SF General reserves judgment when coaching patients to help foster open, trusting relationships.
Collaborator (Non-Members)Larissa Thomas, Michelle Schneidermann
Whenever people hear “no,” they do the opposite. Everyone knows that doing crack is bad for them and also illegal. Us telling them one more time to stop isn’t going to magically make them stop. Instead, it will make them resistant and unreceptive to our coaching.
San Francisco General is a non-profit hospital and level 1 trauma center in San Francisco, CA. It has 598 beds and serves a diverse population, the majority of whom are lower income and do not speak English as their first language. Many are also illiterate in English as well as their preferred language. The hospital also serves individuals who may not have health coverage, housing or access to food. They enroll the most difficult to engage patients who have a history of substance abuse and poor health outcomes. Their transitions program began in 2009 and is influenced by the Care Transitions Program and Project RED.
What We Tried
We withhold judgment and try to meet patients where they are. Instead of saying, “You shouldn’t smoke crack,” we say “How many stems do you smoke?” It shows them that we’re not judging—we just want to understand their behavior so that we can help them. Then rather than tell them to stop, we might ask them to smoke less. The same is true for diet. If a patient is supposed to eat a low sodium diet, but they don’t have a kitchen and can only afford canned beans, we’re not going to tell them not to eat canned food. Instead, we’ll suggest that they rinse those beans out really well before eating them to cut down on the sodium. It’s about harm reduction, not changing them overnight.
The fact that we develop relationships with our patients is evidence that it’s important to reserve judgment. Our patients feel comfortable telling us that they smoked over the weekend or haven’t been following their diet. Knowing that, we can continue to coach them in the most effective manner. We had a really hard patient a few years ago who used drugs and didn’t intend on stopping. He disappeared for a while and when we finally saw him again he told us that he had developed a great relationship with his primary care physician and stopped using—“Friday and Saturday weren’t worth going back to the hospital for 2 weeks.”
Reserving judgment helps us develop therapeutic alliances with patients much quicker. We’re probably the only health care provider they’ve met who hasn’t told them to stop doing this or stop doing that.