Three Reasons Why Doctors Need To Spend More Time Talking and Listening To Their Patients

Since most physicians probably will not be able to get beyond the first couple of lines of this post without yelling at the monitor…I will get to the 3 reasons…and if you stick with me …I’ll present my case for why they are so important.

1. Your visits will be more productive…and shorter
2. You will be a better diagnostician and a much better doctor
3. Your patients will sing your praises to all their friends and family

Reason #1- Your visits will be more productive…and shorter.

Physician experts argue that the best way to improve productivity and time management during the office visit is by improving the way physicians talk with their patients.  Most of you are probably screaming this is not possible because patients:

• Show up with 3-4 complaints/visit
• Just want a “quick fix “or prescription
• Are unfocused and make rambling opening statements
• Appear totally disinterested and unengaged
•  Won’t do what I tell them

Let’s stipulate that all these arguments are true.

Now suspend your judgment for a moment and consider this.

Where is it that patients are taught how they are supposed to behave when in the presence of their doctor?   Have you ever talked to them about such things?  Do you imagine their previous doctors advised them about such things?  Is there a school people are supposed to go to learn how to talk productively with your doctor?

The fact is that patients aren’t taught these things….ever.  They learn these behaviors through the school of hard knocks.  We have all been socialized from childhood to assume the “passive, subservient “sick role” in the presence of our doctors.  That’s not anyone’s fault…it is just the reality of the way health care have evolved.

Now imagine there was a school for patients where they learned things like how the medical interview is structured, what patients can do to prepare for their visit, why time is limited, how to make the best use of the time available, and so on. Then imagine you reinforcing these “learning” at each of your patient visits through repetition, encouragement, and changes in your communication behavior.  In relatively short order patients would begin to “reciprocate“your behavior with the behavior you desire…and viola you have set the stage for shorter, more productive (and organized visits).

Reason #2- You will be a better diagnostician and a much better doctor

Sir William Osler, a founding father of modern medicine, once said “Listen to the patient – they will tell you what’s wrong.”  Numerous other luminaries have said that a doctor’s patient communication skills (talking and listening) are as important as their clinical skills and knowledge.  Talking and listening is how physicians arrive at the correct diagnosis and treatment.  Strong patient communication skills are needed to engage and activate patients.   Talking and listening is therapeutic and to patients.

Some patients will get better with a commonsense explanation of their difficulties; others for some unknown reason remain unchanged. Some patients will respond to friendliness on the part of their physician; others require a more formal attitude. Some can establish rapport with their physician even though they appreciate his intellectual shortcomings.       M. Balint 1957

As physicians come to rely upon EMRs, there is a risk that the computer will come between the patient and physician.  This will result in even less “talking and listening” between patients and physicians, more   disengaged patients, and even poorer outcomes.

Reason #3 – Your patients will sing your praises to all their friends and family  

Let’s face it…with few exceptions…most physicians’ patient communication skills need improvement.   Poor physician communications skills top the list of complaints patients have about their doctor, i.e., physicians that don’t listen, physicians that ignore what they have to say, physicians that don’t provide enough information, and so on.    Many of us have never been exposed to a physician with superlative patient communication skills.   We don’t know what we are missing.

Given how “average” most physician communication skills are…. imagine how easy it would be for a physician with good communication skills (patient-centered) to compete with other physicians in your group or local market.  Soon such physicians will also be rewarded for their ability to create exceptional patient experiences simply by virtue of their ability to talk and listen to patients.

Is what I talk about here counter intuitive…yes.  Does it requires some out of the box thinking…definitely.   Do I have a solution for helping patients and physicians accomplish what I talk about here.   Absolutely.   Contact me to learn more.

That’s my opinion…what’s yours?

 Sources:

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?  Center for Study of Health System Change. Issue Brief. April 2010.

Balint, M. The doctor, his patient and the illness, Inter-national Universities Press, New York, 1957.

