the impact of effective communication communication plays a “significant role” in a top-tier...

You’ve just told a patient that she has a chronic diseaselike diabetes—news that you may deliver fairly often, butto this patient it comes as a shock. In fact, after the ini-

tial words, “You have...” many of the details that follow are ablur; and the patient probably won’t be able to repeat or remem-ber anything else you said. But it doesn’t have to be that way.Good communication techniques can help you make the most ofeach office visit so that patients better understand their condi-tions and what they need to do. In turn, patients who areinformed are more likely to be engaged in their healthcare out-comes.

“I think that doctors often say the same thing so many timesthat the concepts become simple to them,” says Kelli M. Ward,

1. Re-evaluating and updating your communication systems will help your practice keep pace with changesin the healthcare environment.

2. Even simple techniques like using handouts can lead tobetter patient adherence and outcomes.

3. Patient adherence increases when you actively engagethe patient in a meaningful way—e.g., through reflective listening.

4. Better communication can lead to cost savings.5. Spending just 30 more seconds listening to each patient

can make a difference.

8 www.doctorsdigest.net

TOP-TIER COMMUNICATION

The Impact of EffectiveCommunication

Chapter FastFACTSChapter FastFACTS

DO, a family physician and regional medical director at NorthCountry Health Care Community Health Center, Lake HavasuCity, Ariz. “They have to strive to recall that what is simple tothem is more difficult for lay people to understand even in theInternet age.” In the above case, for example, giving the patienta written note of what was discussed at the visit along with a“homework assignment” to review information about her condi-tion would help guide her and would possibly result in a betteroutcome.

Although everyone agrees that “successful” physician-patientcommunication—patients following their doctor’s instructionsand working with their doctor to achieve the best possible healthoutcomes—is desirable, this kind of communication may haverecently received short shrift as you contend with tight reim-bursement, shortened patient visits, new computer systems, andother pressures that may impede good communication. Health-care reform efforts have put the spotlight on communicationsince reform adds even more pressure for time-crunched physi-cians by bringing more patients into the system.

Re-evaluating and updating your communication systems andtechniques will enhance your efforts to cope with the changinghealthcare environment. Those efforts are more important thanever given other realities of medicine today, including increasedpatient involvement in their own healthcare, says Ronald M.Epstein, MD, professor of family medicine, psychiatry, and oncol-ogy, and director of the Rochester Center to Improve Communi-

“I give each patient a one-page sheet thathas a list of the diagnoses we discussed thatday, the refills they received, and a copy ofour plan for that visit in language that thepatient can understand.”

Kelli M. Ward, DOFamily Physician

Regional Medical Director, North Country HealthCare Community Health Center

Lake Havasu City, Ariz.



cation in Health Care, University of Rochester Medical Center,Rochester, N.Y. Patient expectations are higher now, he con-cludes, and patients want to be part of the changes in healthcarethat are being discussed today. They both need and want to takecontrol of their health—and that means more pressure on you toeffectively relay news about their health and treatment choices.

This issue of Doctor’s Digest will give you a fresh look at keyaspects of doctor-patient communication along with practicaltips that you can put into practice. We’ll discuss the benefits ofeffective communication, from increased adherence to improvedaccuracy to reduced malpractice risk. And there are even morebenefits, says Ellen J. Belzer, MPA, president of Belzer Semi-nars & Consulting, LLC, Kansas City, Mo.: Healthcare providerswho are skilled in communication, she says, end up with a“smoother-running practice,” one with greater efficiency,improved morale, and enhanced job satisfaction.

A Hot TopicBecause shorter patient visits are now a reality, physicians

have even less time to establish their relationship with patients.Yet communication skills often take a back seat to high-techmedical procedures, testing, and new treatments. “Communica-tion is low on the totem pole, yet it’s valued a great deal. It’s oneof the keys to quality, cost-effective care,” says Joseph W.Stubbs, MD, an internist in Albany, Ga., and immediate pastpresident of the American College of Physicians (ACP), whonotes that some patients are even willing to pay for more com-munication with their providers. “Concierge medicine appreci-ates communication and focuses on it, which shows howimportant it is to patients. They are willing to pay extra to beable to converse and have extra time with their doctor,” he says.

