It's a fun place to work anywhere. That's where I'm from. So my talk today is entitled Improving the Patient Experience in Your Pediatric PM&R Practice. This is something, as I was thinking about what to present to you, I feel like, at least as I was entering the final few years of my training, I felt pretty confident in the meat and potatoes of pediatric rehab. And so I didn't want to hash old topics. This is something that I felt that is not spoken a lot about in residency. It becomes very important as you enter into being an attending. So what I have done is taken my anecdotal evidence and tried to find supporting literature. And I found three really great papers that most of this talk is based on. So we'll go ahead and get started. First off, I have no financial disclosures. I have plenty of liabilities and obligations. Erin is my wife and Eliza, Haley, and Ava are my four children. So they take everything that I earn and spend it appropriately in most cases. So again, this talk is entitled, they don't care how much, well, actually this is the first paper that I read. They don't care how much you know until they know how much you care. And this was actually a paper we'll get to in just a minute, but centered in the emergency department, but I felt like a lot of the principles applied. So first off, what do patients value? Patients typically value critical thinking, communication, and caring behaviors. And obviously they value a lot more than this, but let's focus right here on communication for the time being. The authors of this paper divided communications into two subgroups, interpersonal and informative. And they suggested that to improve interpersonal communication, which is broadly defined as provider and patient personal interactions, we need to actively listen, maintain eye contact, carry a calm tone and provide reassurance, use humor when appropriate, demonstrate empathy or sympathy more commonly, and then provide purposeful touch. Humor is sort of a difficult thing to titrate into your clinic appointments skillfully. As I was writing this PowerPoint presentation, I was reminded of one of our child life specialists at Primary Children's who was caring or involved in the care of a young man with a terminal brain tumor. And every time she would go into his room, she would open the door and say, hi shit face. And everybody thought it was funny because it was used appropriately. And she knew obviously that the family would take well to that based on her personal interactions with them in the past, but obviously you wouldn't want to start a new patient encounter, you know, with doing that. So a little bit of humor is good, but be careful when you're using it. I've found that in new patient encounters, especially with patients who are cognitively intact and can understand a good dad joke every once in a while goes a long way. And then purposeful touch. I wanted to talk about that a little bit. A good firm handshake goes a long way in a lot of these encounters, especially when you're meeting people for the first time. And along with that, an introduction as you enter attendingship, it becomes difficult sometimes to remember that people don't know who you are. Obviously in first patient encounters, they've never met you. They may have looked at your bio or, you know, looked you up online. That happens quite frequently, but they've never personally met you. So extending a hand, giving a good firm handshake, introducing yourself goes a long way. When I was a resident, as I left my residency, I worked in a continuity pediatric clinic and one patient family left the practice when I left because they trusted me because as they put it, I was the only one that extended my hand and introduced myself when I went into the room. So super important, those things. All right. So things you want to avoid would be repetition of questions, vague answers, and inconsistent answers. So you can imagine as an attending, you've got an MA, a nurse, likely a medical student, a resident, maybe even a fellow that are going in and seeing the same patient and everybody's asking the same questions. And that can get kind of annoying, I think, from a patient and parent standpoint. So maybe touch base with people who've already spoken with the families, fill in, you know, information so that you don't have to go in and ask the same questions. You can verify. So what I'll frequently do is I'll go into a patient encounter and I'll say, I see that your son or daughter has had a hard time sleeping. I've been told that, you know, they fall asleep okay, but are not able to maintain sleep. Is this true? And then you can go on and dig a little bit deeper instead of just saying, you know, tell me about sleep or is your child sleeping? So that way they know that there's been communication behind the scenes and you don't have, they don't have to repeat themselves over and over again. I've starred vague answers there because you can use vague answers skillfully, especially if you're unsure of a particular symptom or how to treat something. Sometimes they're very vague symptoms that we deal with. You know, as I was writing this talk, I, you know, reminded of my chronic pain patients and sometimes they're really odd symptoms that parents want us to address, you know, and as an example, you know, my son will, you know, shake his finger three times every Wednesday after a blue moon and then has an abnormal breathing