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Mack Lipkin, MD, the founding president of the American Academy on Physician and Patient, a society dedicated to research, education, and professional standards in patient-physician communication, reported some interesting data in a PowerPoint presentation he gave in 2000 at the working conference on Diversity and Communication in Healthcare sponsored in part by the U.S. Office of Minority Health. Dr. Lipkin said that physicians’ lowest level of communication skills are reached during their medical residencies; even medical students’ skills were rated higher. Dr. Lipkin, who is also director of the Division of Primary Care in the Department of Medicine at New York University School of Medicine, New York City, went on to explain that, typically, physicians will recover some capacity with communication as they enter practice and years of experience ensue, but they never reach the level they possessed before they entered medical school.

While some hospitalists may consider this a startling claim, few are likely to find it shocking. Although hospitalists believe using good communication skills is an important part of their work, their skills may not necessarily match their beliefs or intentions. Research in progress by hospitalist Paul Mueller, MD, and his colleagues at the Mayo Clinic College of Medicine, Rochester, Minn., reveals that a majority of new internal medicine faculty—regardless of years in practice or background—believe they could benefit from and desire additional training in communication; yet these individuals teach communication skills to medical students (personal communication, 2005).

Medical education curriculum experts nationwide are pumping up their coverage of physician-patient communication to supply the demand stemming from a surge of interest in this topic in recent decades. Some reasons for this include reports and investigations into medical errors, an explosion of medical and health information easily accessible to patients and families, the rise of a vital consumer advocacy and empowerment movement, the reliance on outcomes assessments that include patient satisfaction ratings, a growing emphasis on patient- or relationship-centered care, and the reduced time for medical encounters caused at least in part by cost-containment initiatives.

The relationship between communication and medical outcomes is being increasingly explored, including the effects on physician satisfaction.1-5 But what are the further, personal effects to the individual hospitalist when he or she perpetuates poor communication skills?

If you don’t [communicate] with patients and patient families [about] what is going on [in their care], those relationships very quickly can turn antagonistic. And then the very thing most of us like about medicine—relationships with patients and families—becomes something that people tend to avoid.

—Robert Trowbridge, MD

Communication With Patients And Families

The work of hospitalists depends acutely on communication.

“It’s part of the role of the hospitalist to explain and help shepherd [patients] through the healthcare system,” says Robert Trowbridge, MD, a hospitalist and assistant professor of medicine, University of Vermont College of Medicine, Maine Medical Center, Portland.

Professionals whose medical practice is based on short clinical visits or performing procedures may or may not be good communicators, but it’s probably not as integral to the way they or the situations their patients are going through will be perceived. The conventional wisdom in professional and lay circles tends to be, “He may be a lousy communicator, but he’s a hellava surgeon,” says Dr. Trowbridge.

But most patients expect good communication from their primary care physician and because they are serving that function when a patient is hospitalized, hospitalists should understand that patients and families expect those skills of them. “And if the [hospitalists] don’t do well [in communicating], there can be much more stress on the patients and physicians,” explains Dr. Trowbridge.

What Constitutes Poor Communication?

“First, on one level, poor communication skills are inefficient in talking with patients,” says Steven Pantilat, MD, SHM president. “So, I think it makes your work harder.”

Some examples of communication inefficiency (or ineffectiveness) for a clinician include:2,4,5,6-8

  • Lacking the ability to articulate ideas adequately;
  • Transferring insufficient information between the provider and the patient, including inadequate elicitation of key facts from the patient;
  • Failing to assess the current level of information before supplying new information;
  • Taking too much or too little time in regard to the needs of the situation;
  • Overusing medical terms and not recognizing when patients cannot decipher them;
  • Using little eye contact and appropriate touch;
  • Using closed body language;
  • Being inattentive to the patient’s body language;
  • Using inappropriately open or closed questions when the circumstance calls for the opposite;
  • Not using a patient’s own words when doing so would be helpful to diagnosis or management;
  • Exhibiting a lack of empathy, compassion, understanding, and support;
  • Being inattentive or insensitive to a patient’s feelings;
  • Being inattentive to cognitive, psychosocial, and affective needs;
  • Disregarding the need for shared decision-making;
  • Lacking the skill for or failing to use active listening;
  • Failing to use timeliness in feedback or reporting test results;
  • Neglecting to seek feedback regarding whether cultural, regional, or language/accent differences (both the doctor’s and the patient’s) impede communication; or
  • Using an angry, anxious, or dominant tone of voice.

The second effect of poor communication that Dr. Pantilat cites is that “patients are less satisfied with their care and … to the extent that the relationship with the physician actually has an impact on how patients feel, patients may not ‘get better,’ ” he says. “And I don’t mean, for instance, that with a patient who has pneumonia, their pneumonia won’t get better; but there are a lot of other conditions where feeling like someone is listening to you, feeling like you’ve been heard, feeling like someone has communicated clearly can make you feel better.”7 (See also The Hospitalist, “Patient Satisfaction: The Hospitalist’s Role,” July/August 2005.)8

Inpatient communication tends to be a different kind of communication than that used in some other medical settings—more intense in a shorter time period and conducted between people who are strangers at the time of the patient’s admission. “It’s not that the stakes are higher, but it’s actually just the intensity of it is different,” says Arpana Vidyarthi, MD, a hospitalist who is the director of quality inpatient medicine at the University of California, San Francisco Medical Center.