Renewed focus on doctor-patient communication is largelydue to reimbursement issues: A percentage of many physicians’salaries is now being held back due to patient satisfaction sur-

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THE IMPACT OF EFFECTIVE COMMUNICATION


vey results. This practice is not new, but for a long time the gov-ernment and others have been looking for fresh ways to motivatephysicians, notes Richard H. Carmona, MD, MPH, FACS, for-mer Surgeon General of the U.S., and president of the CanyonRanch Institute, Tucson, Ariz. There is a continuing search forthe right metrics with which to enhance patient satisfaction.Recent healthcare reform measures specify the need for patientsatisfaction provisions without stating any specific provisions,according to Dr. Carmona. “Patient satisfaction and physicianreimbursement are all part of a continued search to find the bestpractices to provide us with the best doctor-patient relation-ships,” he says. This search will ultimately affect physicianreimbursement based in part on patient satisfaction.

In addition, the Patient Protection and Affordable Care Act’semphasis on improved primary care has intensified interest inhow to deliver patient-centered care. Patient-centered communi-cation skills, which have a positive effect on patient satisfaction,treatment adherence, and self-management, are essential to thedelivery of this type of care. These skills can be effectivelytaught at all levels of medical education and to practicing physi-cians as well, yet most physicians receive only limited trainingin communication skills. In the future, policy makers and stake-holders may leverage training grants, payment incentives, certi-fication requirements, and other mechanisms to develop andreward effective patient-centered communication, according toan article earlier this year in Health Affairs.

Moreover, physicians’ communication skills and strategies willbecome increasingly critical as healthcare reform takes shape.Patients will gravitate toward a primary care physician who canbe reached easily, whether via open office hours, virtual officevisits, or ease of emergency contact, notes Paul R. Ehrmann, DO,a family physician and medical director at Family Health CareCenter, Royal Oak, Mich., and associate clinical professor atMichigan State College of Osteopathic Medicine. “I think ashealthcare changes, having a good relationship between patientand physician will be even more important,” Dr. Ward says.

Enhanced AdherenceEffective communication plays a “significant role” in a


� Speech ability or language articulation

� Foreign language spoken

� Dysphonia

� Time constraints on physician or patient

� Unavailability of physician or patient to meet face-to-face

� Altered mental state

� Medication effects

� Cerebrovascular event

� Psychological or emotional distress

� Gender differences

� Racial or cultural differences

Source: Travaline JM, Ruchinskas R, D’Alonzo GE Jr. “Patient-physician communication: whyand how.” The Journal of the American Osteopathic Association. 2005;105:13-18.

Barriers to Patient-physician Communication


patient’s overall adherence to a treatment plan prescribed by thedoctor, according to Wayne J. Reynolds, DO, family physicianat Sentara Medical Group in Gloucester, Va. He discusses theimportance of how information is conveyed to help newly diag-nosed patients understand their conditions. Even the languageused—and the level at which the condition is discussed—needto be coordinated with the patient’s level of understanding andknowledge (see “Barriers to Patient-physician Communica-tion”). “We’ve got to help patients understand what [diseaseslike] diabetes [are] so they comply. Doctors can help themunderstand the rationale behind treatment,” he says.

This is where the handouts Dr. Ward recommends can play asignificant role. She says some physicians confuse the patient bypresenting information in a scattered or offhand manner. Instead,she says, giving something as simple as patient-focused hand-outs discussing common medical conditions—along with per-sonalized care plans—can facilitate good outcomes and healthierpatients. “I give each patient a one-page sheet that has a list ofthe diagnoses we discussed that day, the refills they received,


and a copy of our plan for that visit in language that the patientcan understand,” she says. In addition, she focuses on one issuein each visit. Otherwise, a too-complicated assortment of hand-

outs will wind up in the patient’s circular file rather than rein-forcing any point she tried to make during the visit.

