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Connection in Healthcare

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Northeast Florida Medicine, Vol. 68, No. 3, Autumn 2017

Two Keys to Connection in Healthcare: Presence and Reflective Listening

Sandra Argenio, MD,
and Jennifer Krippner
The Institute for Healthcare Excellence

Address Correspondence to:

William J. Maples, MD
Executive Director, Institute for Healthcare Excellence
3201 Sawgrass Village Circle, Suite 4, Ponte Vedra Beach, FL 32082
Phone: (904) 834-7408
Assistant: Jill Hoover,

Date of Release: September 1, 2017
Date Credit Expires: September 1, 2019
Estimated Completion Time: 1 hour

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This issue of Northeast Florida Medicine includes an article, “Two Keys to Connection in Healthcare: Presence and Reflective Listening” authored by William J. Maples, MD, Sandra Argenio, MD and Jennifer Krippner, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit


William J. Maples, MD, Sandra Argenio, MD and Jennifer Krippner are with The Institute for Healthcare Excellence in Jacksonville, FL. Dr. Maples serves as Executive Director, Dr. Argenio serves as physician faculty, and Krippner is the Chief Experience Officer.

Needs Assessment:

Multiple surveys conducted through national polls and a variety of patient experience survey vendors have highlighted the gap between what patients want from a medical visit and what they receive. Patients want to be treated with respect and dignity, listened to, and know that their providers truly care for them. They want to be able to tell their stories. As we have not closed these gaps over the past 20 years, there is a need to nurture communication skills which will enable the clinical team to be present, actively listen, efficiently gather information and jointly set agendas with their patients and other caregivers, and meaningfully connect by recognizing emotions and responding appropriately to create an environment of trust and compassion. The gaps in creating this culture/environment have led to significant safety risks as outlined by Dr. Peter Pronovost from Johns Hopkins. In addition, ineffective communication is at the heart of efficiency challenges which occur every day in the practice of Medicine.


1. Understand the importance of effective physician and caregiver communication in creating a culture of excellence for our patients and fellow caregivers.
2. Understand the benefits and practice art of reflective listening in clinical and non-clinical encounters.
3. Demonstrate communication techniques useful in building patient and team-based relationships.
4. Learn, understand, and practice mindfulness/presence and its application in a healthcare setting.

CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact Kristy Williford at 904-355-6561 or 

Faculty Disclosure:

William J. Maples, MD reports that he is the Chief Medical Officer, Professional Research Consultants, Inc. and that he has received financial/material support. Sandra Argenio, MD reports that she is faculty for The Institute for Healthcare Excellence and that she has received financial/material support. Jennifer Krippner reports that she is the Chief Experience Officer for Professional Research Consultants, Inc. and that she has received financial/material support. significant relationships to disclose, financial or otherwise, with any commercial supporter or product manufacturer associated with this activity. Drs. Maples and Argenio, and Kripper reports that their article will not include discussion of any investigational or unlabeled use of a product.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

The single most important factor in creating an excellent patient experience is the patient’s interaction and relationship with his or her healthcare provider. In multiple studies over the past few decades, patients tell us what they desire most in their healthcare provider- someone who respects and listens to them. Traditional medical training has devoted little time to the development of communication skills. Through training and practice, healthcare providers can develop a culture of excellence where safety, efficiency, quality and experience of patients, families, and caregivers flourish.

The single most important factor in creating an excellent patient experience is the patient’s interaction and relationship with his or her healthcare provider. The experience culture, safety and healthcare outcomes are influenced by multiple factors. The Institute for Healthcare Excellence (IHE) was founded to help healthcare organizations, physicians, and caregivers implement proven solutions to deliver the best possible care to every patient every day, including optimal outcomes, safety, experience, and efficiency.

At the core of IHE’s RELATIONS™ program are six essential communication skills which include presence, reflective listening, efficient and accurate information gathering, joint agenda setting, connecting with all members of the team, and appreciation. Through nurturing these skills, a culture of respect, compassion, trust, and teamwork is created with the patient at the center of the team. This article focuses on two of these skills: presence and reflective listening.