“Time constraints are a major reason for poor communication skills happening,” says Dr. Trowbridge, whose hospitalist practice involves 60% clinical work with the Maine Hospitalist Group and 40% administrative work involving medical students and faculty development with the Department of Medicine at Maine Medical Center. “Relationships are really what many physicians most enjoy in medicine: with colleagues, … with patients, … with families. Having poor communication skills has a huge impact on job satisfaction and then personal satisfaction,” in many instances because of the heightened levels of stress.

“People are not here because they’re trying to get their lipids down,” says Dr. Vidyarthi. “They’re here because they’re [acutely ill]. When people are very, very ill, or when they’re having an intense experience, they tend to hang on every word.”

For the physician, she says, “there are so many things to communicate and because it is often very complicated, the relationship and the trust have to be built quickly, and information has to be transferred very quickly. Poor communication will lead to potentially not being able to build that alliance with the patient during that short period of time of their hospital experience.”

Hospitalists must be on the lookout for how the constraints of time affect the way they practice and relate to their patients because every nuance of behavior or tone of voice can make a difference to how a patient perceives his or her doctor.

For example, in a study conducted at Harvard University in 2002, investigators used audiotapes of 57 surgeons, 36 of whom had had two or more malpractice claims filed against them.9 Patients were asked to listen to two 20-second clips of audio between these surgeons and two patients. Those surgeons who were judged by the tone of their voices as “high dominance” and “low concern/anxiety” correlated with those who had had previous malpractice claims.

Because there is no continuity of relationship to help steady what might be an emotional response when things go wrong in the patient’s treatment or when patients and families are upset by circumstances, hospitalists may be subjected to blame, resentment, fear, and displaced anger concerning their communications with patients and families.

“Especially if you’re harried in an incredible time crunch, if you don’t [communicate] with patients and patient families [about] what is going on [in their care], those relationships very quickly can turn antagonistic,” says Dr. Trowbridge. “And then the very thing most of us like about medicine—relationships with patients and families—becomes something that people tend to avoid.”

Dr. Trowbridge says that this can become somewhat of a vicious cycle whereby a certain extent of inadvertently “avoiding the patient and family may lead to further communication faults.” On the flip side, using good communication can be a circular process but in a positive way: A good communicator may experience better well-being, which in turn, leads to better communication skills.2,5 Also, on a practical level, the data are clear that bad communication puts you at risk for malpractice litigation.9,10

Communication with Colleagues

“People that don’t have very good communication skills tend not to be successful,” says Dr. Vidyarthi, who practices with the hospitalist group at UCSF and is also an assistant professor there. Her definition of success is closely linked to the quality of relationships; that is, “being well liked by the nurses, building working relationships with … the nurses,” as well as others, including the hospital administrator. “Hospitalists are almost always … doing quality work or performance improvement,” she explained. “They’re on committees. That is the nature of what we do. … Not learning what those [communication skills] are and [not] being able to communicate at [effective] levels would … be a detriment to one’s personal job advancement, but absolutely to one’s job satisfaction as well.”

Collegiality, in fact, is one component cited as a “powerful engine of socialization” in organizational structures more likely to foster the lifelong learning and commitment that are inherent to medical professionalism.1,3-5,11,12

Many of the components of effective communication with colleagues parallel those that are best used with patients. “Communication is what holds that team together,” says Dr. Vidyarthi, whose interests include information transfer and communication as a form for team-building. “In academic medicine, poor communication can impact the teaching environment, the experience of the students and the residents, and that team cohesion. And that can lead to poor patient care, it can definitely lead to a poor educational experience, and it is not enjoyable, so job satisfaction suffers.”

Dr. Pantilat, who is associate professor of clinical medicine and director, Palliative Care Service and Palliative Care Leadership Center at UCSF, theorizes that when interacting with colleagues such as other hospitalists and physicians, nurses, social workers, case managers, and pharmacists, poor communication skills can make the physician’s work tougher. “Poor communication makes your life difficult with your colleagues,” says Dr. Pantilat. “People don’t like talking to you or interacting with you … and your job can generally be more difficult.”

In a 2002 study conducted at Harvard University, investigators used audiotapes of 57 surgeons, 36 of whom had had two or more malpractice claims filed against them. Patients were asked to listen to two 20-second clips of audio between these surgeons and two patients. Those surgeons who were judged by the tone of their voices as “high dominance” and “low concern/anxiety” correlated with those who had had previous malpractice claims.