Adherence increases when you engage the patient in a mean-ingful way. “Patients want you to actively listen and be empathic.It really amounts to … educating them in regards to their condi-tion and making a connection with them. If you don’t engagethem in some way, they aren’t likely to listen to you,” saysRichard F. Multack, DO, Olympia Fields, Ill., a faculty memberof the Institute for Health Care Communication and a physiciancommunication coach. “Active listening involves maintaining eyecontact, respecting personal space, making empathic comments,using body language, and using reflective listening. Reflective lis-tening involves repeating back concerns of the patient word forword, or as close to that as possible, showing the patient that youheard them, were listening, and that you care. For example, ‘Mrs.Smith, you said that you are afraid that you cannot give yourselfthe eye drops. I know that must be really scary for you. I thinkperhaps we can find someone to help you.’”

Attitudes associated with adherence not only impact the effec-tiveness of chronic care treatment regimens, but also lead toincreased patient trust and satisfaction, says Robert M. Arnold,MD, director, Institute for Doctor-Patient Communication at theUniversity of Pittsburgh, Pittsburgh, Pa. “I think doctor-patientcommunication is a hot topic today because patients want theirdoctors more involved than they were 20 to 30 years ago,”

“I think doctor-patient communication is a hottopic today because patients want theirdoctors more involved than they were 20 to30 years ago."

Robert M. Arnold, MDDirector

Institute for Doctor-Patient Communication at theUniversity of Pittsburgh

Pittsburgh, Pa.



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he says, perhaps because patients are better educated. “Patientstoday want their doctors to advocate for them, he notes.

Improved OutcomesA growing body of evidence connects successful physician-

patient communication to positive results, such as reducedpatient stress levels, better treatment adherence, increased physi-cian satisfaction, and fewer medical malpractice lawsuits,according to Christopher Guadagnino, Ph.D., writing in Physi-cian’s News Digest. That communication includes the full spec-trum of patient contact: making phone calls from the front office,reporting test results, conducting office visits that don’t leave thepatient behind, and soliciting patients’ input on decisions abouttheir medical treatments and choices.

Because of the potentially positive affect on outcomes, howinformation is conveyed is as important as the information itself,states John M. Travaline, MD, associate professor of medicine,Temple University Hospital, Philadelphia, Pa. “Patients whounderstand their doctors are more likely to acknowledge healthproblems, understand treatment options, modify their behavioraccordingly, and follow their medication schedules,” he says. Headds that outcomes improve if physicians heed the following:� Assess what the patient already knows about his condition� Assess what the patient wants to know about it (not all


patients want the same level of detail)� Are empathic � Provide information slowly � Keep communication simple � Are truthful � Are hopeful� Pay attention to the patient’s nonverbal language and cues� Are prepared for a reaction

Better communication will help offset the increasing complex-ity of today’s medical practice and its impact on the doctor-patientrelationship. In addition, medical information is more complextoday. Patients may bring in pages of information that they havefound on the Internet about their medical conditions, which you

must interpret or analyze for them. Because there often isn’t timeto go through everything, Dr. Carmona recommends suggestingthat patients come to the office visit with prepared questions.“The doctor should be seen as a collaborator. He should listencarefully, analyze, and look beyond the chief complaint to detectthe patient’s medical problem by understanding the patient andhis lifestyle,” he explains. “And [patients should] leave your officefeeling that their questions have all been answered.”

That process enhances the therapeutic value in the doctor-patient relationship, he says. “So many issues are interrelated inhealth; for example, stress at home, stress at work, an injury,” hesays. “Rather than focus on a specific problem, there is a thera-peutic value in relating with the patient, and it’s all part of thehealing process.” To get there, he says doctors have to resist the“rapid-fire assembly line we’ve been forced into because of the

“The doctor should be seen as a collaborator.He should listen carefully, analyze, and lookbeyond the chief complaint to detect thepatient’s medical problem by understandingthe patient and his lifestyle."

Richard H. Carmona, MD, MPH, FACS Former Surgeon General of the U.S.