Rosenow, E., Patients’ Understanding of and Compliance With Medications:  The Sixth Vital Sign. Mayo Clinic Proceedings. August 2005.

Cene, C., et al. The Effect of Patient Race and Blood Pressure Control on Patient-Physician Communication. Journal of General Internal Medicine. July 3, 2009. 24(9):1057–64.

Patient-Centered Communications – Does “Lack of Time” Justify Physician Reluctance To Adopt It?

I talk with lot of physicians about the need to improve the quality of communications between physicians and patients.   Regular followers of my work will know that I am an advocate for the adoption of patient-centered communication skills by the physician and provider community.

Physicians with whom I talk seldom disagree as to the need for better physician-patient communications.   They know that physician communication skills top the list of patient complaints about their physicians, i.e., my doctor doesn’t listen,” “my doctor ignores me,” and so on.   Rather, they simply dismiss the subject out of hand as being impractical due to a “lack of time” on the part of most physicians.

I can understand their perspective.   Primary care physicians in particular are faced with sicker, more demanding patients, increased payer and regulatory requirements, and are constantly pressured to see more patients.

Yet physician waiting rooms and exam rooms are full of engaged patients (otherwise they wouldn’t be there) who have nothing to do but read outdated magazine.

What would happen if physicians actually put patients to work during wait time?

Here’s what I mean…

What if physicians integrated patient “wait time” into the office visit by:

• Talking to patients (via printed handouts, electronic media, patient portals, etc.) about their evolving new role (and that of the physician and other providers) under health reform.  Contrary to the popular press which touts the empowered patient, most of us still assume the traditional “sick role” during the office visit.  The sick role is characterized by patient passivity, limited information sharing, and minimal question-asking.

• Teaching people while waiting how (using the same media as above) to become “better patients.”   I recall an article where physicians were asked 5 things they wished their patients knew.  At the top of the physicians’ “wish list” was a desire for patient’s to be better prepared and more focused during the visit.  The point being that more prepared patients would help the physician get to the correct diagnosis and treatment plan faster

All of us, beginning in childhood, are socialized into playing the sick role when interacting with physicians.   Just as chronic disease patients needing to develop self care skills and confidence in their self care skills…patients need to be taught skills for (and develop confidence in) how to more effectively talk to and collaborate with their physicians.

•  Laying out a game plan (over a series of visits) for teaching new and established patients when and how to effectively contribute to the medical interview (exam).   Given an average wait time of 22 minutes per primary care visit, it is not reasonable to assume that patients can be taught the above in the course of 1 or 2 visits.  But patients with chronic conditions often visit their PCP 6-8 times a year.  This would afford plenty of time (2-3 hours a year) for physicians to teach (and practice) individual skills to patients (i.e., agenda setting and prioritization, question asking skills, self-care management skills, new medication considerations, etc.).   By reinforcing lessons learned by patients over the course of several visits, it is reasonable to expect that both patient and physician will become more proficient in the use of their time together.

How Exactly Will Better Physician-Patient Communication Lead To More Productive Visits?

Research has consistently shown that patient-centered communications (versus traditional physician-directed communications) can result in more productive office visits as measured by 1)  the amount/quality of information shared by patients, 2) the number of questions asked by patients, and 3)  and the level of patient retention of information shared by physicians.

These same studies show that the adoption of patient-centered communications adds little if any more time to the length of office visits.  Once patients and physicians become proficient in the use of patient-centered communications methods,  physicians may well be able to do more during the visit but in less time.  Here are some of the techniques  characteristic of patient-centered  communications associated with increased visit productivity:

•  Concise visit agenda setting and prioritization wherein both physician and patient  agreed to what can be discussed within the time allowed.  This  also eliminates  the “oh by the way” introduction of last-minute patient agenda items that can occur at the end of the visit.

•  More concise  sharing of relevant information by the patient.

• Greater physician-patient agreement as to the diagnosis and treatment.

• More collaborative decision-making

•  More information retention by patients (how to take new Rx, etc.)

