Strategy 6G: Training To Advance Physicians' Communication Skills
People rarely complain about the technical aspects of the health care they receive because—in the absence of an obvious error—patients are generally unable to judge technical competence. However, they and only they are well-equipped to judge the ability of clinicians to communicate with them effectively. Even though a clinician explains a diagnosis, test result, or treatment option to a patient, if the person walks away and does not understand the explanation, it has not been an effective communication.
Poor communication can have a serious impact on health outcomes. Patients may not provide the clinician with adequate information on their health or related concerns; they may not comply with the physician's orders—and in some cases, they may not even understand what they have been told. According to a study at the University of Kansas School of Medicine in Kansas City, patients' reports of their understanding of the post-discharge information and instructions they had received was significantly less than what their doctors perceived. For example, while the physicians thought that 89 percent of the patients understood the potential side effects of their medications, only 57 percent of patients said that they understood.1
In addition to affecting the patient's experience with health care, poor patient-physician communication has important consequences for medical practices. One study found that, in a three-year period, 20 percent of Massachusetts state employees voluntarily left their primary care physician because of the poor quality of their relationship, which was a function of trust, the patients' sense that the physician knew them, the level of communication, and personal interaction.2 Poor communication is also a contributing factor in a majority of malpractice suits.3
While the curriculums of most medical schools now include some form of training in communications skills, this is a fairly recent phenomenon. Traditionally, medical education has paid little attention to the skills that promote effective interactions with patients. Most practicing physicians have not been taught to appreciate the patient’s experience of illness; nor do they learn how to partner with patients and serve as a coach or guide. As a result, they typically do not know how to communicate with patients in a way that maximizes understanding and involvement in decision making, lets the patient know that his or her concerns have been heard, and ensures that the care plan meets the needs of the patient.
To compensate for this deficiency in medical education, numerous health plans and medical groups are training practitioners in the communication skills they need—either through in-house programs or through communications programs offered by outside organizations. Most of these programs are optional, but a few organizations require the participation of all doctors. In some organizations, the program is mandatory only for those doctors who consistently receive low scores in this area.
The purpose of these programs is to improve providers' effectiveness as both managers of care and educators of patients. It is also believed that trained physicians may allocate a greater percent of clinic-visit time to patient education, leading to increased patient knowledge, better compliance with treatment, and improved health outcomes.
The most effective and efficient way of offering training in physician-patient communication is in the form of seminars or workshops where you can cover many strategies for improved communication in a relatively short period of time. Workshops may also use case studies to illustrate the importance of communication and suggest approaches to improving the physician-patient relationship.
For clinicians, workshops may serve multiple purposes, including increasing their understanding of the physician's roles, offering insight into the importance of connecting with patients, and increasing confidence in their interviewing skills. In addition to basic communication skills, the training can cover:
- History-taking skills,
- Issues related to communicating across cultures,
- Communicating with "problem" patients,
- Interviewing techniques (including skills to help promote behavioral change)
- Empathic responses.
Some programs also address weaknesses in written communications, which can be a serious problem for clinicians who use e-mail to communicate with some patients. Group Health Cooperative in Seattle, for example, offers a training curriculum on how to write emails to patients.
Training in behavioral change concepts can help physicians identify patients who are likely to be receptive to their advice and guidance. To help physicians better understand the process of behavioral change, some medical groups and health plans are teaching physicians about the Transtheoretical Model (see box below) and encouraging them to identify where patients are in these stages and to focus their educational efforts on patients who are ready to change.
If patients are precontemplative, physicians do not need to be spending much time convincing them to stop or start a new behavior. But if they are contemplative, then the time required to coach them about things they can do to adopt the desired behavior is well-spent.
One of the best-known examples of an in-house program to inculcate strong communication skills in clinicians is the Thriving in a Busy Practice program developed by Terry Stein, M.D., at Kaiser Permanente. This comprehensive communications curriculum strives to develop the ability of physicians to relate to patients effectively in both routine and difficult settings. In particular, it is intended to help physicians learn and practice techniques for dealing with difficult patient encounters. Over the past decade, the workshops have been expanded beyond the issues that typically confront primary care physicians to include guidance pertinent for different specialists (such as emergency physicians).
Evaluations of this program have found a positive impact on the clinicians. One study found that clinicians reported improved confidence in their ability to conduct effective medical interviews and handle difficult situations. It also found that, after taking the course, fewer clinicians reported frustration with patient visits (specifically, the percent reporting frustration with 11 percent or more of patient visits fell from about half before the course to about one-third afterwards).4 However, the impact on patient satisfaction is not yet clear: One study found that the program had no impact, but noted that other factors may have influenced that finding.5
- Rogers C. Communications 101. Bulletin of the American Academy of Orthopaedic Surgeons 1999;47(5).
- Safran DG, Montgomery JE, Chang H, et al. Switching doctors: predictors of voluntary disenrollment from a primary physician's practice. J Fam Pract 2001;50(2):130-6.
- Flaherty M. Good Communication Cuts Risk. Physician's Financial News 2002;20(2): s10-s11.
- Stein TS and Kwan J. Thriving in a busy practice: physician-patient communication training. Eff Clin Pract 1999;2(2): 63-70. Available at: http://ecp.acponline.org/marapr99/thriving.pdf. Accessed September 22, 2008.
- Brown JB, Boles M, Mullooly J, et al. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Ann Intern Med 1999;131(11):822-9.