April 1999 Bulletin

Do you talk or communicate?

Experts say orthopaedists need to listen to patients

By Sandra Lee Breisch

Do you dominate the dialogue between you and your patients and not inquire about their concerns? Do you find your patients typically utter "uh-huh" or "okay" while you explain procedures, education and/or counseling? Do you get bombarded with questions from patients at the end of the visit and/or receive messages from them some hours, days, even months later?

If so, you may not be communicating with your patients.

So says communication researcher Wendy Levinson, MD, chief section of General Internal Medicine and director, Robert Wood Johnson Clinical Scholars Program at the University of Chicago. She co-authored a study, "Communication between surgeons and patients in routine office visits," that points out some deficits in the communication process.

The study, published in Surgery, February 1999, analyzed specific communication behaviors associated with 676 audiotaped routine office visits with 37 orthopaedic surgeons and 29 general surgeons. The communications were coded for structure and content. "For orthopaedic surgeons, the consultations lasted 12.7 minutes and for general surgeons, 13.1 minutes," says Dr. Levinson. She notes that orthopaedic surgeons spent about half of their time talking to patients about education and counseling.

"Ideally, you would like there to be a dialogue between patients and surgeons, but in fact, it's more the doctor talking and the patients listening to them counsel them about medicine or therapy," says Dr. Levinson.

So, how can orthopaedists close the communication void?

"In general, there's literature that shows patients are more satisfied with the office visit when physicians are interested in the context of their life and understand about their specific problems related to their condition," explains Dr. Levinson. "In surgical visits, we found that only 1.3 percent of the dialogue talked about the psychosocial aspects of the patients' problems."

Since time is of the essence, how can orthopaedists do this effectively within their time restraints?

"There are ways of communicating properly and efficiently in a realistic time so the patient feels listened to and not rushed, or [the physician] spending three hours discussing every X-ray with the patient," explains communication expert Robert Buckman, MD. He is a medical oncologist, associate professor at Toronto-Sunnybrook Regional Cancer Center, University of Toronto. "The secret of good communication is involving the patient by listening, acknowledging their emotions and exploring them. Then, come up with a strategy and closure to the office visit. It's participation, but not control."

In a collaborative effort with other communications experts, Dr. Buckman developed, "A Practical Guide to Communication Skills in Clinical Practice," a set of CD-ROMs with depictions of office visits that demonstrate effective tips on how to deal with feelings and uncover hidden problems, special or difficult situations.

For example, some scenarios demonstrate how to open up the communication channel. Dr. Buckman suggests, asking "open questions," such as "how are you?" or "how did that make you feel?" Pause when a patient speaks, nod, smile, saying "hmm" or "tell me more about that," and repeating one key word from the patient's last sentence in your first sentence. Clarify any of your patient's "ambiguous" or "awkward" comments.

"Acknowledging the emotional content of the interview is the central skill that is perceived as being supportive," stresses Dr. Buckman. Some of the techniques involve an empathic response and identifying the emotion. "For instance, you can respond in a way that shows you have made the connection between the two such as 'that must have felt
awful,' or 'this information has obviously come as quite a shock,'" he explains.

Knowing the patient's perception of their condition and seriousness is also key. "Ask the patient to say what he or she knows or suspects about the current medical problem," explains Dr. Buckman. "Then listen to the level of comprehension and vocabulary. Note any mismatch between the actual medical information and the patient's perception of it, including denial."

Dr. Buckman stresses, "I guess what all of us communication experts are saying is, 'These skills are no more mysterious than the skills an orthopaedist needs to do a hip replacement.' But you need both sets of skills."
Are you listening?

In a survey of 700 orthopaedists, 86 percent believed their patients would say the orthopaedists listen to them.

When asked to rate, on a scale of 1 to 5 with 5 being excellent, whether all orthopaedists listen to their patients, only 21 percent gave high ratings of 5 or 4 to other orthopaedists; 49 percent, a neutral rating of 3; and 28 percent, a rating of 2 or 1 (poor).

In a random survey of 193 consumers asked to rate, on the same scale of 1 to 5, whether orthopaedists listen to patients, 35 percent of consumers gave high ratings of 5 or 4; 30 percent, a rating of 3; and 11.9 percent, a rating of 2 or 1.

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