Help with Health Care’s Rules of the Road
Deirdre Mylod, PhD, Vice President, Improvement Services, Press Ganey Associates
Tuesday, August 09, 2011
I recently returned from a wonderful experience in the Dominican Republic. I took care to read about the country ahead of time, and even learned some Spanish. We landed in Puerto Plata on the northern coast, went through customs, picked up our car and headed out to the main road, Route 5. Immediately we realized we were not in Kansas anymore. The rules of driving were so different from what we were accustomed to that at first we felt like there were no rules. What seemed to be a two-lane road had in fact three or four lanes of traffic, including small motorcycles, cars, trucks and livestock, all of which frequently included multiple passengers perched atop.
Over the next few days, the rules of the road began to emerge. Driving was still more intense than at home, but it slowly became clearer how to navigate, react to and predict the other drivers’ behavior. As we figured out the rules, we felt less foreign and much safer, not just driving but in our travels in general.
This prompted some interesting conversations about social mores in a broader context. It seems we feel comfortable in our own culture and environment in part because we know the rules – even if we can’t verbalize what those rules are. Entering a new environment that has different rules can be very disorienting. But what initially seems like chaos slowly becomes navigable as we figure out or are given hints about what these rules are. Until the new parameters are second nature, we’ll continue to feel a bit awkward and unsure. But those who know the rules may not understand our hesitation because it’s hard for them to unlearn what they instinctively know, or to take the perspective of one who comes to a situation with a completely different set of expectations.
I think that those who work in health care have a sort of bilingualism that they’ve developed. That is, staff members operate outside of work in the larger American culture, and also have internalized a sub-culture of how health care works. Patients often haven’t had the time or the opportunity to get the crash course in how to be a medical “tourist” – to know how to navigate the language, landscape and customs of the health care environment. As a result, they feel disoriented, stressed and unsafe because their familiar roles are removed and they don’t know what to expect. And health care workers can have trouble noticing how foreign it all can seem to patients because this is the environment they work in every day.
Imagine a tourist guide for prospective patients: It might start with key phrases that would be useful to know and to be able to say at the appropriate time. This way patients would understand “PRN” or “push fluids” and could appropriately speak up to say they feel their “condition has worsened” while in the ED. The social customs of health care might be more difficult to articulate once you get past the obvious ones like it being acceptable to discuss bodily functions or disrobe in front of people you’ve only just met.
But since a complete “travel book” for patients is impractical, successful organizations often take an approach in which caregivers essentially act as tour guides as often as possible. This is accomplished by recognizing what would feel different or unusual for the patient and giving explanations and advance notice to patients about what is coming. Further, establishing a good relationship with patients includes making it feel safe for them to ask questions about what is going on as they work to get to know this foreign environment. If we assume the informal role of ambassadors, we can help patients feel welcome in this often foreign land of health care. This would make the drive a bit smoother for everyone.