American healthcare is in the midst of a transformation to address the rising costs of healthcare and sub-optimal access of healthcare for United States citizens. At the cornerstone of this transformation is a shift from the traditional fee-for-service payment structure to a value-based payment system which is rooted in providing desired outcomes, without harm, without waste, and with an excellent patient experience for the patients being served. Although re-engineering of healthcare via the electronic medical record and processes such as lean and six-sigma have been robustly pursued over the past decade, physicians have had significant challenges to eliminating harm, removing waste and improving efficiency, and creating an excellent experience for patients and fellow caregivers. As reimbursement/payment models increasingly shift to reward individual providers and institutions for the value they deliver, the external pressures have increased to answer the question of how best to accomplish this transformation.

Healthcare organizations have worked diligently at creating a culture which generates an excellent experience for their patients and caregivers. However, most organizations have not engaged physicians to partner in leadership of this work. The Institute for Healthcare Excellence has recognized the importance of physicians, who by definition lead American healthcare, to be at the forefront of leading this cultural transformation in partnership with nursing and administration leadership. By creating a program that is relevant to the practicing physician and clinical team and also reconnects caregivers to their purpose, physicians and clinical leaders readily and willingly step forward to become internal faculty for this work. As healthcare organizations witness their leaders cohesively moving this work forward, a magical catalyst surfaces for all of the mission critical work of the organization.

Communication in Healthcare Curriculum



The first skill introduced in the RELATIONS™ curriculum is Presence. Presence is the basis of good communication. Many errors happen due to lack of presence or attention to the task at hand. Mindfulness is the tool that can help healthcare providers develop a better ability to be present in their everyday interactions and tasks with patients, families, and colleagues. Mindfulness is defined as “present moment attention without judgment.” 1 Being present without judgment in every conversation and patient interaction is key to patient satisfaction, outcomes, safety, and efficiency. Due to the complexities of delivering healthcare, mindfulness can frequently be challenged, contributing to serious safety events. On November 29, 1999, the Institute of Medicine released a report “To Err Is Human: Building a Safer Health System.”2 The report aimed to eliminate preventable harm in healthcare by 2010; unfortunately, there is still much to be done to reach that goal. Physicians and caregivers make errors for a variety of reasons which have little to do with lack of good intention or knowledge. As stated by Hughes, “Humans have many intellectual strengths (e.g. large memory capacity and an ability to react creatively and effectively to the unexpected) and limitations (e.g. difficulty attending carefully to several things at once and generally poor computational ability, especially when tired).”3 Improving safety requires recognizing and respecting human abilities, strengths and limitations. Effective communication cannot occur when one or both parties are not paying attention to each other or to details required for care. A review of The Joint Commission reports found that communication failure (rather than a provider’s lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes.4

Being present through mindfulness is a skill that can be taught and learned. A study in 2014 from the Warfighter Performance Department, Naval Health Research Center and University of California San Diego followed eight marine infantry platoons (n=181).5 One half of the marines were trained in mindfulness while the control group received “standard” training. After stressful combat simulation, the marines trained in mindfulness showed:

   -“Elite performer” brain pattern on functional MRI (showing increased grey matter density in areas of the brain associated with executive function—specifically, attention, and emotion6)

-Enhanced recovery after stressful situations (heart rate, respiratory rate, plasma    neuropeptide Y concentration)

            -More efficient deployment of neural processing and autonomic responses

The marines who were trained in mindfulness could reach peak performance compared to the control group.5 Reaching peak performance when delivering healthcare can be critical given the highly complex nature of medicine.

