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Dr. Greenberg:
As clinicians, we always do our best to ensure that patients leave our office feeling happy, healthy, and pleased with their care. But unfortunately, that isn't always the case. So how can we speak with those patients who are less than satisfied with their care?

Welcome to DermConsult on ReachMD. I'm Dr. Michael Greenberg, and joining me today to discuss his recommended approach for consulting displease patients is Dr. Howard Steinman, a board-certified dermatologist and fellow of the American College of Mohs Surgery. Howard, thanks for being here today.

 Dr. Steinman:
Oh, it's great to be here. Thank you for having me.

Dr. Greenberg:
To start us off just quickly, because we have a lot to cover, how did you become interested in patient satisfaction practices? 

Dr. Steinman:
It happened because early on in my practice, I'll just admit that I'm now 66, I had a bit of what is now called imposter syndrome. And I was always very anxious when someone had an adverse reaction. In my practice, I primarily remove skin cancers surgically. So if someone came in that was upset about their care, it was difficult for me to go in the room, which is very common with a lot of physicians and other providers and nurses, especially because I knew that I had caused whatever they were upset about. And I discovered actually at a nurse's station in the hospital across the street from where I worked a mnemonic that said LAST: Listen, apologize, satisfy, and thank. And I said, "That's interesting, I need to look that up, because perhaps it'll help.” And when I looked it up, I came across this very helpful mnemonic or memory aid called BLAST, B-L-A-S-T, which stands for believe, listen, apologize, satisfy, and thank. And it was actually invented by a restauranteur who at the time owned a coffee shop. And he had invented it so that his hostesses, you know, teenagers, could deal with complaints effectively and calmly and retain them as customers.

And I started looking into the issue of patient satisfaction, eventually wrote a paper on this and started teaching other people. And I found that once I had incorporated BLAST into my mindset, I had no difficulty dealing with patient complaints. I felt quite comfortable going in the room and was able to solve the overwhelming majority of patient’s concerns very quickly and easily and kept them satisfied and reassured and retained their trust.

Dr. Greenberg:
Great. So let's take this acronym, BLAST; let’s take it apart and letter by letter. Break it down for us if you would.

Dr. Steinman:
Okay. So before I say the B for believe, an essential concept is when patients are unhappy or anyone is unhappy, whether it's a hotel or restaurant, or with your spouse or teenager, or your doctor, is they've had unmet expectations. If your expectations have been met for any experience in your life, you're satisfied. If your expectations have not been met, you're not satisfied. So a silly example is you can go to the finest restaurant in the world, and if you had expectations that exceeded what they offered, you're not going to be satisfied. And if you went to the worst restaurant you could imagine, and you had lower expectations and they were met, you'd be happy with that lousy restaurant. You have to assess patient’s expectations and resolve any unmet expectations to resolve any dissatisfaction that they have.

So the mnemonic is believe, listen, apologize, satisfy, thank. So when you go in the room, you have to understand that you're sort of in a somewhat dominant position as a doctor, and the patient may be fearful or angry and wondering how you're going to react. And so belief is essential. You walk in the room, you ask them what the problem is, you sit down, you turn off your mind and your mouth, and you make eye contact, and you ask them what's going on. And as they're answering, you have to evoke belief. You have to feel belief because if you don't, you'll make facial expressions or body movements that will exhibit non-belief. And if the patient doesn't feel you believe them, even if their complaint is not accurate or rational, you've lost. You've lost their trust. If you will evoke belief, then you're halfway there. The patient knows you're on the same team. There's no further adversarial issues, and you can proceed. And the key point is to shut your mouth and let them talk. Because studies have shown that the average physician interrupts patients within 20 to 30 seconds of when they started talking. And you need to let them express what's bothering them. Because only through that, can you determine what expectation hasn't been met. Sometimes it's obvious, sometimes it's not. So evoke belief. And once you've done that, everything settles down a little bit.

