Improving Patient Communication

Part 2 of 3: Verbal Communication

Patrick Hunt, MD, MBA

Educational Objectives

• Identify verbal communication strategies that enhance patient understanding and satisfaction.

• Describe research findings about the relationship of communication and malpractice claims.

• Identify and demonstrate verbal communication techniques which can lessen malpractice risk as well as improve clinical outcomes and increase patient satisfaction.

• Integrate improved verbal communication skills into daily practice.

Pre-Questionnaire

• The major determinant by which patients base their decision to choose a physician is:

A. Where they went to medical schoolB. Number of years in practiceC. A compassionate and caring attitudeD. Amount of experience treating patients with

their medical conditionE. Whether or not they’re board certified

Pre-Questionnaire

• Primary care doctors who have never been sued:

A. Solicited patients’ opinions

B. Encouraged patients to talk

C. Laughed and used humor more

D. All of the above

E. None of the above

Verbal Communication

• We’ll approach the verbal section by correlating it to the behavior of doctors who have never been sued.

A Comparison

• Primary care doctors who had never been sued versus those who were:– Used more orienting statements (educating patients

about what to expect and the flow of the visit). – Solicited patients’ opinions.

• Ask the patient what they think.– Encouraged patients to talk.– Took time to explain and checked understanding.– Laughed and used humor more.– Spent enough time so patient didn’t feel rushed.

Orienting Statements

• Help patients get a sense of what the visit is supposed to accomplish and when they ought to ask questions.– “First I’ll examine you, and then we’ll talk

about the problem.”– “I will leave time for your questions at the

end.”

Empowerment

• Most patients make a self-diagnosis.

• It’s extremely helpful to elicit and acknowledge it early in the interview.

During the Exam

• “Do you have any idea what may be causing your symptoms?”

• “Thanks for sharing that with me. Let’s see what we’ve got here.”

Share Your Diagnosis

• Discuss any discrepancies between your conclusion and the patient’s.

Agree on a Treatment Plan

• If more tests are needed, tell what they are and why the patient needs them.

• Discuss options.

• Tell them when they can expect results and how they’ll get them.

Buy In

• Did I miss anything?

• Does that sound okay to you?

“Communication”

from the Latin communicare, “to share or make common”

Two-Way Flow of Information

• “Taking a history” suggests an act of extraction.

• Often it’s an assault of closed-ended questions, punctuated briefly by faint “yes” or “no” answers from the patient.

“BUILD A HISTORY”

rather than

“TAKE ONE”

Effective Dialogue

• Use open-ended questions that can’t be answered with just a “yes” or a “no.”

• These invite patients to reflect on their problems, pain and symptoms.

• Best open-ended question is: “And?”

Closed-Ended Questions

• Don’t use too early in the interview – patient can feel shut out and passive, less likely to volunteer.

• Announce they’re coming: “Now Mr. Smith, I’d like to focus in on that chest pain and ask you a series of questions…”

• a.k.a. “Smile and Nod” questions.• Example: “Any….(symptom)”

Closed vs. Open

• Closed– Is the pain in one spot or all over?– Is it mostly on the right side?– Did you try aspirin for the pain?

• Open– How would you describe the pain?– Where do you feel it the most?– What medication have you tried?

Two best words to improve doctor patient communication?

Two best words to improve doctor patient communication?

“WHAT ELSE?”

Don’t Interrupt

• A JAMA article found that 72% of the doctors interrupted the patient’s opening statement after an average of ____ seconds.

Don’t Interrupt

• A JAMA article found that 72% of the doctors interrupted the patient’s opening statement after an average of 23 seconds.

Don’t Interrupt

• Physicians often redirect patients’ initial descriptions of their concerns.

• Once directed, the descriptions are rarely completed.

• Consequences of incomplete initial descriptions include late-arising concerns and missed opportunities to gather potentially important patient data.

Don’t Interrupt

• “I don’t have time to listen to a patient drone on and on…”

• Patients who are allowed to state their concerns without interruption used only an average of 6 more seconds.

Narrate During the Exam

• Explaining what you are checking for builds trust and reassures the patient.

Restating

• Restate the patient’s basic ideas using your own words.

• Shows that you are listening and understanding.

Summarizing

• Summarize the major points made and feelings the patient has expressed.

• “Let me see if I have this right…”

Assessment

• Tell them your opinions, your Dx if you have one, then the plan.

Jargon Use

• Can cause resentment, making patients feel befuddled, stupid, or angry.

• Doctors think they don’t use jargon, yet studies show they do and often don’t realize it.

