Physician communication skills in clinical medicine

Marc Imhotep Cray, M.D.
Communication Skills
In Clinical Medicine
Prepared and presented by
Companions:
eNotes: Fundamental Communication Skills and the Doctor
Patient Relationship.pdf
Articles: Travaline et al. Patient-Physician Communication: Why
and How. J Am Osteopath Assoc. 2005 Jan;105(1):13-8.

Communication Matters!
Communication impacts:
 Diagnosis
 Adherence
 Patient satisfaction
 Physician satisfaction
 Malpractice litigation
2

In Fact...
According to defense attorneys, communication
breakdown is the most important event
leading to a patient's decision to litigate.
 35% Physician communication
 35% Physician attitude
 10% Patient financial incentives
 20% Other
3
Physician scores on a national clinical skills
examination as predictors of complaints to medical
regulatory authorities.
JAMA. 2007 Sep 5;298(9):993-1001.

Communication is Not "Just Talking"
 Communication is most commonly used
medical procedure
 Communication skills are not innate or fixed
 Communication skills can be learned and improved
 Physicians can improve health outcomes by
learning how and when to use specific
communication techniques
4
Richards T. Chasms in communication.
BMJ. 1990 December 22; 301(6766): 1407–1408.

Physician Tasks- The Two Fs
Biomedical Tasks
 Find it!
 Fix it!
5

Physician Tasks :
The Four Es
Communication Tasks
 Engage the patient!
 Empathize with the patient!
 Educate the patient!
 Enlist the patient in his/her own health care!
6
Poor Communication Between Doctors Costs Patients’ Lives, Apr 30, 2013
www.thedoctorschannel.com/view/poor-communication-between-doctor

The First E - Engagement
 Is the interview an inquiry
or an inquisition?
 Who is in charge of the
inquiry process?
 What does interruption say
about roles?
 How many complaints are
"normal?"
7
Clarke AR, Goddu AP et.al. Med Care. 2013 Nov;51(11):1020-6.
Thirty years of disparities intervention research: what are we doing
to close racial and ethnic gaps in health care?

Agree Upon an Agenda for the Visit
 Ask - "Is there anything else you would
like to talk about?"
 Ask - "Is there anything else you were
wondering about?"
 Ask - "What were you hoping we'd
accomplish today?"
8

Pay Attention to Two "Voices"
Physicians have a "voice,"
the voice of medicine.
This voice...
 Wants to obtain a history.
 Asks close-ended questions
to get "facts"
 Constructs a differential
diagnosis.
Patients have a “voice”, the
voice of experience.
This voice...
 Wants to tell the "story" of
the illness
 Is concerned with the
personal meaning of the
illness.
 Speaks in response to
open-ended questions
9

Translate, Bridge, Funnel
 Translate - Converse in one "voice"
while thinking in another
 Bridge - Acknowledge when topics are
being changed and give the reasons for
the changes
 Funnel - Direct the flow of conversation
by asking for information about topics of
specific concern
10

Outcomes of Successful Engagement(1)
Develop a more accurate
diagnosis
 Obtain more information
about the illness.
 Understand the effect of
the illness upon the
patient.
Increase the likelihood of
adherence
 Establish an improved
physician-patient
relationship.
 Discover the health
belief system of the
patient
11

Outcomes of Successful Engagement(2)
Establish an effective relationship
 Create an opportunity for partnership.
 Demonstrate interest in the patient's
point of view
 Provide the patient with an opportunity
to tell their story
12

The Second E - Empathy
 Being Seen
 Being Heard
 Being Accepted
13

Being Seen Techniques
N.B. See new patients with their clothes on at
the beginning of the interview
"See" the patient - acknowledge...
 Facial and bodily expressions of feelings.
 Mode of dress and physical presentation.
 Notable physical characteristics.
Eliminate physical barriers - desks, charts, etc.
14

Being Heard Techniques
 Use the language of the patient.
 Give feedback to the patient
 Ask for feedback from the patient
 Invite patient to tell his/her story welcome
the story:
 Feelings
 Values
 Thoughts
15

But There's a Problem...
 Physicians acquire more than
13,000 new words during
their training
 They use them with patients
 Adapt to patient's "voice"
(language, beliefs, etc.)
 This requires concentration
16

Being Accepted Techniques
 If you must judge judge behavior not the
person
 Communicate your understanding of
patient's feelings and values (do so in a
way that they can correct you)
 Use appropriate self-disclosure
17

Steps in Communicating Empathy
 Recognize the emotional moment
 Pause to question: "What's going on here?"
 Name the emotion you believe is present
 Communicate your understanding of the
emotion and validate its presence
 Respect the patient's efforts with the emotion
 Offer support and partnership
18

Outcomes of Establishing an
Empathic Connection
 Reduced anxiety related to isolation or
abandonment
 Improve adherence
 Increased level of connection:
1) Increased patient satisfaction
2) Increased physician satisfaction
 Reduced physician frustration
19

