine and "giggling” was a sign of "carelessness and cold heartedness" to the patient.

This moment of "giggling" caused much anxiety that the anxiety lasted up to and after the procedure. I still have problems coping with the whole thing. It is amazing how one person’s actions affected my feelings.  -JS

Now, we might react to JS’s story by saying he is over reacting, and is too sensitive.  But that does not matter.  The fact remains that one of us failed to relate to JS in a warm and caring fashion, and it left him sad and hurt.

 The simplest way to be certain that we treat the whole patient (their feelings and interpersonal needs as well as their physical infirmity) is to act with love.

 “Gag!” you might say, “My patients don’t love me, why should I love them?”

 The type of love that we, healthcare professionals, have for our patients is Agape, the unconditional love of all humankind.  We love our patients because they are people.  Our patients know it by the way we act.  For us, Agape is not a feeling, it is actions.

 “What are you saying, that I walk around hugging everybody in the clinic or hospital?” 

 No, Agape is manifested by what we say and how we say it and what we do and the way we do it.  Patient satisfaction blossoms naturally from every patient encounter when we act with Agape.

 “Well, what do I do?”  Agape exists when we act with compassion, respect and humility.  Let’s talk briefly about each of these.

 Compassion is expressed with empathy, by ministering to our patients, and by giving our undivided attention.  The core of compassion is empathy.  This is the ability to look at someone, listen to them, and then put our self in their shoes and feel what they are feeling.  It takes effort to do this, but once we practice it, our patients will know we care.

We minister to our patients when we show our sincere concern, by comforting their fears.  The nurse in JS’s story missed an opportunity to minister and comfort a fearful patient…perhaps she forgot to practice empathy. 

Our patients deserve our attention, so No Multitasking!  While with patients, we should make eye contact, and say “Excuse me,” when we focus on our paperwork or our machines, or when we leave their side. 

 Respect is felt when we behave courteously, when we validate our patient’s efforts and when we are completely honest with them.  (It seems that the nurse in JS’s story not only lacked empathy, but was not honest about why she giggled.) 

Courtesy is easy:  We must remember to always say, “Please,” “Thank you,” “May I,” and “sir” or “ma’am.”  Patients love this.

Validation requires that we suspend judgment, no matter what silly thing the patient may have done, and praise them for their efforts.  Perhaps JS should not have chosen to have two procedures done in one day, but this is not a reason to laugh at him; instead it is a reason to be certain he understands the ramifications of his decision, and to praise him for being earnest about his health.  Validation means we allow our patients to save face, no matter what they might have done wrong, and then to teach them what we feel is right.

Honesty is the core of a good therapeutic relationship.  It’s good to admit small mistakes and explain how and why things are happening.

 Humility is the most often neglected virtue.  To be humble, we must remember to translate medical-ese, to admire our patients and to be gracious.

Translation of our nomenclature, jargon and acronyms is essential to break down the walls of superiority which separate us from our patients.  We must assume that our patients have no knowledge of any medical terms and procedures.  For example, when a patient proudly states they are here for an EGD, we can say, “Oh, good, an esophagogastroduodenoscopy.  That means…” We define what each letter stands for, and then explain what each word in our definition means, without asking the patient if they know what it entails, thereby saving the patient from the embarrassment of admitting ignorance.

The best way to win our patient’s satisfaction is to admire, praise and compliment them.  For example, we could have complimented JS by saying, “Wow, you are a very strong person, having two procedures in one day…I don’t think I could do that!”  We should praise and admire anything we can.

Being gracious is simply shedding the formal austerity of clinical encounters.  To do this we apologize for any problems or delays, we sit down, and we smile at our patients.  Remember, our patients are people first and patients second.

 In sum, love, Agape love, is an honorable way to treat everyone we meet, especially patients.  When we remember to act this way, patient satisfaction improves naturally.


This article originally appeared in Endo Nurse Journal, but I thought it was worth sharing with everyone. I am a practicing emergency medicine physician and author of Love Your Patients!  I consult, lecture and write on healthcare professional-patient interactions and patient satisfaction.  For more information, keep looking around my website,


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Last modified: 02/23/10