pattern for five minutes or whatever. That kind of stuff doesn't fit into a particular pattern and not something that I'd feel comfortable with, you know, answering, but you don't want to blow it off. And so given the old doctor, let's keep an eye on it is okay, as long as you're providing some sort of explanation as why, you know, we're giving a vague answer. Another thing that comes to mind is concussions. You know, children, they recover from concussions at different speeds and different rates. And so sometimes giving vague answers, but explaining why it's a vague answer is okay. The biggie for me is the inconsistent answers. And that comes into play, I think, a lot in multidisciplinary clinics when a patient may see a neurologist, a neurosurgeon, a rehab doctor, a urologist, and if everybody's given different answers to the same problem, that can be disconcerting to some of these families. And so just making sure everybody's on the same page goes a long way by way of interpersonal communication. So if we've talked about this, let's now talk about informative communication, which is broadly defined as provider-patient professional interactions. Things you'll want to do is keep it free of medical jargon, be clear, be accurate, be confident, and provide written instructions. And that, of course, goes along with, you know, having a firm, solid knowledge base of the symptoms or conditions that you're treating, especially by way of being clear and being accurate. So now let's transition a little bit to time. One author suggested that the perception of time spent is more important than actual raw time spent, and that's a big deal, especially if we're looking at greater efficiency in clinic, if we're looking at ways to increase the perception of time without necessarily increasing the raw amount of time that we're spending, that can go a long way in your practice. Ways to do this include to deliberately act in an unrushed manner, sit, don't stand, allow patients don't stand, allow patients to write expectations for the visit and directly address them, answer all questions, avoid rushing to a specific diagnosis. This particular paper was written through the lens of dermatology, so it's easier for them, I think, to rush to a specific diagnosis than for us, but nevertheless, it's one of the things that they had mentioned. And then provide detailed explanations and written information. It's important to remember that we are the product that's being provided when our patients come and see us. And so I try to always give my patients some sort of good as they're leaving my clinic visit. If that's education, great. If it's a prescription, fantastic. If it's, you know, a little bit of outpatient physical or occupational therapy, fantastic. But at the very least, they should leave with some sort of piece of paper explaining why they were there, you know, the treatment plan and a follow-up date. That becomes particularly important when we're dealing with titrating medications. You know, when I sit down in clinic and verbally express a titration schedule of baclofen or gabapentin, parents may look at you and nod their head, but it's more difficult in practice. And so giving those written instructions becomes very important. It's also important to recognize and address the emotional needs of patients and their families. Three subcategories of emotional needs would include uncertainty or coping with uncertainty, suffering or recognition thereof, and empowerment. So uncertainty usually arises from lack of information. This is something that I think us in general as pediatric rehab docs are very, very good at. We can give information regarding the particular disorders that we deal with, and we can provide, you know, prognostic information to our parents and just kind of explain to them what to look out for. And that gives them a source of empowerment. And we'll get to that in just a minute. It's also important to understand that we make life-altering diagnoses. We prescribe big medications and we perform invasive procedures. And so recognizing that becomes very important. And I like to soften that blow a little bit. I think it's a little bit different if you're talking with a parent who looks obviously scared about the new diagnosis of cerebral palsy, let's say. Instead of saying you look terrified or you look scared, you could say something like, some of my other patients' parents have expressed that they're, you know, very concerned about this particular diagnosis. That's a normal feeling. You know, would you like to talk more about cerebral palsy? And then that just opens up the door to have further discussion so that they can deal with uncertainty. And then empowerment, this becomes very important, especially to me in my practice, this concept of shared decision-making. Parents really want to be viewed as sensible. So when they come to our clinics with problems or issues, we, even if they seem dumb to us, they're certainly not dumb to our patients' parents. And so addressing those and then helping parents participate in the decision-making is very important. That's a little bit more difficult, I think, from a provider standpoint, because then you don't just have the one right way in your mind to solve a problem, but you have multiple ways to address a particular problem. So if your patient's parents have, are against the idea of starting a medication and giving it three times daily for the