By Carol Milano
Worth The Investment?
When Harvard Medical School recently surveyed over 2,000 patients
about their office visits, poor communication with their doctors
emerged as THE most likely cause of dissatisfaction and switching
The Harvard study highlights a need that America's medical
schools are already acknowledging: the importance of stronger
communication skills. Approximately 75% now offer courses on
this topic. Physicians long out of medical school are discovering
that attending professional communications workshops can lead
to more accurate diagnosis, better patient compliance, higher
retention rates, more referrals, lower staff turnover, reduced
malpractice premiums, and fewer lawsuits.
Gains may be intangible, as well: asked to cite a benefit
of his communications training, Fred Husserl, MD, instantly replies,
In 1989, burnt out and considering quitting nephrology, "I
used to walk in, see certain names in my [appointment] book,
and get a knot in my stomach. The issue was being able to handle
those parts of medical practice that have nothing to do with
medicine, which can become more of a problem than the textbook
part that I know well," he reflects.
Dr. Husserl credits a communications workshop with improving
both his and his patients' behavior. Understanding his own attitudes
helped him learn how to help a patient make a change, remain
neutral when his advice is ignored, and discover "how I
can be the best doctor for that particular patient." Estimating
that 50% of his patients are addicted to tobacco, alcohol, or
another unhealthful habit, Dr. Husserl says, "Unless you
know how to work with the patient and help them through that,
you can't practice good medicine." He's proud that he now
has a good rate of smoking cessation, the strongest single statistical
contributor to death from renal disease.
Convinced that becoming a better communicator enabled him
to stay in nephrology, Dr. Husserl took an advanced workshop
so he can train residents at the busy Ochsner Clinic Foundation
in New Orleans, where he is Acting Head of the Nephrology section.
"Now, when patients don't receive a requested answer or
prescription, they don't leave angry, frustrated or feeling not
listened to, but with a sense that we had an honest disagreement.
There are very few, if any, difficult patient interactions that
I can't handle. I leave my practice each day knowing I have
no unfinished business (like a disagreement with a patient) --
I don't carry home any angst." Although he's limited his
practice to nephrology, Dr. Husserl says, "My measure of
success is that a few times a month, a patient or their family
member asks me to be their GP."
The Need for Better Communication
In the Harvard study, 12% of subjects had considered changing
doctors. "Physicians underestimate patients' desire for
health information and overestimate the amount of time they spend
providing it. Patients want to feel heard," observes lead
investigator Nancy L. Keating, MD, MPH, a Health Care Policy
researcher. "Providers' decisions to limit tests, procedures
or referrals are often entirely appropriate. Communication strategies
to increase discussion about such decisions may result in fewer
patients leaving the office feeling they were not provided a
needed service," the authors suggest. (Journal of General
Internal Medicine, January, 2002).
Patient frustration or disappointment may even signal a potential
legal problem. Examining the association between patient complaints
and doctors' risk management experience, "Risk appears
related to patients' dissatisfaction with their physician's
ability to establish rapport and communicate effectively,"
report Gerald B. Hickson, MD, and his colleagues at Vanderbilt
University School of Medicine. (JAMA, June 12, 2002)
Why is dialogue so difficult? "Most medical training
involves learning about disease-but much of the time, we also
deal with the person wrapped around the disease. Pathophysiology
encompasses all the sciences related to disease. The 'science'
of dealing with the rest of the person is communication,"
explains Frederic Platt, MD, a general internist in Denver who
also teaches communication skills at University of Colorado School
The Value of Better Communication
Fortunately, the essentials of good communication (listening,
understanding, exchanging information, empathy, etc.) can be
learned--and a growing number of physicians are choosing to acquire
Bayer Institute For Health Care Communications, the leading
firm in this specialty, has trained over 40,000 clinicians and
health care staff in more than 3,500 workshops. Associate Director
Vaughn Keller, Ed D, finds that, "A truly skilled physician
will get different diagnostic information than an unskilled communicator,
who frequently will not get significant health problems to surface.
Communication also affects adherence to a therapeutic regimen,
because the doctor never really it talked it through with the
patient. Skilled communicators can have a tremendous impact
on whether a patient makes lifestyle changes," says Dr.
Keller, a Lecturer in Medicine at Yale School of Medicine.
Dr. Platt concurs. "Too often, doctors get the story
wrong. Asking, was the pain more on the right side or the left
side, helps lead to a correct diagnosis, critical to treatment.
People want to be heard and understood. Patients feel better
right away if you give feedback showing your understanding and
confirmation. The key value of better communication is improving
the quality of patient care and the likelihood of a good outcome."
Steven Zabrowski, MD, a general internist in Plainfield CT,
has a private practice, in addition to working with ProHealth
Providers, an 80-office group practice. He, too, is pleased
to see higher compliance rates and better quality of care. "It
takes less time to listen initially than to have patients come
back in deteriorating condition, and not get better. If people
are comfortable calling you, they'll come for treatment earlier
than they might otherwise."
Last year, staff turnover was 33% at ProHealth, which has
200 providers throughout central Connecticut. . Since communications
training began last November, turnover is down by 50%. "We
were very pleased. It's so expensive to recruit and train new
staff, we have to make staff retention a company priority,"
Dr. Zabrowski stresses. Communications training at ProHealth
involves everyone who works at each facility. Dr. Zabrowski
has found that office atmosphere, including more harmonious
communication between physicians and support personnel, has
a strong influence on patient satisfaction and retention.
