Dr. Gerard S. Letterie

The next pathway that I’d like to explore is the delicate and changeable relationship between you, (the patient) and partner and your provider team. I use the words delicate and changeable to suggest that the balance is a subtle one. But the bedrock force of this balance is communication in an open and clear style. Imagine two arms of the balance (the sort that you see in a lab): on one arm of the balance is your ability to express goals, boundaries and what is important to you and on the other arm is the ability of your providers to hear you, be present for you and provide the best practice options guided by an understanding of you and the literature most pertinent to you care. It’s upon this basis that a clear and well delineated treatment plan now and in the future will be based.

Let’s start by describing a framework within which to move forward.In the second part of this article, we will discuss specific cases and how the rapport vs report model may be relevant.

A Three Dimensional Space

Think of your evaluation as a three dimensional space with depth, breadth and width. To get the image right and understand the metaphor, think of your favorite room at home. This 3-D space is a mental place you will go to for planning, sorting out options and making key decisions. Create and design the space carefully as you will spend a great deal of time there and hopefully have an environment that will see you along the way to dream fulfillment. And as with any personal space, we’re careful about what we bring into the space and exercise care in selecting intimate items. You will bring several key elements into that space as part of your in fertility evaluation such as your providers and their team, personal issues, goals and hopes and dreams and a treatment plan based on the most current understanding of what medically and scientifically best suits your specific case. We try our best to create a space that is nurturing, an environment that encourages thought, positive emotions and support. The biggest and most important items are you and your family but a close second is your provider and the team that will guide you along this journey and the bond that you share with this group.

Let’s talk about the events that will occur and how we can expect things to happen. There are two elements: the personal and the medical. To convey these tightly related but very different aspects of your care, I use the opposing terms “laboratory report” versus “patient rapport” as a convenient tool to convey this duality and the complex and emotional relationship that each carries. I view the “laboratory report” part of this communication paradigm as information driven. It is intended to be more quantitative and precise: the medical side of the equation. The “patient rapport” is personally driven and a space in which medical information about your fertility options is placed in a context meaningful to you: the personal side of the equation.

In this paradigm, these two lines of information coexist and the communication is two sided: the ability to effectively communicate medical information with clarity and precision (the “report”) but also to use the information within the broader context of your own plans and way forward that is most meaningful to you (the rapport”). The exchanges with your providers should be based on your need to know what’s medically best, your need to communicate what will fit best into your personal plan for your family building and to partner with a team that can do both equally well. This concept is not new and is the cornerstones to effective communication in any professional setting where the problems are complex and driven from two sides (pick up any business book addressing communication to staffers and you’ll get a sense of what this means in another setting).

STEPS TO THE PROCESS

Establishing rapport

Thoughtful dialogue:
Fertility care offers the opportunity to step away from acute medical care (think: sudden onset of chest pain that requires an evaluation in the emergency department) and toward a more nuanced and personal approach to problem solving in a non-acute setting. This approach is not boutique medicine or what some characterize as “high touch” (as if there were degrees of “touch” or effective communication) nor hand holding. This approach is targeted and effective communication and plotting a path forward that meets your needs.

Qualities in the communication paradigm that I’m referring to:
Let’s talk about some bullet points that create an atmosphere for effective communication and address the issue of rapport:

• Accessibility
• Responsiveness and openness
• Engagement
• Safe connection
• Clarity

These points should translate into a shared sense of what’s going on medically and where these options fit into your planning. The more you share these qualities of communication with your provider, the more effective and timely will be your evaluation. Remember that you are in a relationship with your provider and their team that is medically based and personally driven. But there is also a business side to this. You want to move the process forward in as short an interval as possible with the least cost and most clinically effective options.

Your narrative:
Everyone has story and history of how they got to where they are. Hearing that story and narrative provides valuable information to your team (in a verbal manner supplemented by a standardized form if available). But telling it also gives you the opportunity to relate your story with all its subtleties and hoped for outcomes. Our patients need to be understood and many times need to be reminded that there are solutions and answers that may be out of the norm or away from what you initially expected. Your narrative should provide a basis for setting priorities and sorting options with a final game plan ready to execute. As a less significant but no less vital aspect of this discussion, we all need to be reminded (patients and providers alike) that things don’t always go smoothly and how we manage these times is an important part of the journey. Hence the space in which these discussions are held should be marked by a secure and open dialogue and environments that encourage questions and information exchange.

Interpreting reports:
Here is my take on lab tests: Any lab report such as FSH testing or imaging study such as an ultrasound or HSG is not a pass or fail test. The results of a lab test are intended to adjust options and calculate odds or percentages of success. Look at it this way: a lab test should tell us: With Option A, you can expect success with Treatment A of X%. Or: With Option B, success of Y%. Lab tests don’t make final decisions though they are a key component in crafting your final plan. Nor (and I’ll state the obvious) are they indicators of success in life or your quality as a person or partner.

But tests are deigned as tools to re-adjust upward or downward the likelihood of success for various treatment options in any medical setting but in fertility care in particular. We request certain core tests as part of an infertility work-up whose results influence in part our pathway forward. Simply put, these test should provide the basis for: a discussion of the options, your likelihood of success with each option and the approximate costs for each option. It’s a trifecta and it’s that simple. Initial evaluations should give each member of the team enough information to make intelligent decisions regarding direction and costs (both emotional and financial). The final course forward results from combining the report within the context of rapport and understanding.

Coming soon: Case Studies.... check back for part II of this installment.