rest of, you know, their child's life, maybe we address it instead in a targeted fashion with, you know, with Botox, and we don't have to get back with them three times daily. Or if gabapentin is a non-starter, and if they have sleep issues, maybe we try a little amitriptyline, or, you know, just having different ways to address the same problem becomes very important. That way, we provide parents with education, we provide them with some options, and then they help us make a decision that's right for them and their family. That was an animation that my son made. He wanted to help me out with my PowerPoint presentation, so it makes me giggle every time I transition from that slide to this one. Obviously, it becomes very important. It's very important to address the medical care needs for our patients. This involves having a solid knowledge base and skills in titrating medications and providing, you know, recommendations regarding the diagnosis that we treat. It's also important, I think, to recognize where you have little skill and to, you know, let parents know that instead of fumbling through a particular treatment plan that you don't have a lot of skill in. I think parents, not I think, I know parents appreciate, you know, the words, I don't know, or I can find out, or here's another specialist for you to see, and a common example of that for me is antiepileptic medications. I just tell my parents point blank I have little skill in titrating these medications, but I have a good friend in another department who can help you out. Let's get you over into his clinic. So, saying I don't know is not a bad thing, but being confident in your skill set is also very important. Regarding procedures, it becomes really important to operate in an organized and predetermined manner, and that's central to patients and parents feeling safe and secure with you as their provider. A big example of this, I think, for me, especially as I was working through residency, is just the logistics of getting, you know, all of your supplies and equipment ready for back-up and pump refills. You know, having that all set up and prepared in an organized manner, being very methodical in your procedures becomes very important, and then this idea of interprofessional communication, being able to use technical terms during those procedures may reassure patients of your competence. This seems a little counterintuitive, especially, it seems I just told you to stay free of jargon, but when you're talking with your MAs or nurses, using a little bit of medical jargon is okay. You know, if you're doing Botox to a patient, you know, you may throw out some technical terms. Well, I just injected the hip adductors, let's place the patient prone now and finish up with the hamstrings. That kind of stuff is okay. And then obviously making sure that you're doing the right procedure and the right medications to provide symptom relief and your patients will keep on coming back to you. So why should we care? For me, this is an A equals B plus C equation. I think if we have a high quality of communication, we're gonna have higher patient engagement and then that's gonna correlate with higher quality of care. And that's been shown in a few different articles that I've read and it's also very intuitive. So in my experience, my patients and their families have become my friends and I genuinely look forward to seeing most of them. There are a few that I could probably name that I don't necessarily look forward to, but for the most part, I enjoy being in clinic with my patients and their families. I always call their parents by their first name and not mom or dad. For me, it's just weird walking into a room and saying, hi mom, because they're not your mom, they're Janice or whoever they are. And then I record that information in the EMR. It's usually one of the first lines is this patient presents with their mom or with their father and then comma Janice. So next time I see them, I can extend my hand and say hi Janice and not mom and that goes a long way. I also record other personal things in the EMR for talking points and future visits. So I often will record my patient's favorite foods, their teacher's names, their hobbies, their future goals and all that kind of information is perfectly appropriate to put in there. Then as you're looking at your note and getting ready to go into your next appointment, you have that information in there and then their talking points and that creates this relationship between you and your patients and their families. I've also found it very effective to sing during painful procedures. So Botox and back up and pump procedures, I'll sing a song and I think it's not necessarily pretty, it's more shocking than anything else but I get comments about that often. And sometimes I'll have a patient be very scared about a procedure, I'll start singing them the cowboy song and it just comforts them a little bit and it also outwardly shows parents that I care about their son or daughter's comfort. Going back to empowerment, I always educate parents. I look at myself as an educator and then both myself and parents and patients can decide a course of action. Usually if I've done it appropriately, most of the time parents will decide what I would have decided anyways. I'm really not trying to sway them one way or another, I just try to teach them and help them see things through my lens and then that empowers