Working with healthcare organizations across the country, IHE’s direct observations have found that less than 20 percent of physicians and caregivers have developed a formal practice of mindfulness. As busy professionals, many physicians and caregivers feel that the development of this skill requires a significant investment of time. Mindfulness can occur in brief moments. Examples include taking a breath before entering each exam room and allowing a moment to clear other thoughts. Surgeons often describe using the few moments while scrubbing to focus on the patient and the procedure at hand. One military physician described his mindfulness moment as “I leave ‘me’ outside of the room before I enter a patient exam room.” Moments of mindfulness can be found in offices, chapels, closets, or even restrooms—a place to take a moment to quiet multiple thoughts and focus on the task at hand.

Mindfulness is practiced formally and informally. Formal practice refers to finding a regularly scheduled time to purposefully cultivate present moment attention. An example of formal mindfulness is as follows:

            “When I press start on my coffee maker in the morning I sit down and practice mindfulness for five minutes; I notice what it feels like to breathe and let go of any distractions that take me away from the breath during the five minutes of practice.”

Informal mindfulness refers to finding moments during daily tasks/activities to be mindful. An example of informal mindfulness is as follows:

            “When I wash my hands in-between patients I practice mindfulness for a few seconds; I notice what it feels like to have my feet on the ground as I wash my hands and let go of the thoughts about the future or the past that take me away from the awareness of my feet on the ground in this present moment.”

The practice of mindfulness has resulted in multiple benefits, including:

            -Improvement in mood disturbance, depression, anxiety, and stress7

-A decrease in caregiver burnout8 (emotional exhaustion and personal accomplishment subscales)

            -Improvement in caregiver empathy9

            -Finding meaning in work9,10

            -Empowerment and engagement at work10

            -Emotional stability10


Aetna evaluated the effectiveness of mindfulness training in a cohort of 50,000 employees. Twenty-five percent of the employees participated in mindfulness training and the remainder served as the control group.11 Individuals who participated in mindfulness training had a 20 percent increase in sleep quality, 28 percent reduction in stress, 19 percent reduction in pain, 3-5 percent savings in employee health costs, a $3,000 per employee per year decrease in healthcare costs, and a 62-minute increase in productivity per week.


Reflective Listening

The second skill introduced in the IHE RELATIONS™ curriculum is reflective listening. Sir William Osler counseled his fellow physicians at the dawn of the 20th century with the following words of wisdom:

            “Listen to the patient:  He is telling you the diagnosis.”

Patients commonly reflect that physicians and caregivers are too busy to listen to their concerns. Approximately one-third of hospitalized patients state nurses or aides were too busy to address an immediate concern.12 Patients perceive healthcare workers as rushed and hurried. Physicians must find a way to change these perceptions while dealing with the complexity of healthcare and the many demands placed on the healthcare team.

Multiple studies have examined what patients most desire from their healthcare team over the past few decades. The results have consistently found “Having a doctor or healthcare provider who listens to me” at the top of the list. A recent study illustrated the top three attributes that people rated as “extremely important” contributing factors for a successful healthcare visit (Table 1).13

The skill of reflective listening is an excellent starting point for beginning a dialogue. With reflective listening, the listener’s attitude is curious, non-judgmental, and seeks to understand the patient’s perspective. Use of open-ended questions is critical to reflective listening. Listening is critical to gaining the trust of the person in front of you. A doctor’s ability to listen, reflect back and explain in an empathetic manner has a profound impact on a patient’s care. However, on average, physicians interrupt their patients’ narratives in 18 seconds to “take control” of the situation.14,15,16 During approximately one-third of primary care visits and one-third of subspecialty visits, patients report they never were able to talk about the primary reason they came for the visit.17 Healthcare providers cannot expect patients to be compliant with care plans if they have not been listened to and do not feel they are part of the plan.

Training in Reflective Listening: A Case Study

The skill of reflective listening can be taught and implemented into physicians’ and caregivers’ daily routines as outlined in Figures 1-3.

Following implementation of communication skills within the RELATIONS™ program, a healthcare organization demonstrated improvement of patient’s perceptions of their physicians listening to them and being understanding and caring. The national percentile rankings are from approximately 800 surveys over eight quarters of patient experience surveys conducted within the large healthcare organization.


