August 1998 Bulletin

18 seconds to trouble

". . .to be a good doctor you must understand the patient and that requires listening. . . . "

Physicians must develop good communication skills to provide good health care and patient satisfaction

By Sandra Lee Breisch

James G. Samarco, MD, recalls a time back in the 1980s when he "thought" his 90-second postoperative visit with a patient was over. But his nurse assured him that it wasn't. "As I looked down, I found that the patient's hand was firmly attached to my lab coat," explains the solo practitioner in Cincinnati, Ohio. "I realized that I was not understanding the patient. I fell short of completing the patient's care plan. So, I pulled up a chair and listened to the patient's concerns for 15 minutes."

Fortunately, for Dr. Samarco, such an epiphany changed his relations with patients. "It's one thing to provide good care, but to be a good doctor you must understand the patient and that requires listening," says Dr. Samarco. His practice also focuses on good communication skills from the front desk on up.

Yet, for other physicians whose bedside manners fall into the category of "patient indifference" or "brusque behavior," their epiphany about a failed patient-physician relationship often begins in court.

The bottom line: a good patient-physician relationship may be one of the most important deterrents to a litigious situation. So says Jane Abaray, an attorney for Waite, Schneider, Bayless and Chesley, in Cincinnati, who handles medical malpractice referrals. "Most of the cases I see are 'failure to diagnose' and most of the cases go back to the physician's 'failure to listen.' Physicians think they have the answer before they hear what the patient has to say, but the doctor who is listening is going to make a better diagnosis, reduce the possibility of making an error in diagnosis or treatment and have a better rapport with the patient. Secondly, it will reduce the patient's inclination to consult with an attorney if some type of error does occur."

Exactly how much time does it take for a physician to interrupt a patient's dialogue? On the average, doctors spend 18 seconds listening to a patient before they interrupt them and less than two minutes of a 20-minute visit imparting information to them, according to research provided by the Bayer Institute For Health Care Communication, Inc., West Haven, Conn.

"Most patients never returned to the story they were about to tell," explains J. Gregory Carroll, PhD, director for the nonprofit organization that offers accredited continuing medical education classes to help physicians identify and develop specific communication approaches to help them deal with uncomfortable clinician-patient situations.

"In the surgical specialty, it's an even greater concern because one can spend so many years perfecting their technical skills only to find that they're the target of some malpractice litigation which primarily has to do with their communication patterns, not their skills as a surgeon," notes Carroll.

Developing good communication skills has become a singular challenge for physicians whose attempts at congeniality often conflict with other demands in an era of managed care. High patient volume, surgeries, continuing medical education and time spent on research leave little chat time.

Physicians' communication skills also have struck a cord with managed care plans and other insurance companies. "A number of managed care plans will do exit interviews with former members," explains Carroll. "What they found is about 25 percent of the patients report the reason they left is, 'I didn't like the communication process with my physician.' In terms of a market retention strategy, among other reasons, this becomes a major problem to solve if you're looking to increase or at least maintain your membership base."

Thus, in an effort to bridge the patient-physician communication gap, about 75 managed care plans such as Kaiser Permanente, PacifiCare Health System, Group Health of Minneapolis and Harvard Pilgrim Health Care of New England have sent their physicians back to communication schools like Bayer. So far, Bayer has been instrumental in helping more than 20,000 physicians in the U.S. and abroad smooth over difficult clinician-patient interactions.

Physician-owned insurance companies in six states also are jumping on the communication bandwagon. In 1989, insurers in Oregon became the first that offered 4 percent to 10 percent reductions on malpractice insurance over a period of one to two years to physicians who improved communication skills; others in such as Colorado, Michigan, Ohio, Virginia and Missouri followed suit.

"We believe that risk management should be a proactive activity-in that we try to teach those behavioral changes necessary to avoid malpractice suits," explains Kathy Gardner, BSN, PhD, assistant vice president, Risk Management Department, Copic Insurance Company, Denver, Colo., who has sent over 2,000 physicians out of some 4,300 physicians they insure to Bayer's classes. "We take a team approach to our educational program-not only with physicians, but staff that works with our physicians on how to avoid malpractice lawsuits."

With physicians serving on Copic's board of directors, Gardner says the company's awareness about the importance of effective communication between physicians and patients is very keen. "In claims reviews, they've seen where there have been communication breakdowns in the relationships between the consulting physicians, patients and physicians, and nursing staff and physicians. Communication is so central to everything and the more effective it is, the more positive our relationships become."

In a study entitled, "How the Medical Lawsuit Pie is Cut: Lawyers Tell What Turns Some Patients Litigious," published in Medical Malpractice Prevention in 1986, defense attorneys for an insurance company were asked to prepare a summary of each case they handled and identify the most important event precipitating the filing of a lawsuit. The study found that 35 percent of the cases involved physician communication problems such as failure to discuss and disclose and failure to respond promptly to requests for the doctor's presence; and 35 percent were attributed to physician attitude (in a hurry, air of superiority, appearing indifferent or cold).

A study published by the Journal of the American Medical Association, Feb. 19, 1997, entitled, "The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons," analyzed specific communication behaviors associated with malpractice history in primary care physicians and surgeons. Wendy Levinson, MD, one of the authors who is chief, section of General Internal Medicine and director, Robert Wood Johnson Clinical Scholars Program at the University of Chicago, said in an interview, "It's clear that effective communication in surgeons is different than in primary care doctors. …Broadly [in the study] we found that primary care doctors who never had been sued used more humor. They oriented the patient to what was going to happen in the visit and gave the patient more understanding of the process of medical care. They encouraged the patient to talk and listen; and gave them more information about the therapy they were taking…"

As Dr. Levinson points out, "A more collaborative style of communication is needed-asking the patient's opinion, listening to what they believe, treating them as equal partner in decision-making is strongly associated with patient satisfaction."

Carroll says it's important to "act on building a partnership." However, a physician also should acknowledge any difficulties to the patient. For instance, she says, "Inform your patients, 'I find it difficult to proceed knowing that you have a different view of the situation than I do.' Or 'I sense you are angry (annoyed) with me, may we discuss this together?' or 'This appears to be difficult for you to talk about. Is there some way that I can make it easier?'"

It's a good idea to encourage problem-solving. Some verbiage that Carroll suggests include, "I want to solve this problem we seem to be having. My thoughts about the situation are [fill in the blanks]. What are your thoughts? Is there something that I can do at this point to help us work together more effectively?"

Patient expectations of physician services should be clear. If they're not, he suggests asking patients, "What were you hoping I would be able to do for you today? or You have quite a bit of experience with doctors: what works best for you?"

Other tips include "being sensitive to the patient's words." Listen to what is important to the patient. Acknowledge it and incorporate it into your agenda. Use the patient's words whenever possible. Ignore patient content if needed to establish boundaries.

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