The Third E - Education
Assume the following
questions and answer
them as a matter of
course:
 What has happened to me?
 Why has it happened to me?
 What is going to happen to
me?
20
Can Doctors Really Educate Patients in 15 Minutes?
Aug 17, 2012
http://www.thedoctorschannel.com/view/can-doctors-
really-educate-patients-in-15-mins/

Mysteries of the Medical World
 What are you (they) doing for me (to me)?
 Why are you (they) doing this rather than
that?
 Will it hurt me or harm me? How much?
How long?
 When and how will you know what all this
(tests, procedures, etc.) means?
21

Patient Survey (1)
In a telephone survey of 1000 randomly
selected adults:
 25% reported they had stopped seeing a
physician at some time because of
communication problems
 60% reported they wanted physicians to do
a better job explaining options
22
Patient-physician communication: why and how.
J Am Osteopath Assoc. 2005 Jan;105(1):13-8.

Patient Survey (2)
 50% said, "Ask if the patient has more
questions."
 48% said, "Ensure the patient understands
what the physician has said."
 47% said, "Explain what the physician is
doing."
23

The Fourth E - Enlistment
 The challenge is to enlist the patient as an
active decision maker and participant in
her/his health care
 Active decision making can not be assumed
 Adherence can not be assumed
 Physician action influences both
participation and adherence
24

The Price of Failure
 Patients do not adhere to physicians'
recommendations at least 30% of the time
 Non-adherence with prophylactic
medication among asymptomatic patients
can be more than 50%
25

What's Going On?!?
 3 billion new prescriptions
are written in U.S. each
year
 Up to 50% will never be
filled or taken
 Up to 50% of those filled
will only be partially taken
26
Generation Rx How prescription drugs are altering American lives, minds, and body
J Clin Invest. 2006 February 1; 116(2): 287. doi:10.1172/JCI27774
Americans Skimping on Medication, Sep 14, 2012
http://www.thedoctorschannel.com/view/americans-skimping-on-medication/

American Prescription Drug Use
27
Generation Rx How prescription drugs are altering American lives, minds, and body
J Clin Invest. 2006 February 1; 116 (2): 287.
“The average number of prescriptions drugs per person,
annually, in 1993 was seven
The average number of prescriptions drugs per person,
annually, in 2000 was eleven
The average number of prescriptions drugs per person,
annually, in 2004 was twelve”

The Poor Adherence Myth
Myth - "Poor adherence can be attributed to
patient characteristics."
In fact, no consistent relationship has been shown
between adherence and...
 Age
 Gender
 Social economic status
 Marital status
 Personality traits (introverted, gregarious, etc.)
28

Factors Affecting Adherence
 The objective severity of the disease does
not affect adherence
 what the physician believes has limited impact
 The subjective perception of seriousness of
the disorder does affect adherence
 what the patient believes is critical
29

What Does Affect Adherence?
 The patient's perception of seriousness of
the disease
 The patient's perception of efficacy of the
treatment
 The duration of treatment and the illness
 The complexity of regimen
 The relationship with the physician
30

Enlistment Techniques
To improve adherence physicians must:
 Demonstrate compassion
 Communicate:
 Personal concern for the patient
 Personal interest in patient's future well-being
 Activate patient motivation
 Share responsibility with the patient
31

“Assume a Self Diagnosis”
 The patient has an internal belief system
which explains to him/her what is
happening with his or her health
 This includes:
 cause of a health problem
 meaning (consequences and symbolism) of
the problem, and
 how the problem might be resolved
32

To Improve Adherence, the
Physician Must Be Willing to...
 Discover the patient's beliefs:
“cause, meaning and cure”
 Discuss the patient's beliefs
33

Enlistment Technique
 "This is what I think is going
on State your explanation
 Ask-How does my explanation
fit with what you have been
considering?"
34
Walker J, Leveille SG et.al. Inviting patients to read their doctors' notes:
patients and doctors look ahead: patient and physician surveys.
Ann Intern Med. 2011 Dec 20;155(12):811-9.

Outcomes of Enlistment
 Increased likelihood of adherence.
 Empowerment of the patient: motivation.
 Greater range of choices for physician and
patient.
 Partnership between physician and
patient.
 Increased patient and physician
satisfaction
35

There is a Need to End-
How to Disengage
Summarize diagnosis, treatment, and
prognosis
Review next steps:
 Future visits, phone calls, etc.
 Tests, referrals, etc.
 Say good-bye, express hope
36

37
THE END
See last slide for further study resources.

Further Study:
38
Recommended textbook reading:
Bickley LS, Szilagyi PG. Chapter 3: Interviewing and the Health History.
In: Bates’ Guide to Physical Examination and History Taking, 10th Ed.
LWW, 2009.
Article:
Goold SD, Mack Lipkin M. The Doctor–Patient Relationship Challenges,
Opportunities, and Strategies. JGIM Volume 14, January (Supplement 1)
1999.

Physician communication skills in clinical medicine

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