them and we go on and make good choices. And as I'd mentioned earlier, I always have trusted friends in other subspecialties. So if I have little skill in titrating a particular medication or treating a particular diagnosis, it's nice to know people in my hospital system that have skill in those things. So having a good sense of camaraderie with your fellow physicians and other subspecialties becomes very important. And I think if you really like your job, it shows when you go into clinic visits. This kind of stuff really takes time and can decrease efficiency. So in order to streamline visits, I always arrive before usually an hour or an hour and a half before my clinic starts. And I look through my patient's charts, I know who they've seen, I know emergency department visits, I know treatment outlines of other providers and I have all that written down so that when I'm in my patient encounters, I can say, oh, I see you saw Dr. Fu in neurology and he had mentioned XYZ, that goes a long way to establishing a good relationship and building trust between you and your patients and their families. I always have a written outline and it's always the same outline. I go through systems-based so I don't miss anything in particular. And then as the patient's families or the patients are talking, I can move through my outline and fill in the blanks so that I don't have to have them repeat things so that I don't miss anything. And that way I can ask very open questions and oftentimes get the answer to two or three questions with one open ended question. And then I don't have to address those later on because they've already been addressed. I don't rush through difficult conversations. I try to be present and cut myself some slack if I'm running a little bit behind. It's important, I think, to kind of prioritize what's most important. And oftentimes if a patient or their families are opening up to you with some sort of difficult topic, it becomes counterproductive to start looking at your watch and trying to cut them off and that kind of stuff. So oftentimes it's a little bit better to maybe run 10 minutes behind and try and catch up a little bit later on than cut your patients or their families off. I don't look at my watch during clinic visits. Most rooms will have some sort of clock or something to help kind of keep you on time. But looking at your watch, patients and parents really pick up on that kind of stuff because you're too busy or you don't have time for them. So that kind of stuff is counterproductive. I also don't work on other things during the visit. So I don't answer text messages, obviously. I typically don't type on the computer or write my note during the encounter. I know some providers are very skilled at doing things like that. I am not. So I've come to learn that I will write handwritten notes on a piece on my outline that I've already prepared, but I don't get on the computer and stare at the computer and write my note during that encounter. I know that some of my partners are very good at doing things like that. I'm just not. And that's something I've come to terms with and probably something you should pay attention to. Of course, it's important to remember that you're not me, you're not your attendings, you are you. Don't try to be somebody else or you'll come off as disingenuous. Just take a little bit of time during your last years of residency or fellowship and your first years as an attending, pay attention to what works for you and what doesn't work for you and hone in on that great patient experience. These are the three papers that I was speaking about earlier. This first one by Graham and Endicott, it was the one that was entitled, They Don't Care How Much You Know Until They Know How Much You Care, but through the lens of the emergency department. Fantastic paper, I would recommend pulling it up and reading it. The second one entitled, The Patient Experience and Health Outcomes is another great one. And then the third one by Golden Beeson, Recommendations for Improving the Patient Experience in Specialty Encounters is another great one. That's the one through the lens of dermatology. So all three papers are fantastic if you wanna take a peek at them and give them a good read. And I think that's it. This is my email address. You're welcome, anybody's welcome to email me. It might take a week or two for me to get back to you in typical Dangerfield fashion, that's how I roll. But that's my presentation. I'm happy to answer any questions. Thank you, Dr. Dangerfield. I'm gonna invite people to put... Oh, we've got one in the... Mary, are you with us? Yeah, I was just finding my unmute button and I have found it. That was really excellent. And I feel like pointing out a lot of practical strategies that we can all incorporate into practice and some interesting things that we wouldn't have necessarily thought of. But it does look like Dr. Green has a question. How do you handle post-appointment education paper format? The discharge paperwork and key parts, right? It's a great question. Yeah, that's a really good question. Fortunately, a lot of EMRs have that built into them. Oftentimes, you can ask your staff or your nurse to help you provide a good written outline of your patient or of your clinic visit. So it's pretty easy in most EMRs to do that. I have to say, I'm not fantastic at that, but I am really good at just providing handwritten instructions. So, again, if