Strategy 6G: Training To Advance Physicians' Communication Skills
6.G.1. The Problem
6.G.2. The Intervention
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Training To Advance Physicians' Communication Skills
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6.G.1. The Problem
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
"With patient characteristics and structural features of care taken into account, those with the poorest-quality physician-patient relationships in 1996 were 3 times more likely to leave the physician’s practice over the ensuing 3 years than those with the highest-quality relationships."
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.
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.
6.G.2. The Intervention
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.
Support in Improving Physician Communication
For help in implementing this strategy, consider the following resources:
Institute for Healthcare Communication, New Haven, CT
The Institute for Healthcare Communication (formerly the Bayer Institute) offers a variety of workshops to help clinicians develop and hone their communication skills. It also offers books, videos, and practical guides on how to improve communication.
American Academy on Communication in Healthcare, Chesterfield, MO
The American Academy on Communication in Healthcare (AACH) is an interdisciplinary group of medical educators and clinicians that share a common interest in patient-clinician communication and relationships, and psychosocial aspects of health care.
The Foundation for Medical Excellence, Portland, OR
The Foundation for Medical Excellence is a non-profit foundation that sponsors a variety of educational programs and consulting services for licensed physicians. Its programs include education and research in physician-patient communication.
Motivational Interviewing Network of Trainers, Fairfax, VA
The Motivational Interviewing Network of Trainers (MINT) is a non-profit organization that provides training, coaching, and consultation on the use of motivational interviews to promote behavior change.
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.
A Model of Behavioral Change
The Transtheoretical Model lays out five unique "Stages of Change:"
- Precontemplation is the stage in which there is no intention to change behavior in the foreseeable future. Many individuals in this stage are unaware or under-aware that a problem exists.
- Contemplation is the stage in which people are aware that a problem exists and are seriously thinking about overcoming it but have not yet made a commitment to take action.
- Preparation is a stage that combines intention and behavioral criteria. Individuals in this stage are intending to take action in the next month and have unsuccessfully taken action in the past year.
- Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves the most overt behavioral changes and requires considerable commitment of time and energy.
- Maintenance is the stage in which people work to prevent relapse and consolidate the gains attained during action. For addictive behaviors, this stage extends from six months to an indeterminate period past the initial action.
A full explanation of this model can be found at Cancer Prevention Research Center. Home of the Transtheoretical Model. Detailed Overview. Available at: http://web.uri.edu/cprc/detailed-overview/. Accessed July 31, 2017.
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
Read More About Improving Communication Skills
- American Medical Association. Section II: Resources Emphasizing Communication Skills. In: Cultural Competence Compendium. Chicago, IL; American Medical Association 1999: 89-106.
- Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: A patient-based approach. Ann Intern Med 1999 May 18;130(10):829-34.
- Coulter A. The Autonomous Patient: Ending Paternalism in Medical Care. London: Nuffield Trust 2002.
- Jackson C. It Pays to Listen: The Importance of Doctor-Patient Communication. Amer Med News 2001 May 21.
- Nelson AM, Brown SW. Improving Patient Satisfaction Now. New York, NY: Aspen Publishers, Inc. 1997 April.
- Nigg CR, Burbank P, Padula C, et al. Stages of change across ten health risk behaviors for older adults. Gerontologist 1999;39:473-82.
- Prochaska JO, Norcross JC, DiClemente C. Changing for Good. New York, NY: William Morrow and Company, Inc.; 1994.
- Prochaska JO. Helping patients at every stage of change. Behavioral Approaches to Addiction Journal 1992;1(1):2-7.
- Ranier SB, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: A systematic review. J Am Board Fam Pract 2002;15(1):25-38.
- 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.