Jargon Use

• Lay, easy-to-understand terms first.• Bridge with “or as we call it…”• Medical term last: “You have high blood

pressure, or as we call it…hypertension. Hyper-tension.”

Verify Understanding

• Doctors checked for patient understanding only ___ of the time.

Verify Understanding

• Doctors checked for patient understanding only 34% of the time.

Verify Understanding

• Rather than putting the patient on the spot by saying, “now repeat it back to me.”

• Put the onus on you: “We’ve covered a lot of information here. Just so I can be sure my explanation was clear, let’s go over how you’ll be taking your medication…”

Verify Understanding

• Write it down• Visuals• Assume 4th grade reading level• Tell a family member• Repeat, Repeat, Repeat

Up at the End

• Try to end the exam on a positive note whenever possible without giving into false-hope.– “Let’s see how you do on this new blood

pressure medicine. I think you’ll have a lot more energy to play with those grandkids.”

Don’t Forget

• Always THANK the patient for coming in for the visit.

Enhance

• Note personal patient information• Make small talk• Take advantage of empathic moments

Patient Personal Information

• Jot down personal info nuggets in chart – “Loves Lakers,” “Son accepted to West Point” – that you’ll use next time the patient comes in for a visit.

• Also share these with staff – and have them ask the patient.

• Impact on patient is: “Wow. They all know me here. They really care about me.”

Small Talk

• You’re double booked and running late usually means small talk is DOA.

• If possible, do a few moments at the beginning and end of interview.

• Try for 30 to 60 seconds.

Empathy

• Empathy means expressing your understanding of the patient’s feelings, values, and experience as if they were your own.

• Look for empathic moments to further your relationship with the patient.

Biggest Mistake – Missed Moments

• Patient: “My stomach has really been bothering me. I’ve been under a lot of stress lately.”

• Doctor: “Are you still taking your ulcer medicine?”

Biggest Mistake – Missed Moments

• Patient: “My stomach has really been bothering me. I’ve been under a lot of stress lately.”

• Doctor: “I’m sorry to hear that. Tell me more about the stress.”

Message

• You are interested in them, not just the disease.

Queries

• “Can you tell me more about that?”• “What has this been like for you?”• “How has all of this made you feel?”

Clarifications

• “Let me see if I’ve gotten this right…”• “Tell me more about…”• “I want to make sure I understand what

you’ve said…”

Responses

• “Sounds like you are…”• “I imagine that must be…”• “I can understand that must make you

feel…”

Share Some of Your Personal Details

• “Doctors that shared details of their social and family issues had a greatly increased number of satisfied patients.”– Dr. Bernard Lown, Harvard School of Public

Health

• Humor and laughter are shown to have positive psychological and biological effects as well as acting as a communication tool and social lubricant.

Humor

Using Humor in the Patient-Physician Encounter

• Gentle humor can be an effective tool in showing patients empathy, demonstrating your humanness, and helping patients relax in a stressful situation.

• Humor should be self-depreciating, should never be mean-spirited, and must always be beliefs sensitive to cultural and personal preferences.

Using Humor Can Be ATricky Business

• In some ways one of the more difficult techniques to use.

• Can do harm with used incorrectly.• How have you used humor?

Time

• For YOU…time is real and rationed, counted in precious seconds and minutes.

• For PATIENTS…time is a perception, measured in warm smiles and murmurs of understanding.

Cameos

• Primary care physicians who NEVER had a claim against them also had longer visits (18.3 vs. 15 minutes).

Time Perception

• When doctors sat down during an office visit rather than stood, 96% of patients thought the visit was longer even though the time of both visits was exactly the same.

Vocal Communication

Three dimensions to your voice1. Volume

2. Rate/Pausing

3. Pitch

Vocal Communication

• Three dimensions– Slow down and soften tone when asking

difficult questions.– Combine with forward lean for greater effect.– Pauses show control. They also allow the

patient a mental breather when assimilating information.

Vocal Communication

• Vocal tone– Even more critical for patients who may not

understand English very well.

• Volume– Remember that older patients may not hear that well

– and may be too embarrassed to tell you they don’t hear anything you’re saying.

• Pitch– Monotone suggests boredom or lack of interest.

Vocal Communication

• “Ums” and “Uhs”– What do they mean to you?– “I’m thinking, I don’t know and I’m buying

time, I’m lying…”

Vocal Communication

• The effect of tone of voice on propensity to being sued– Audio recordings of doctors who had been sued and

others who hadn’t were made while they were talking to patients.

– Both groups had the content filtered so that individual words couldn’t be recognized.

– Findings showed that dominant voices and less concerned tones tended to be in the sued group.