President, Canyon Ranch Institute Tucson, Ariz.



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economics of today” in order to develop a meaningful, trustingrelationship with each patient.

The connection between good communication and preventionis quite clear to Craig M. Wax, DO, a family physician in Mul-lica Hill, N.J. “I’m a believer that the most efficient and cost-effective healthcare is prevention,” he says. His waiting roomhas two large three-ring binders full of medical and preventiveinformation for patients to read. He also hosts a regional radioshow in which he discusses various medical topics that augmenthis time with patients in the exam room. For his “digital age”patients, he has a Website, webcast, and podcast. The webcastand podcast derive from his radio show and are online atwww.wgls.rowan.edu. “I think communication is the best thingwe can do on all levels for healthcare to succeed,” he says. “Ifwe can help people do smart things to prevent illness, the cost oftreating that illness is averted.”

Effect on Healthcare CostsA patient comes in with chest pain. Instead of just following the

“chest pain protocol” and ordering serial EKGs, cardiac enzymes,and IV infusions, you may get a lot more information by askingspecific questions such as how and when the pain occurs, howlong the pain has lasted, what makes it better, and what happenedwhen it first started. Depending on the answers, you may needonly an EKG, then give the patient a reliable answer to his or herconcern, Dr. Stubbs says. That process of communication, hesays, not only limits the overall cost of diagnosis, but also makesthe patient more comfortable with the process and improves hisor her comfort level with the physician.

Engaging the patient in his or her own health is likely to leadto cost savings because that patient should ultimately do better


and need fewer healthcare resources, according to Dr. Ward.“Preventing an illness or finding it early lowers cost.” Adherentpatients, Dr. Multack notes, reduce costs by eliminating orreducing the number of office visits, ER visits, and extra moneyspent on prescriptions.

However, Dr. Arnold thinks that the full effect of communica-tion on lowering healthcare costs has not yet been completelyexplored. “When doctors take time to talk about something sim-

ple, communication can help avoid unnecessary costs,” likeadditional prescriptions or follow-up visits to ferret out the rea-sons why a patient has not adhered to treatment, he says.

Some physicians are following through on their good inten-tions. For example, Dr. Ehrmann doesn’t use an answering serv-ice to take his calls; instead, he gives patients his cellphonenumber. His personal cellphone is used for both personal andbusiness calls and he says he doesn’t get bothered by nuisancecalls. Dr. Ehrmann believes giving patients tools to communi-cate with their physician will help them take charge of their ownhealthcare and improve their relationship with him or her by fos-tering trust. “Fostering doctor-patient trust decreases healthcarecosts since it nips problems in the bud and provides patients eas-ier and quicker access to me, and I can then identify problemsearlier that will usually not lead to the emergency room visit andhence higher healthcare costs,” he says.

“Fostering doctor-patient trust decreaseshealthcare costs since it nips problems in thebud and provides patients easier and quickeraccess to me, and I can then identifyproblems earlier that will usually not lead tothe emergency room visit and hence higherhealthcare costs.”

Paul R. Ehrmann, DOMedical Director

Family Health Care CenterRoyal Oak, Mich.




Focus on Patient AgendaAccording to a study by communications experts Howard B.

Beckman, MD, and Richard M. Frankel, Ph.D., published in theAnnals of Internal Medicine, patients who were asked by aphysician to describe their concerns were usually redirected afteran average of 18 seconds, having verbalized only their first con-cern. In another study, published in JAMA, patients who hadbeen redirected returned to their agenda and talked about theirother healthcare concerns in only one of 52 visits, according toM. Kim Marvel, Ph.D., et al, who examined the extent to whichfamily physicians extract patients’ agendas, and concluded thatphysicians do often redirect patients’ initial descriptions of theirconcerns, and once redirected, the descriptions are rarely com-pleted. Only 28% of physicians solicit the patient’s completeagenda, up only slightly from the 23% found in Beckman andFrankel’s study. Missed opportunities to gather potentiallyimportant patient data and late-arising concerns are the resultsof incomplete initial descriptions. It takes little time to solicitpatient agendas, and this practice can improve interview effi-ciency as well as yield more patient data, they noted.

