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Alissa perrucci

Your patient has the answer

by Alissa Perrucci, PhD, MPH

published 06/29/16

Recently in clinic we worked with a patient who really struggled with her pregnancy decision. She’d come in twice for counseling, during the last visit had decided to have an abortion, and had her laminaria placed. On her operative visit, however, she was considering having her laminaria removed to continue the pregnancy.

Patient struggles such as these usually are stressful for staff, even in the best scenarios. We worry that we didn’t do a skilled enough job working with her ambivalence, we contemplate concepts such as competence, and we worry about doing no harm. We have been known to miss the forest for the trees—to miss the fact that our patient is a person, making her own decision. That she has agency, even in the context of low freedom. And that all along she has been making decisions, even if those decisions seem contradictory or do not progress simply and cleanly from our perspective.

I have found that one of the most rewarding components of nurturing and developing members of the clinic team is talking about how to prevent and manage the stress and burnout that comes from the temptation to take ownership of and responsibility for other people’s behavior. This is a lifelong practice for me personally. Working in direct care is difficult; we have to have a way to be empathic and compassionate while maintaining our sanity, at a minimum, and ideally maintaining our gratitude and passion as well. Essential to maintaining this perspective is an acknowledgment of the personhood of the other; their right and their ability to make their own health care decisions.

Believe in your patient

You are the health care professional, and you bring to the table expertise and knowledge in nursing, medicine, and counseling. Your patient is the expert on her life and needs. Believing in her means you are freeing her and freeing yourself. Living this principle allows us to be authentically present to our patients, to actively and deeply listen, and to remain curious, open, and interested in them.

When we trust that the patient has the answer to her dilemma, we understand that her decisions may differ from what we would decide for ourselves. To work toward living this principle we free ourselves from the notion that we possess knowledge about the rightness of another person’s decision that she herself does not possess. We free ourselves from the notion that we can control events and outcomes. Our liberation is grounded in the belief that women are people—that they are subjects in the world, and that they are capable of making their own decisions.

There are three behaviors that prepare us to believe in our patients and stay fully engaged in and energized by our work. I think of these as the “state of mind” in which we approach our work. The behaviors are: listening, not assuming, and self-reflecting.

1. True listening first involves a commitment to stop talking

We can only listen when we create a space for the patient to speak. Listening can be augmented through open-ended questions. During a period of listening, consider opting for one open-ended question in lieu of a series of closed-ended questions. For example, after imparting test results or answering a challenging question about D&E, consider a period of silence followed by an open-ended question such as, “How is it for you, hearing that?” You can tailor the question to suit your style, but the point is its open-endedness.

We are often tempted to fill the space between ourselves and our patients with the sound of our own voice. The more uncomfortable or uncertain we are, the more compelled we are to fill it. With experience, we realize that we are strong enough to hold that space. So, the next time you’re concerned that you don’t have something clever to say, create a space of silence instead. You are giving your patient permission to express herself and reminding yourself to access your own competence and confidence.

2. Not assuming means that we step out of ‘professional mode’

In ‘professional mode,’ we are supposed to have the answers. When we are not assuming, we allow ourselves to learn from the patient. Learning from the patient comes from asking questions that seek to understand her personal experience. It involves letting go of assumptions around a shared understanding of feelings or the meaning of different life events. Lead with your desire to learn. When your patient in the abortion clinic says that she saw pictures on the Internet of fetal development, ask—with a genuine curiosity and openness—what that was like for her. Allow yourself to be surprised by the answer and willing to validate that meaning for her.

3. Self-reflecting is last, but not least

The practice of self-reflecting on our values surrounding contraceptive care, pregnancy decisions, and all kinds of patient choices begins with answering the following questions:

a) “What scenarios in my work do I find difficult?”
b) “Which contraceptive/pregnancy/other decisions do I find myself wanting patients to make?”
c) “What decisions do I think are foolish?”

This exercise brings into conscious awareness our preferences, biases, and judgments about the behavior of others—which is part of being human.

Taking it to the next level, we can reflect on how these preferences are connected to expectations that we have about our own behavior and our tolerance for our own imperfections. With experience, we know that while we care about others, we are not the same person, and if faced with a similar situation might make a totally different decision. Our liberation comes from acknowledging this connection, yet believing in the rights of others to make their own way.

Trying this in your practice

Growing and improving in any skilled activity requires two things: practice and feedback. Psychologist K. Anders Ericsson coined the term deliberate practice to illustrate the qualities and behaviors of people who achieve mastery in their particular domain of interest. It’s not just about putting in the hours, but also having a way to evaluate one’s performance through feedback.

That can be scary, but if you have access to it, consider having a colleague observe some of your patient interactions. Another approach is to pay closer attention to how patients respond to you. How much personal information do they share? Do they ask difficult questions? When you respond to a difficult question, what shifts do you notice in their countenance, the tone of their voice, or their language? You have in front of you the opportunity to gather data on the impact of your style and content. Use it to inform and adjust your approach. Allow yourself to be inspired to build your skills and increase your happiness.

Alissa Perrucci, PhD, MPH, is the Counseling & Administrative Manager at the Women’s Options Center at San Francisco General Hospital. Alissa began her work in this field after answering an ad in the Pittsburgh Post-Gazette in 1997 for an abortion counselor. She continues to be inspired by her memories of the hard-working women and men in that facility as well as all the abortion counselors that she meets around the world and in her home clinic today.
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