Vocal Communication

• Vocal Tone– A compassionate, caring tone of voice,

increased patient satisfaction and compliance.– There was no difference in the amount or

quality of information they gave their patients.

A Comparison• Primary care doctors who had never been sued

versus those who were:– Used more orienting statements (educating patients

about what to expect and the flow of the visit). – Solicited patients’ opinions.

• Ask the patient what they think.– Encouraged patients to talk.– Took time to explain and checked understanding.– Laughed and used humor more.– Spent enough time so patient didn’t feel rushed.

• Doing these demonstrates to the patient that you are compassionate, caring and concerned.

Decrease Risk of Being Sued

• Used more orienting statements• Solicited patients’ opinions in caring tone of

voice• Encouraged patients to talk• Took time to explain and checked understanding• Laughed and used humor• Spend enough time so patient didn’t feel rushed.

Top Determinants of Patient Satisfaction

• Doctor understands the patient• Doctor’s tone of voice• Doctor asks about patient concerns• Patient feels comfortable asking questions• Patient perception that sufficient time is

being spent with them

Decrease Risk vs. Patient Satisfaction

• Decrease Risk of Being Sued– Used more orienting

statements– Solicited patients’ opinions in

caring tone of voice– Encouraged patients to talk– Took time to explain and

checked understanding– Laughed and used humor– Spend enough time so patient

didn’t feel rushed.

• Top Determinants of Patient Satisfaction – Doctor understands the patient– Doctor’s tone of voice– Doctor asks about patient concerns– Patient feels comfortable asking questions– Patient perception that sufficient time is being spent with them

With these Techniques to Enhance Communication You’ll Have…

• Higher patient satisfaction– Patients assume equal level of confidence in doctors.– Differentiating factor in building market share is

patient satisfaction.

• More business– 84% of patients choose a particular physician based

on how well they communicate and whether or not the clinician shows a caring attitude.

• Less risk of being sued

Rapid and Profound Effect on Patient Satisfaction

• The techniques presented in this course will significantly improve patient satisfaction scores…

• …in many cases as high as 50%.

Benefits

• In addition to…– Higher patient satisfaction– More business – Less risk of being sued

• You’ll also get…– Better compliance rates– More effective and shorter interviews– Better health outcomes

In one way, the most important benefit of all…

greater personal enjoyment and satisfaction from your practice.

Applying these Techniques

• Change starts with awareness.• Ask a colleague to come in during an

exam and provide feedback.• Practice a few of these in a safe

environment with family or friends.• With practice, techniques become part of

your natural style.

Post-Questionnaire

1. True or False– Primary care doctors check for patient

understanding less than half of the time.

2. Doctors interrupt a patient’s opening statement after an average of ___ seconds.

Post-Questionnaire

3. Physicians using a dominant tone of voice while taking a history from a patient:

A. Have better rates of patient complianceB. Have increased patient satisfactionC. Have a greater likelihood of being suedD. Have shorter examination timesE. Have better patient understanding of the

information given to them

Post-Questionnaire

4. Which of the following is not an empathic statement?

A. “How has all of this made you feel?”

B. “Are you still taking your ulcer medicine?”

C. “Let me see if I’ve gotten this right?”

D. “Tell me more about that.”

E. None of the above.

References• Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The

relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997 Feb 19;277(7):553-9.

• Marvel KM et al. Soliciting the patient’s agenda: Have we improved? JAMA 1999; 281:283-287.

• Korsch, B.M., Gozzi, E.K., Francis, V. Gaps in Doctor-Patient Communication. Pediatrics. 1968; 42(5):855-871

• Ley, P., Bradshaw, P.W., Eaves, D. A Method for Increasing Patient’s Recall of Information Presented by Doctors. Psychological Medicine. 1973; 3:217-219.

• Coulehan JL, Platt FW, Enger B, et al. Let me see if I have this right ...: words that help build empathy. Annals of Internal Medicine. August 2001; 135(3):221-7.

• Buxman K. Humor in critical care: no joke. AACN Clinical Issues. 2000; 11:120-7.

References• Haakana M. Laughter in medical interaction: from quantification to analysis and back. Journal of

Sociolinguistics. 2002; 6:207-35.

• Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Medical Care. December 1993; 31(12):1083-92.

• Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Medical Care. November 1989. 27(11):1027-35.

 • Luallin, M.D., Sullivan, K.W. The Patient’s Advocate: A Six Part Strategy for Building Market Share.

Group Practice Journal. July/August 1998; pp. 13-16.

• Desmond, J. National Committee on Quality Assurance review of managed care organizations, communicating with today’s patients. 0-7879-4797, 2000, p.9.

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