Post-Discharge Communication

In the traditional medical model, a primary care physician would see patients in her/his office, the hospital, or rehabilitation. With the expansion in hospital medicine, patients are now “handed off” and seen by a number of providers. Hand-off fumbles can mean critical information may be lost, leading to poorer outcomes and greater readmission rates.13-15

Forging and maintaining effective communication with colleagues following the discharge of patients is an area where few in-house physicians do well, says Dr. Vidyarthi, who has it on her agenda to tackle this “huge problem” for her institution in the coming year. There are two pieces to that problem, she says. One is to accurately identify the patients’ primary care physicians and the other is to make contact with them.

“You could page them, but they’re in clinic, and they can’t take five minutes out when you can’t take five minutes out,” says Dr. Vidyarthi. “The communication with the primary care physician is actually a field in and of itself.”15

Part of her plan is to devise some means of “physician-independent generated communication,” perhaps a letter or e-mail sent from the hospital to report to a primary care physician that his/her patient has been admitted to the hospital.

“That raises a flag to that primary so they can try to find the hospitalist, which is usually very easy … because we’re always in the hospital,” says Dr. Vidyarthi. “And it’s the first stage of the communication: Now that person is aware. If I can find them, if I can access them, they’ll be able to take that time out, because they know their patient’s there.”

In her work as a senior fellow at the Center for Health Professions at UCSF, Dr. Vidyarthi strives to “embed communication into the larger framework of organizational change.” And what does a hospitalist do if an institution’s post-discharge communications system is not up to par? There are three basic things you can do to help overcome this source of frustration, she says. The first is to continually build relationships with primary care providers.

“If I send an e-mail to somebody and they know who I am, they are much more likely to respond to that because they know me,” says Dr. Vidyarthi.

Next, find a system that works for you. “Don’t wait for the rest of the systems to be put in place,” she says. “This is about personal practice. And if that means you take five minutes in the morning to send an e-mail or five minutes in the evening, whatever it is, find [a system] that really works and figure out a way to evaluate it.”

A good way to do this, Dr. Vidyarthi suggests, is to take a quick survey in the midst of talking to that primary care physician to ask whether the medium, content, and timing that you used to contact him/her worked well.

“Then,” she says, “if you have five primaries that you talked to [who] maybe said, ‘Yes, that was helpful to me,’ or ‘Not so much really, I had all that info already,’ at least you have data. Asking ‘Do you think this will help your patients when they come to see you in the office?’ is a great question [to solidify] performance improvement. In other words, find out if what you’re doing is being effective.”

The final step to overcome a lack of an effective institutional system for post-discharge communication is to share what you’ve learned with others. “These little pieces can really empower others to make a difference,” says Dr. Vidyarthi. “Trying to change and overhaul an entire system will turn off even the most motivated of people who want to improve the system, so focus on your own personal practice models. Change it, figure out what works, and then try to disseminate it. That makes it feel and seem much more doable.”

Conclusion

Hospitalists who exercise poor communication skills with patients, families, and colleagues can experience multiple negative effects, including poor patient-related outcomes and an increased risk of malpractice litigation. Personally, consistently using poor communication may make work more difficult, reduce job satisfaction, and reduce work success and enjoyment with hospital teams and primary care physicians. TH

Contributor Andrea Sattinger makes good communication a priority every day.

References

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  2. Roter DL, Stewart M, Putnam SM, et al. Communication patterns of primary care physicians. JAMA. 1997;277:350-356.
  3. Konrad TR, Williams ES, Linzer M, et al. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Measuring physician job satisfaction in a changing workplace and a challenging environment. Med Care. 1999;37:1174-1182.
  4. Shanafelt TD, West C, Zhao X, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20:559-564.
  5. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519.
  6. Novack DH, Suchman AL, Clark W, et al. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997;278:502-509.
  7. Greenfield S, Kaplan S, Ware WE Jr. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520-528.
  8. Torcson PJ. Patient satisfaction: the hospitalist’s role. The Hospitalist. 2005;July/Aug:27-30.
  9. Ambady N, LaPlante D, Nguyen T. Surgeons’ tone of voice: a clue to malpractice history. Surgery. 2002;132:5-9.
  10. Levinson W, Roter DL, Mullooly JP. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-559.
  11. Frankford DM, Patterson MA, Konrad TR. Transforming practice organizations to foster lifelong learning and commitment to medical professionalism. Acad Med. 2000;75:708-17.
  12. Falkum E, Vaglum P. The relationship between interpersonal problems and occupational stress in physicians. Gen Hosp Psychiatry. 2005;27:285-291.
  13. Coleman EA, Smith JD, Min SJ, et al. Post-hospital medicine discrepancies; prevalence, types, and contributing factors. Paper presented at the Society of Hospital Medicine Annual Meeting; April 29-30; Chicago, Illinois: Society of Hospital Medicine 2005.
  14. Burniske GM, Burnett A, Greenwald J, et al. Post-discharge follow-up telephone call by a pharmacist and impact on patient care. Paper presented at the Society of Hospital Medicine Annual Meeting. April 29-30; Chicago.
  15. Wachter R, Shojania K. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land; 2004.

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