I'm titrating a medication like Baclofen or Gabapentin, I'll just handwrite on a piece of paper, days one through three do this, days four through six do this. And then obviously on the script, there's handwritten instructions there as well. So there's a number of different ways. Fortunately, with our EMR, it's pretty easy to give them a patient or a visit outline. Thank you. Next question from Dr. Kivlahan, can you expand upon how you determine your follow-up frequency? So three months, a year, four? Yeah, for me, it just comes down to, obviously, if you're doing targeted spasticity management with botulinum toxins, I'll typically have patients come back in three-month intervals. So that's kind of a no-brainer. Baclofen pumps are also kind of a no-brainer. The pump tells us when they need to come back. But in other circumstances, it really depends on how much I'm managing. So if I'm managing six different medications and outpatient therapies, I'll have them come back relatively frequently, maybe four times a year, every three months. If it's a kind of a check-in, not really managing many medications or therapies, maybe it's an annual check-in to make sure everything is rolling okay. So yeah, I remember struggling with that a little bit as a resident, kind of determining what frequency to have patients return to clinic. But I think in your first couple of months as an attending, it becomes a little bit more clear. And then you sort of hone in on it. And I always provide my number too. So if I've got a patient who's coming back every six months or every year, I'll hand them my card with my number and my email address and say, hey, if you've got any problems before a year, come on back. I'm happy to answer those questions. We'll get you on my schedule. So there's some like no-brainer things like Botox and Baclofen pumps. And then I just look at it as how much am I managing and what frequency do I need to have them come back to titrate those medications? Again, if there's any other questions, put them in the chat or the Q&A. We're monitoring both of them right now. Dr. Dangerfield has included his email address, like he said there, so if people have questions that they want to ask more that way, you could always reach out. Just as a reminder, if you listen today and you want to get CME credit, you can go to AAPMNR, just give it a little bit of time for Megan to get everything situated from the AAPMNR standpoint to get posted. And then you'll just indicate that, you'll fill out an evaluation, indicate that you listened and including your CME. That's also the case for people who are listening to this asynchronously. Dr. Green does have another question. Curious, how long are your patient appointments? And she also said, thanks again, great lecture. Yeah, that's a good question. My patient, my clinic visits are typically 45 minutes in duration. And I found it much more effective for me to kind of front load my schedule. So I see patients in the morning and early afternoon, and then I spend the late afternoon dictating and putting in orders and things like that so that I'm home fairly regularly for dinner with my family. That's helped me out a lot. I used to have kind of patients throughout the day and I found myself falling behind on documentation and placing orders. And I was missing a lot of revenue from late charts. And so understanding how I work and my clinic flow played a big role in how I've designed my clinic. It's important to know that too, as an attending, as a resident, you just kind of follow other people's schedules, but you want to really pay attention to what works for you as an attending and then design your clinic likewise. Hopefully that answers your question. They're 45 minute time slots typically. And I, you know, unless it's a new chronic pain patient or something like a difficult diagnosis to treat, I'm usually right on time with 45 minute time slots. I think that's a really great point too. And I totally agree with you too. I'm actually doing that with my schedule a little bit as well, because documentation takes time and keeping, yeah. And it's clinical work. Yeah. So when I started, I had an admin day once per week, and it was, you know, it became a practice of me, you know, falling behind four days out of the week and then having a day to try to catch up. And it just wasn't working. You forget some, you know, intricate details of your clinic appointments and things like that. So for me, it just worked out to block some time in the afternoon for documentation, placing orders. Again, my revenue generation increased because I wasn't losing, you know, that revenue from late charts and things like that. So it just worked for me. That's not something necessarily I thought about was even possible, you know, as a resident and new attending. And now that I've kind of, you know, kind of mid-career now, I'm starting to, my eyes have kind of been open as far as schedules go. All right, again, practical advice that you don't necessarily read in a textbook. So I'm sure your lecture was full of, so it looks like we might be finished with our question section here. Thank you so much for joining us and for your excellent lecture. And thanks for everyone who joined us as well. Yeah, thanks. See ya. Bye.

patient experience

pediatric PM&R practice

effective communication

interpersonal communication

informative communication

emotional needs

time management