• Greater patient adherence

That’s my opinion…what’s yours?

Related Post:

Do Medical Home Physician Really Communicate Any Better Than Non-PCMH Physicians?

Six Seconds To More Effective Physician-Patient Communications

Sources:

Politi, M. C., & Street, R. L. (2011). The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice, 17(4), 579-84.

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine : JABFM, 24(3), 229-39. doi:10.3122/jabfm.2011.03.100170

Marvel, K, Epstein, R, Flowers, K, Beckman H.  Soliciting the Patient’s Agenda, Have We Improved?  JAMA. 1999;281:283-287.

Will Information Technology Squeeze Physicians Out Of Their Central Role In Health Care?

Not by a long shot if patients have anything to say about it.

Turns out that while most of us (90%) would like be able to make a doctor’s appointment and check lab results online….85% of us also still want the option of be able to talk to our physician face-to-face.  These are the finding from a recent 2012 study conducted by Accenture.

These finding will no doubt come as a surprise to many of those high tech newcomers to health care looking to make physician and trips to the doctor’s office a thing of the past with some new “killer health app.” You wouldn’t believe how little many of these software and app developers know about how health care works.  Then again, if you have looked at some of the EMRs, PHRs, and patient portals solutions being hyped out there maybe you could believe it.

What is significant about the finding cited above is that patients at least get it.  They understand the value of a having a relationship with a knowledgeable physician or similar health care provider.  In spite of, and for some, because of the plethora of health information outlets on the web people want to know that they always have access to your family doc when the chips are down.

What newbie software engineers and  smart phone app developers fail to understand is that health care is fundamentally about social interactions…not technical data transactions like depositing a check or making an airline reservation.

Here’s what I mean…based upon some 20+ years working in health care:

• From the get go…going back to Hippocrates…health and health care delivery has been about the relationships between people starting with the  physician-patient.relationship.

• The most important diagnostic tool a physician has at their disposal is not a smart phone…but their ability to talk with and observe  patients verbal and non-verbal behavior.

•  “Talk” is not only how physicians diagnose problems and recommend the appropriate treatments…talk is also how patients are able to engage in the health care.  Perhaps the most overlooked aspect of talk (and touch) during the medical exam is the therapeutic benefits patients derive from being able to express heart-felt fears and concerns to someone who hopefully cares.

The unfulfilled promises of so much of health information technology today (like Electronic Medical Records, Personal Health Records, and Patient Portals), with some notable exceptions like Kaiser, Group Health and the VA, can be traced directly back to developers not understanding that their job is to enable physician-patient relationships not get in their way or try and replace them.

Check out this related post – Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

I don’t consider myself a Luddite when it comes to health information technology…nor would I put most physicians in this category.  The health industry is going through massive change, and unfortunately in such time, there is also a lot of false starts and waste that comes from ill conceived HIT solutions.  I suspect that tech vendors that take the time to learn the business that is health care, and commit themselves to improving the physician-patient relationship…will do just fine.

 The Take Away…

The physician-patient relationship remains paramount for us patients.  Yes there are problems…yes physicians and patient need to learn to do a better job communicating with one another.  But when everything is said and done…when the chips are down…we don’t want to be forced to diagnose and treat ourselves.  We want to be able to see and talk with our doctor when we want.  And honoring the patient’s perspective after all is what patient-centered care is all about right?

And oh by the way…we still want the convenience of being able to go online to schedule an appointment and check out lab tests.

That’s my opinion…what’s yours?

Sources:

Squeezing out the doctor -The role of physicians at the center of health care is under pressure.  The Economist. June 2012.

Could mobile apps replace doctors?  KevinMD.com

 

Improving The Way Doctors And Patients Communicate – A Silver Bullet For Fixing What’s Wrong With Health Care?