And then you want to do L, is combined with belief, you have to actively listen. And when you're actively listening to someone, again, you are trying to determine what's bothering them. You're trying to evoke empathy and figure out what's bothering them and how you can help. So you have to actively listen. And the purpose of your listening is to determine their unmet expectations and what they're upset about. So you have to sit down calmly face them and believe and listen. And most patients will express what they're concerned about within three minutes. So this whole BLAST concept is not a time-consuming event. It saves you time if you're a physician because if we don't satisfy the patient, they're going to call your office again, or they're going to bother your office manager or they're going to go to someone else and badmouth your care. So you go in the room, you sit down, you evoke belief, you calmly listen to determine what their unmet expectation is.

And once you've determined that, then you get to A, which is apologize.  And most agents will go, “Apologize? That's the last thing you want to do. It will lead to litigation. You've admitted you've done something wrong.” And that's not what the apology is all about. The apology is apologizing for their upset, for their unmet expectations, for their having to come in, and their disappointment. And you use the apology to redirect their unmet expectations and form the basis for solving their problems. So for example, if it's a reasonable unmet expectation, you could say, “– We’re very, very sorry about the medication causing rash. It can happen sometimes. It does happen 1 or 2% of the time, and I'll do everything I can to take care of it.” If it's an unmet expectation, you can say, “‘I’m very sorry that your wound got infected. But you know, infections occur 1 or 2% of the time despite the best possible care and wound care.” You apologize in that way.

Once you've apologized for their unmet expectations, then you satisfy them. And the first thing you want to do with S is resolve anything that can't be unsolved. You might want to say, “I’m very sorry that you have a scar there. And I'll do my best to improve the scar. But you need to know that I don't have a magic wand. I can't make this scar completely disappear. But we can do the following.” And then you propose two or three things that you think will satisfy the patient and let them pick.

So by going through this process of B, L, A, and S - you have diminished any sense of confrontation. You are now on the same team, you've established rapport and trust. And now you're going to propose solutions in a much more calm environment. And then if that can happen, if you can satisfy the patient, do so. If you can’t satisfy the patient, then tell them why you can't. But leave the door open, say, “Look, why don't we meet again in a week. And we'll see how you feel about this complication or side effect,” or “let me talk with my office manager and see what we can do about altering your bill if you're upset.” Or if they're upset about a wait time, you could say, “Look, it'd be best if you made the eight o'clock appointment for me or the one o'clock appointment because that way you won't have to wait.”

And once you've done that, you thank them. And you thank them for several reasons. One, you thank them for “bringing this to my attention. I'm very grateful that you trusted me enough to come in and let me know.” You're thanking them for not tarnishing your opinion with others by complaining to their friends and to other doctors about the “lousy care” that they received. And this whole process has remarkable effects on people. It's not a gimmick. It's not a script. It's just a natural behavior that relies on normal human nature.

Dr. Greenberg:
For those just tuning in, you're listening to DermConsult on ReachMD. I'm Dr. Michael Greenberg, and today I'm speaking with Dr. Howard Steinman on how he communicates with displeased patients.

Let's switch gears for one second, Howard. I'd like to focus on the importance of presence. One of my teachers told me the greatest gift we give to each other is the quality of our presence. Do you have any thoughts on presence in this process or on being present?

Dr. Steinman:
Yeah, by presence, I think there are two ways you can interpret that.  A lot of doctors avoid going in the room at all because they are anxious or afraid or just torn up inside or bothered, or they feel they don't have time. And I will say that if the physician or provider themselves doesn't go in and solve the problem and satisfy the patient, it’s ineffective. So you want to be present in the room when a patient has a complaint because it's easier for you to take charge and solve it.

The other thing you're referring to is to be present in the moment with the patient. You want to go in the room, you want to sit down, you want to act as if there's no other distractions, you're going to put your charts away, you're going to fold your hands and look at them calmly and be present with them as they express their concerns.

Dr. Greenberg:
So how can we implement these techniques in our offices? Do we need to have somebody come in and teach it? Or is your paper sufficient just to read to our staff? Where do we start?

Dr. Steinman:
I think that someone in the office can certainly look at the paper. There are other articles that have referenced BLAST that I've written up that also talk about patient satisfaction. But the paper itself is usually sufficient.