Ms. Belzer says spending just 30 seconds more listening toeach patient during the course of a visit can make a big differ-ence. (See “Why Patients Hold Back.”)

“A lot of times people put off going to a doctor because theydon’t think he talks to them or is open to them. So if they thinktheir doctor will listen and make himself affable, they are morewilling to go in sooner, which lowers their healthcare costs inthe long run,” says Daniel Levy, MD, a pediatrician in OwingsMills, Md., and past president of the Maryland chapter of theAmerican Academy of Pediatrics (AAP).

“Despite the fact that communication is not reimbursed, prob-ably 80% of diagnoses come from effective communication,” Dr.Stubbs says. “Communication is the key to establish any doctor-patient relationship that’s a healing relationship.”

Education, Recertification, and CommunicationAnother sign of the times is the increasing focus of medical

education and assessment on communication skills. For exam-ple, the American Board of Internal Medicine (ABIM) requires


Patients may not ask questions because they� Fear the answer� Want to avoid feeling stupid� Consider their uncertainties trivial� Feel rushed� Were previously brushed off by the doctor

Patients may not disclose problems because they� Do not want to seem negative or ungrateful� Want to be strong� Think their concerns are not legitimate� Do not want to add to the doctor’s burdens� Believe nothing can be done

Source: Wenrich MD, Curtis JR, Shannon SE, et al. “Communication: What Do Patients Want andNeed?” Journal of Oncology Practice. 2008; 4:249-253.

Why Patients Hold Back


internists and subspecialists to maintain their certification bycompleting a medical knowledge and practice performance self-assessment in addition to passing an exam. Among the practiceperformance options are three modules focusing on communica-tion skills with peers and patients. Two of these communicationmodules are also available for use in training programs becausethey help address Accreditation Council of Graduate MedicalEducation (ACGME) general competencies, including Interper-sonal and Communication Skills. (See fact sheets athttp://www.abim.org/about/fact-sheets.aspx.)

And future physicians may have even more training in com-munication. The Liaison Committee on Medical Education(LCME) and the Accreditation Council for Graduate MedicalEducation (ACGME) both recently identified interpersonal andcommunication skills as core competencies. They were spurredby a report by the Institute of Medicine, which noted that half ofall causes of mortality and morbidity in the U.S. are related tosocial and behavioral factors and said that the medical profes-sion had not been successful in consolidating the knowledge ofsocial and psychological variables into standard medical prac-tice. And the National Board of Medical Examiners has sinceadded a Communication and Interpersonal Skills subcomponent


to its medical licensing examination. Some states have made specific efforts to stress professional

communication skills. For example, all of Pennsylvania’s med-ical schools have incorporated programs into their curriculum tohelp students cultivate empathetic encounters with patients. Atthe University of Pittsburgh’s School of Medicine, the first com-munication skill-building course groups ten medical studentswith two simulated patients and two faculty mentors. Thepatients job is not to present a standardized patient’s medicalhistory, but rather to help the physicians focus on interpersonalcues and communicate effectively during presentation of diffi-cult issues. The mentors and “patients” both coach students.

Something You Don’t Know Given all the pressures of daily practice, it may be tempting

to dismiss improving communication because it’s “somethingyou already know,” Ms. Belzer says. But she notes that betterskills will be valuable in today’s increasingly complex health-care system: from increased adherence and patient satisfactionto fewer malpractice lawsuits.

And for those who feel there’s nothing new to learn, she cau-tions that everyone can improve by learning updated strategiesand honing existing skills on an ongoing basis. ”It’s a basic tenetof communication that what you say and how you say it have adirect bearing on the response you receive,” Ms. Belzer says.“Keeping a focus on communicating in the manner that bestreaches each individual patient will pay off in myriad benefits tothe doctor and patient alike. A simple human connection withthe patient as a whole human being can improve patient percep-tions about everything associated with the visit–from quality ofservice to quality of care.”



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