Sometimes a picture is worth a thousand words…

Why It’s So Important For Physicians To Listen – The Patient’s Perspective

A recent qualitative study (structured interviews) of patients conducted at       McGill University School of Medicine underscores the importance of listening in physician-patient interactions.   In this study, patients were asked to identify the qualities of a good physician.   The following is a typical patient response:

“A good physician is somebody who will listen to what the problem is and explain to you what it is and what is being done.’’

When people were asked why listening by the physician was so important, researchers discovered three important themes that have apply to every provider today.

Theme #1 – Respondents (people/patients) believed that listening was essential if the physician was to arrive at the right (and credible) diagnosis. 

Representative Comments:

• ‘Physicians “should trust the person in front of them and hear what they’re saying. . .because I know my body better than anybody else.“

• ‘‘Listen to what they [patients] have to say; not just what other people wrote about them in the doctor’s notes.

• ‘‘[If] I feel that I haven’t had enough time with you to tell you exactly what my story is, even when you give me a prescription I’m going to say, ‘Really? Is this prescription right for me and for my illness? Or [is it] going to give me more complications?’. . .and I think sometimes that’s why you find patients will take it for 1–2 days and after that they forget about it, because they say, ‘He didn’t hear what I had to say about this pain.

Theme #2 – Listening is healing and therapeutic.

For years researchers have written about the therapeutic value of strong physician-patient communications.    Turns out patients recognize the same benefits.  For example,  a physician who listens and “validates the patient’s perspective or expresses empathy may help a patient experience improved psychological well-being—fewer negative emotions (e.g., fear, anxiety) and more positive ones (e.g., hope, optimism, and self-worth) “

Representative Comments:

• ‘‘If a doctor doesn’t respect the patient, or doesn’t listen, the patient feels more worried and unsettled and this has an impact on their health.’’

• ‘‘Sometimes, listening to a person will cure half of your problem. . . like it takes two or three months to get an appointment. In those two–three months, you make your problem worse by thinking, ‘Oh maybe it is this, or that or that or that.’

• ‘‘if you listen to the patient and give the patient respect, what you are actually doing is helping that person take responsibility for their own health – that they are also in control of the healing process and are involved somehow. So the doctor has to not take all the power away from the patient.’’

For related patient (and physician thoughts) on this subject, check the following story and COMMENTS on CNN

Theme #3 – Listening can foster and strengthen the doctor–patient relationship if it is authentic

Representative Comments:

• ‘‘I want the doctor. . . to have empathy and to listen and to look into my eyes and to make me feel that for that short moment…you are hearing me, you are there for me, and you give me that sense that I matter

• ‘‘It still makes me angry when I think about how I was. . .how I sort of felt ridiculed for my looking into alternative options.’’

• I think they [physicians] should listen out of respect. Sometimes I think that caring and compassion can be patronizing, if it is insincere. You can still be arrogant and project this caring and compassionate facade.

Take Aways

Over all I was struck by the following as I read this study…particularly the respondent comments.

• People/patients in the study clearly recognized the link between effective listening (by providers) and quality of care.    Too often providers are quick to discount the accuracy or validity of patient perceptions of quality whether in the hospital or doctor’s office.  The comments reflected in this study suggest otherwise.

• Listen skills are essential to patient engagement and positive patient experiences.   To be engaging, providers must be “relevant” from the patient’s perspective.   To be relevant, providers must solicit and listen to what patients want to tell them.

• If listening is therapeutic and has the power to heal…does this mean that physicians who 1) do not solicit or 2)  ignore or gloss over patient input are not practicing at the “standard of care?”  Given that poor physician-patient communications is a leading cause of malpractice suits it would seem so.

• Health care providers (physicians and hospitals) would do well routinely do a “deep dive” into their patient satisfaction research to get a true and realistic handle on the quality of their provider’s listening and other communication skills.   I am not sure that the standard HCAPS and CHAPS survey instruments  probe physician-patient communications far enough.

That’s what I think.  What’s your opinion?

Source:

R. L. Street et al.   How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling, 2009. 74(3), 295-301.

J.  Jagosh et al.  Patient Education and Counseling.  85 (2011) 369–374