Figure 1: Doctor's understanding and caring following implementation of RELATIONSTM skills


Figure 2: Doctor's keeping the patient informed following implementation of RELATIONSTM skills


Figure 3: Doctor's involving the patient in decision-making process following implementation of RELATIONSTM skills

Following initiation of the Institute for Healthcare Excellence Communication curriculum, the skills were gradually diffused to the entire active physician, nursing and allied healthcare team over a two-year period. The steady improvement of listening and communication skills is clearly demonstrated as the program was implemented.

The skills of presence and reflective listening are an excellent starting point for developing a culture rooted in teamwork, trust, respect, and compassion with the patient at the center of the team. These skills, in conjunction with four additional core skills introduced in the IHE RELATIONS™ for Healthcare Transformation program including 1) efficient and accurate information gathering, 2) joint agenda setting, 3) connecting with all members of the team, and 4) appreciation, provide the tools necessary for caregivers to navigate the healthcare transformation upon us. In working with healthcare organizations across the nation who have successfully introduced the skills in the RELATIONS™ for Healthcare Transformation program, IHE has directly observed significant and sustainable improvement in HCAHPS (with improvement to top decile in the communication associated metrics), patient experience metrics, employee engagement metrics, culture of safety metrics, multiple safety and outcomes metrics, and empathy and burnout metrics.

Significant and sustained improvement in the here-to elusive journey to create an excellent experience culture for patients and caregivers can finally be achieved through focusing on these behavioral skills in contrast to a lengthy list of tactical solutions. In addition, by nurturing skills which reconnect caregivers to their purpose, it is possible to restore joy and resiliency for all caregivers practicing medicine.

1. Dinenberg, Robert E. Mindfulness for Peak Performance. Presented at: Excellence in Healthcare Conference; 2016 May 20; Miami, FL.

2. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. 1st ed. Washington (DC): National Academy Press; 2000. 273 p.

3. Hughes R. Patient Safety and Quality. An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Publication No. 08-0043. 4. Rodak S. Ten Most Identified Sentinel Event Root Causes. Becker’s Infection Control and Clinical Quality. 2013 Sep 25.

5. Johnson DC, Thom NJ, Stanley EA, et al. Modifying resilience mechanisms in at-risk individuals: A controlled study of mindfulness training in Marines preparing for deployment. Am J Psychiatry. 2014;171(8):844-53.

6. Kaufman B, Gregoire C. Wired to create: unraveling the mysteries of the creative mind. New York (NY): Perigee; 2015. 252 p.

7. Fortney L, Luchterhand C, Zakletskaia L, et al. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013;11(5):412-20.

8. Horner JK, Piercy BS, EureL, et al. A pilot study to evaluate mindfulness as a strategy to improve inpatient nurse and patient experiences. Applied Nursing Research. 2014 Aug;27(3):198-201.

9. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009 Sep;302(12):1284-93.

10. Beach MC, Roter D, Korthuis PT, et al. A multicenter study of physician mindfulness and health care quality. Ann Fam Med. 2013 Sep-Oct;11(5):421-8.

11. Gelles D. At Aetna, a C.E.O.'s Management by Mantra. The New York Times. 2015 Feb 27: Page BU1.

12. Care Quality Commission. National Results from the 2014 NHS Inpatient Survey. 2015 May. 53 p.

13. Wen LS, Tucker S. What do people want from their health care? A qualitative study. J Participatory Med. 2015 Jun 25; Vol. 7.

14. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984 Nov;101(5):692–6. 15. Rhoades DR, McFarland KF, Finch WH, et al. Speaking and interruptions during primary care office visits. Fam Med. 2001 Jul-Aug;33(7):528-32.

16. Groopman J. How Doctors Think. New York (NY): Houghton Mifflin Company; 2007. 310 p.

17. Freidin RB, Goldman, Cecil PR. Patient-physician concordance in problem identification in the primary care setting. Ann Inter Med. 1980 Sep;93(3):490-3.