An expert in human behavior change shares his framework for effective communication with patients who present with sleep disorders.
The most expensive component of a masterful painting is its frame. In fact, the next time you’re in a world-class museum or your local gallery, look carefully: each painting is contained within a beautiful, often intricate, frame. Even simple frames cost hundreds of dollars, and expensive frames can cost much more. The purpose of these carefully chosen frames is to provide a structure to highlight and draw attention to artwork itself. In fact, the more effective a frame is, the less you notice it is there. But when you step back and gain perspective, it is evident that the frame was crafted and chosen with great care.
In much the same way, great patient communicators employ purposeful structure to maximize the impact of their messages. But unless you step back, you’ll never notice the structure of the message and you’ll miss the forest for the trees. You’ll continue to use more words when fewer would do, and too many of your patients won’t fully understand or adhere to your recommendations.
In this article, you’ll learn how to frame your messages for reduced frustration, improved efficiency, and better adherence and outcomes among your patients. We’ll use insomnia as an example throughout, but you’ll find these skills apply in virtually any teaching or training situation.
Are Insomnia Patients Challenging?
When I lecture, teach, or supervise medical practitioners in insomnia management, the most common feedback I receive is that patients with insomnia are “difficult to treat.” These patients frequently seem to require more time and effort than, for example, routine obstructive sleep apnea (OSA) patients. This extra time and effort frustrates both sleep specialists and other healthcare providers—not to mention patients themselves. (For more tips on maximizing patient adherence in the context of OSA, check out my Sleep Review June 2012 article, “Cognitive Behavioral Treatment in Action.”)
A majority of insomnia patients present with psychosocial stress and/or mental health comorbidities. Particularly when stress levels are high, insomnia patients can be very talkative and seem needy, scattered, or disorganized. This can make it challenging to identify rapidly the most salient issues and develop a targeted treatment plan, while also ensuring that patients feel heard. Providers and patients both often feel hurried, stymied, and unsuccessful.
The Problem: Lack of Context
The single biggest barrier to effective patient communication is lack of context. Patients have too much to say, and doctors know too many facts. So patients talk about what is important to them, and doctors tell patients much of what they know. (What doctors should be doing is telling patients only what they need to know, and no more!) Many words are said, but not much is heard. Without a common framework, it might as well be two ships passing in the night. But it doesn’t have to be this way.
For Improved Communication, Structure Is Your Friend
The human brain learns through structure—we do best when we know what comes next. This applies especially to patients seeking expert guidance. Hence it is incumbent on you, the expert, to have a plan and to communicate that plan effectively. If you master this skill, your patients will have no choice but to follow your reasoning, understand your intent, and better adhere to your collaborative treatment plan.
Wickwire Funnel Framework (WFF)
In the WFF model, less is more: the less you say, the more your patients will understand. All of your structured communication will circle around one word or phrase. After all, if you can’t quickly and easily identify your main point, how can you expect your patients to do the same? Image courtesy Emerson M. Wickwire, PhD (used with permission)
This communication system is based on over two decades of experience in psychology, coaching, language, and instructional design. As you learn and rehearse the system, you’ll experience dramatic improvements in efficiency, effectiveness, and confidence in administering behavioral interventions—even to difficult insomnia patients.
To employ the Wickwire Funnel Framework (WFF), first choose one word or phrase that underlies the most basic cause of the current predicament. Next, frame the issue very clearly and succinctly. The easiest, most effective, and most efficient way to do this is state the problem and the solution—the exact opposite of the problem—from a 20,000-foot view. For example, when I talk to patients about OSA, I explain, “The problem is that there is not enough space in the upper airway for air to get through. Therefore, the solution is to increase space in the upper airway.” In this instance, my one phrase is “not enough space.” Everything that I teach patients about OSA flows from this problem/solution frame, including discussion of treatment options, acclimating to therapy, and so on. The clearer you are, the easier it will be for your patients to understand.
Once you have framed the problem and general solution, increase specificity. In most instances, I recommend breaking your recommendations into guiding principles, confirming patient understanding, and then concluding with specific behavioral instructions. You can think of this as moving from 20,000 feet to 10,000 feet to boots on the ground.
3 Steps to the WFF
1. Frame the problem.
a. Choose ONE word or phrase to explain the cause of the problem.
b. Clearly and succinctly state the problem and solution. Use this format:
“The problem is ____.”
“The solution is ____.”
c. Confirm patient understanding.
2. Provide guiding principles.
a. Identify 2-3 simple truths that underlie the suggested changes.
b. Confirm patient understanding.
3. Provide specific behavioral recommendations.
a. Tell the patient exactly what to do between now and your next follow-up.
b. Confirm patient understanding
c. Problem-solve as needed to overcome potential obstacles.
Real-World Application—The WFF in Action
To provide you with a sense of what this looks like in practice and how the WFF can improve the efficiency of your insomnia care, here’s a sample dialog involving stimulus control (the one word in this example is “repetition”):
You: The problem is that through repetition, your body has learned that the bed is a place to be awake. Therefore, the solution is to retrain your body that bed is a place for sleep. Does that make sense?
Patient: Got it.
You: Next, I’m going to give you two guiding principles to explain how this works. The first is, we need to avoid time awake in bed. Second, we need to re-pair the act of getting in bed with falling asleep quickly and staying asleep. Do those make sense?
Patient: Yes. But how the heck do we do that?
You: I’m glad you asked. First, from now on I only want you to get in bed at night when you are highly confident that you are ready to sleep. Second, if you are unable to fall asleep, or if you awaken during the night and are unable to fall back asleep in 20 minutes, then refer to rule number one. Get out of bed, avoid stimulating activities, and only return to bed when you are highly confident that you are ready to fall asleep. Do you follow?
Patient: Yes, that makes sense. But what should I do if I can’t sleep at night?
You: That’s a good question. Let’s come up with a few possibilities…
Is There a Catch?
If you’re like most health providers, you might be thinking that you are already spending more time than you’d like with difficult patients. Of course, it takes effort to identify the critical steps for your patients, develop unequivocally clear language, and practice your new approach…until it becomes second nature. If you want to increase efficiency and improve patient outcomes—and stop wasting valuable time—then you need a proven system to communicate. Try my funnel approach for a month. You’ll never look back.
Wickwire
Summary
If you work in sleep medicine—or any area of healthcare, for that matter—your patients’ success will largely be determined by how well you are able to help change human behavior. In today’s high-pressured healthcare environment, you must be able to say what you mean quickly, effectively, and confidently—in a way that patients understand. Much like the frame that guides your eyes to the painting, the structure of your communication should be clear, intentional, and powerful. Follow these steps, and you and your patients will be glad for it.
Emerson M. Wickwire, PhD, ABPP, CBSM, is director of the insomnia program at the University of Maryland School of Medicine. He is a recognized expert in the non-drug treatments of sleep disorders and motivational approaches to managing chronic disease. He is also associate editor of the Journal of Clinical Sleep Medicine and a member of Sleep Review’s editorial advisory board. Wickwire learned the power of language for masterful communication during his years as a secondary school English instructor and summers studying literature at the University of Oxford (UK).