And I tell people that this is important for especially physicians and providers. All of us, I think, can say one of the biggest fears we have in an office is one of our patients collapsing in front of us and having a heart attack or a cardiac event. And once we've taken CPR or once we've taken ACLS, advanced cardiac life support, you're no longer that nervous about it. Because you have the knowledge and the equipment and experience not that you're not going to be a bit anxious, but you'll be able to take care of the problem; you have confidence. And once you've learned BLAST, it just changes your perspective on complaining patients. And every physician has had someone come out of the room, their nurse will say, “Oh boy, Mr. Steinman’s really angry, and he's angry about your result and angry about the bill.” And I go, “That’s okay. I can go in. Give me 5 minutes with him, 10 minutes, and I'll be able to take care of this.” So once one person has learned BLAST, they can easily teach everyone else in the office. And an interesting verb made out of it, when I taught full time at a university, I would come in in the morning and one of the residents on call would say, you know, “Your patient X called last night and he was upset about this. And I BLASTed him and he's fine.” So BLAST became a verb in the department where I first taught it. Once you've seen it and read about it and tried it once or twice, that's all you really need.

Dr. Greenberg:
Okay, I'm going to switch gears for one second again because I think this is important. How important is the understanding that when a patient's unhappy, they're expressing fear?

Dr. Steinman:
It's very important. That is a key concept. I teach everyone I can teach, including my staff that when patients have to go to a medical office, they're just afraid to begin with, if it's a surgical visit, or they're worried about their illness, or they're worried you're going to find something, they’re worried the doctor is going to scold them about their weight. And so I operate under the assumption that patients are not only fearful, but they're also in a strange environment where things can hurt them and you're doing weird things to them. So I think it's important for physicians and their staff to operate under the assumption that patients are a bit fearful every time they come in. And things that we’re totally used to, the smells and sights and sounds and equipment that's routine to us, is new or fearful for them. And it's a very key concept, Michael, that you should assume, no matter how calm they appear, that patients are fearful and anxious, or they wouldn't be in your office. Right? So I think that's the key concept.

Dr. Greenberg:
And we have actually two people in fear, we have the doctor fearful that he's going to make a mistake or get sued, the patient fearful. I think we have to get to resolving both of those people's fears.

Dr. Steinman:
Exactly. But I think it's incumbent on the physician or provider to control their anxiety. And it's incumbent on the physician to create a safe, calm environment for them. I tell every patient “I cannot make this completely pain free, but I can sure try to make it stress free.” And that's my motivation and my staff's motivation when we're treating patients.

Dr. Greenberg:
Okay, so before we wrap up, Howard, you've shared a lot of really great information. I'd like to hear your thoughts and how we can make this part of a curriculum in medical training. Do you see a path forward for this?

Dr. Steinman:
Yes, I really do feel that starting early in people's careers, they should be taught something similar to BLAST because it's an acquired skill. And once you have the skill, you find yourself incorporating it in other parts of your life, not only medicine, but if someone's upset with you or angry with you in regular life, you can see how BLAST would be important to use. And believe it or not, no one knows you're using it. It is just human nature. And it's actually taught a lot in the service industry. I've been at some fancy hotels or restaurants or places where I've heard someone complaining, and the person's BLASTing them and they don't even notice it. What they're doing is just a way to assure the person that everything is going to be okay and that they're going to solve your problem. And it's certainly easy to incorporate and this is less than an hour lecture in medical school or in nursing school or to give your staff. Because everyone on your staff if you're in healthcare needs to know it. Your receptionists need to know it, your billers, your colleagues, and certainly your support staff in the clinical side need to know how to BLAST people. And it's one of the first things I teach a new employee is BLAST.

Dr. Greenberg:
Those are all great thoughts to keep in mind as we bring our program to a close. I want to thank Dr. Howard Steinman for speaking with me today and for sharing his approach to consulting displeased patients. Howard, it was great having you on the program.

Dr. Steinman:
Thank you. I really appreciate you having me.

Dr. Greenberg:
For ReachMD, I’m Dr. Michael Greenberg. To access this episode and others from our series, visit ReachMD/DermConsult, where you could Be Part of the Knowledge. Thanks for listening.