October 1999 Bulletin

Communications 101

'It's never too late to work on these skills. . . .'

Physicians learn how to build rapport, empathy

By Carolyn Rogers

At the heart of a typical medical encounter, a doctor and patient are simply exchanging information. As long as both parties speak English (or another common language), communicating shouldn't be a problem, right? Well-wrong.

Even when both people are apparently speaking the same "language," the patient-physician encounter is fraught with communication "pitfalls" that can thwart the most well-intentioned doctor. Even minor misunderstandings between a physician and patient can lead to a wide range of problems.

In recent years, this communication problem appears to have worsened. Harried physicians reacting to pressures wrought by managed care are running headlong into the new consumer-oriented patient.

Poor patient-physician communication often equals poor outcomes, including:

Breaks in communication, if left unresolved, can have dangerous consequences, according to a recent study at the University of Kansas School of Medicine in Kansas City. Ninety-nine patients and their attending physicians were surveyed about time spent prior to discharge discussing the post-discharge treatment plan and the patient's understanding of this plan. All of the patients had been discharged recently from an academic medical center with the diagnosis of acute myocardial infarction or pneumonia. The results showed that physicians reported spending more time discussing post-discharge care than did patients. Physicians also believed that 89 percent of patients understood the potential side effects of their medications, but only 57 percent of patients reported that they understood. Similarly, physicians believed that 95 percent of patients understood when to resume normal activities, while only 58 percent of patients reported that they understood.

Luckily, these important "communication skills" don't have to be inborn-they are teachable. Nearly every medical school in North America now offers some type of instruction in communication skills, according to Gregory Makoul, PhD, founder and director of the program in Communications and Medicine at Northwestern University Medical School in Evanston, Ill. Makoul is currently working with the Association of American Medical Colleges to examine how medical schools teach and assess communication skills. While the study findings are not yet complete, Makoul says, "We've found that while communications skills courses are variable from school to school, there is an indication that this type of instruction is increasing. Things are definitely on the right track; there's lot of creativity and diversity in the methods."

While this development is encouraging, most practicing physicians received little, if any, formal training in patient-physician communications when they were in medical school. What about them?

"It's never too late to work on these skills," Makoul says. "While most doctors are already pretty good at communicating, I know many very experienced clinicians who still see the need to work on these skills. They recognize that you're never done learning them-that's encouraging to see."

Numerous opportunities now exist for physicians to hone these critical communication skills. The Bayer Institute for Health Care Communication Inc., West Haven, Conn., for example, has conducted more than 1,200 communication workshops for more than 18,000 clinicians in the last 12 years. The nonprofit organization offers accredited courses that help physicians identify and develop specific communication approaches they can use to prevent uncomfortable clinician-patient situations.

Physicians' communication skills also have struck a chord with managed care organizations (MCOs) and other insurance companies. Bayer reports that when MCOs conduct exit interviews with former members, 25 percent of those patients report the reason they left is, "I didn't like the way my physician communicated with me." In terms of market retention, this is major concern to insurers who want to increase or at least maintain their membership base.

In an effort to bridge the patient-physician communication gap, more than 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, or have developed their own programs.

Recognizing that good communication skills are essential to the practice of good medicine, Kaiser Permanente launched its own training program ten years ago.

"When physicians communicate well-that is, they listen attentively, convey their concern, and involve patients in decisions about their care-patients are more likely to follow through with treatment and to feel better," says Terry Stein, MD, director of clinician-patient communication for Kaiser Permanente's Northern California Region.

The first element of the program to be implemented , Dr. Stein says, was a one-day class, "Thriving in a Busy Practice." The intent of the course is to improve physicians' skills in everything from establishing rapport with patients quickly to demonstrating empathy with individual patient concerns.

"This course really caught on because it helped our physicians recognize that communications skills can be learned and can make a big difference in successful practice," Dr. Stein says. "Prior to the course, 52 percent of respondents said that more than 10 percent of their patient visits were frustrating. Three months after the course, the percentage dropped to just 34 percent of physicians experiencing that level of frustration."

Kaiser now offers a whole menu of programs and services, and many courses have waiting lists. "It's not one-size fits all," Dr. Stein says. "The courses span from a single lunchtime event to a five-day residential program where we go off-site and work with actors, small group discussions and videotaping."

Of the 3,700 physicians in Kaiser's Northern California region, approximately half have attended at least one communication program in the last six years.

"To me, that's beyond preaching to the choir," Dr. Stein says, "that's a pretty large chunk."

Some of the techniques that are taught in these courses, Dr. Stein admits, might appear to be pretty basic. "Some of it is basic," Dr. Stein says, "but since most of us never learned these techniques in medical school, a lot of doctors have developed habits that interfere with their effectiveness."

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