Conversely, with a dissatisfied patient, "you're not
just losing the patient, but all the potential referrals he or
she could have made," says Susan Keane Baker, author of
"Managing Patient Expectations" (Jossey-Bass, 1998).
A specialist in service quality and patient satisfaction, Baker
believes the biggest stumbling block in most medical practices
is that patients are sometimes reluctant to voice complaints
because they don't want to be perceived as difficult. "Without
being asked, they may not share important information,"
The Legal View
Physicians' Reciprocal Insurers (PRI) of Manhasset, the second
largest medical malpractice writer in New York State, is actively
involved in training physicians they insure. For over two years,
they've offered a Bayer workshop, Clinician/Patient Communication,
and they're adding The Difficult Clinician/Patient Relationship,
after working with Bayer to tailor the programs to the needs
of PRI clients.
What's PRI's incentive? "Our principal reason is to
support our doctors in their practices. Diagnosis and treatment
rests in large part on communicating with a patient. We believe
and the data support that a physician who is better
able to communicate will find more adherence to treatment. The
literature points to minimized instances of malpractice,"
says Marjorie Thomas, PRI spokesperson, "and we believe
it will help to decrease the number of malpractice cases."
The training, part of PRI's Risk Management Education program,
allows a physician to earn a 5% premium credit for completing
both the workshop and the follow-up home study project. Similarly,
Colorado Physicians Insurance Company also considers good communication
essential, and encourages their doctors to attend communications
workshops, reducing their premiums by a small amount upon completion.
Communications training programs range from a few hours to
the week-long workshops offered by Bayer, a not-for-profit organization
established in 1989. "For changing communication behavior,
there really is a dose response," notes Dr. Keller. "It's
not unlike language training." All trainers stress the
necessity for role-playing, practice and feedback to actually
improve skills. Listening exercises are crucial.
In Bayer's highly-regarded one-week course on Clinician/Patient
Communication, the small-group format provides one trainer to
every three or four health care providers. (In addition to MDs,
courses may be attended by ODs, MPHs, nurse-practitioners or
other health professionals.) Standardized patients simulate
a particular situation, helping participants learn specific communications
techniques as well as strategies for dealing with patients they
experience as difficult. Follow-up includes meeting with a "coach"
for one hour per month over the next year, to review audio or
videotapes of patient visits.
Programs can be offered through hospitals, national and state
medical associations, insurance companies, or at a training firm's
facility. Large group practices sometimes hire an experienced
trainer to present an on-site program to their participating
doctors. Some individual trainers, like Susan Keane Baker, will
work with a small group practice staff (of six or more employees),
in sessions of several hours.
CME credits may be available; Bayer Institute courses are
fully recognized by the Accreditation Council of Continuing Medical
Education, for example. The American Academy of Family Physicians
gives credit to members who take a recognized communications
course. Some training programs provide credit that meets state
risk management requirements, or counts as points in a particular
Fees vary widely. Bayer's one-week program, at its West Haven
CT headquarters, costs $2,500, which includes all materials and
most meals. However, when presented by a sponsoring organization
(such as the American Academy of Orthopedic Surgeons, Veterans'
Health Administration, or PRI), the same communications workshops
are usually free to participants. In addition to providing
instruction, the sponsoring group typically covers the cost of
materials and CME credits. (In PRI's case, doctors not insured
by the company are welcome to attend their workshops, for a fee.)
Improvement in communication skills can actually be measured.
The usual tracking instrument is the Patient Satisfaction Survey.
"Our data show that 75% of people in the one-week program
jump at least one quartile on surveys; 40% jump two quartiles,"
reports Dr. Keller.
Patient Satisfaction Surveys are also an excellent diagnostic
tool. "When health care organizations start doing them,
they gradually begin to see what the difficulties are in their
own practice," Baker's learned.
Dr. Keating, also a primary care general internist at Brigham
& Women's Hospital in Boston, has been affected by the results
of her own study. She now tries to "be more aware of how
I'm interacting with my patients, and to identify what their
expectations are during a particular visit or conversation.
At the start of each interaction, I say, 'tell me what's on your
mind today,' which gives the patient the chance to shape the
agenda." Before her research, she was less conscious of
trying to elicit a patient's real concerns, and feels she's far
better at it now. "My belief is that it will make my patients
trust and respect me more, have more faith in my recommendations,
and come to see me more freely," she says.
"How many times do I leave a patient with the sense that
our relationship is sour or strained?" asks Dr. Husserl,
the formerly discontented nephrologist. "Almost never.
I may have time pressure, but no feeling of a situation I really
can't handle. Commmunication skills have given me the satisfaction
of making medical practice pleasant, and the control and confidence
to handle difficult issues that come up with patients."
RESOURCES FOR READERS:
To get more information about communications training programs,
check with your malpractice insurer, medical associations, or
hospitals where you have admitting privileges to see if they
offer (or recommend) courses. Any of these providers can be
Bayer Institute For Health Care Communications
www.bayerinstitute.org For a complete catalog of courses,
Society For Teachers of Family Medicine
www.stfm.org 800-274-2237 Established
in 1967, the society has over 5,000 teachers of family medicine
American Academy On Physicians & Patients
consortium of physicians who teach communication skills to medical
Susan Keane Baker www.susanbaker.com 203-966-4880 Request a copy
of their special report, "100 Ways To Make Your Organization