Increasingly, lower extremity practitioners are realizing the clinical importance of patient communication. They’re also starting to realize that effective communication requires more than just using the right words.
By Hank Black
The clinician with the “doctor knows best” attitude, the one with the indecipherable medical jargon, the “cold fish” who cannot look patients in the eye and erects an invisible barrier to questions or opinions. They are among the practitioners whose inability to communicate adequately with patients can lead to low satisfaction scores, loss of patients to competitors, and, most important, poor clinical outcomes. That’s why, increasingly, lower extremity practitioners are exploring ways to improve their patient communication skills.
The recognition of the critical importance of provider-patient communication took flight with the emergence in recent decades of patient-centered concepts of care, and is given added weight by the incorporation of patient satisfaction scores in determining compensation from Medicare and other payers.
A patient-centered relationship requires that the patient be involved throughout the treatment process1 via a structured model of interaction that includes an explanation of the disorder, treatment goals, and clinical evidence, all delivered by the practitioner in nonemotional terms and without medical jargon.2,3 The provider must apply clinical skills with genuine personal engagement in addition to using the right words.4
“A patient is, first, a person, and I want to engage with them just how I would with any person,” said Grace Torres-Hodges, DPM, who is in private practice in Pensacola, FL. “I always try to remember that as a healthcare professional in a world of computers, automation, and regulation, good communication technique is something I can control in order to gain the trust of my patient. If we forget to remember that the foot with the diabetic ulcer or that ankle sprain is connected to a person, we neglect the most important part of the entire visit—establishing the relationship between the doctor and the patient.”
Evidence continues to accumulate suggesting that patient-centered communication has a positive impact on patient satisfaction, treatment adherence, and self-management of diabetes and other chronic diseases.5-8 Clinicians for whom that’s not incentive enough might also consider that breakdowns in communication make it more likely that patients will initiate malpractice actions.9
Improved communication can begin with small gestures, sometimes nonverbal. Torres-Hodges starts with a knock on the exam room door, a self-introduction, and a moment of touch by shaking hands.
“You have to earn their trust through honesty,” she said. “Eye contact is important, then listen and observe. Hear how they are talking, acknowledge their words with a nod. Don’t be afraid to smile, and when you talk, speak slowly and expect the same from your staff. It takes consistency for it to become a habit, but almost anyone can do it.”
Positivity is a plus for achieving a bond with patients. Morin et al showed a positive style of communication helped decrease early clubfoot recurrence.10 And a study of patients with knee osteoarthritis (OA) found patients whose provider communicated a high expectation of reduced pain following acupuncture or sham acupuncture had less pain than patients whose provider was neutral about pain relief.11 A secondary analysis concluded the provider’s style of communication heightened the benefit of treatment, mediated by patient self-efficacy. 12
By the same token, negative emotional language should be avoided, according to researcher Jaap J. van Netten, PhD, who has examined how poor communication can discourage patients from wearing prescribed orthopedic footwear.13 Persons with rheumatoid arthritis, for example, may feel guilt or shame if you refer to their foot as being “difficult,” said van Netten, a senior research fellow at Queensland University of Technology’s School of Clinical Sciences in Brisbane, Australia.
“Negative communication can destroy a relationship and diminish the chance for the client to have a role in the process,” he said.
Despite recognition of their importance, there’s still little inclusion of communication skills in educational curricula for healthcare professionals.
“There are a limited number of education hours and everybody is competing for them,” according to Michael D. VanPelt, DPM, FACFAS, assistant professor of surgery at the University of Texas Southwestern Medical Center in Dallas.
Despite the acknowledged importance of good communication, however, most clinicians never get feedback about their interactions with patients and typically have been left to learn communication skills on their own.”14
But there is some evidence this may be changing. In August, the National Surgical Patient Safety Summit (NSPSS) called for standardized assessment of surgeons’ competence with regard to effective communication with patients and others.15 The recommendations stated that nontechnical skills such as patient communication, including patient-centered shared decision-making, are necessary for optimal patient safety in the perioperative period.
The American Academy of Orthopaedic Surgeons and the American College of Surgeons sponsored the summit, and its recommendations will be used to create National Surgical Patient Safety Standards and surgical safety education curriculum proposals.
The event emphasized the need for undergraduate medical education to include the teaching of communication skills that would be reinforced in residency programs with simulation training and appropriate feedback, and additionally backed by continuing education throughout a clinician’s career. It also recommended that knowledge of the shared decision-making process be a requirement for surgical residency programs and surgeon credentialing.
Skills for residents
With funding from the Hartford Foundation, the Hospital for Special Surgery (HSS) in New York City started a program in 2009 designed to improve the communication skills of orthopedic surgery residents when relating to older adults.
“By 2030, twenty percent of the US population will be over sixty-five years old, so it is vital for physicians to develop effective and sensitive communication skills during their residency training to promote positive outcomes with older adults who often perceive themselves as stigmatized and powerless in healthcare settings,” said program director Linda Roberts, LCSW.
The program is structured so small groups of third-year residents, with the guidance of a social worker who specializes in aging issues, are made conscious of the needs of older adults as well as long-standing myths about this population. Many young doctors think all older patients are cranky and can’t or won’t learn anything new, Roberts said. In the sessions, residents are taught effective communication skills to use with those patients, including eye contact, the use of open-ended questions, and asking patients to repeat back what they heard the doctor say.
In the program’s second phase, the residents present a musculoskeletal topic to about 25 adults aged 65 years and older. Following the presentation, they interact more personally with a smaller group of seniors by demonstrating exercises.
“We observe the sessions and give feedback,” Roberts said. “The idea is to sensitize residents to the needs of older adults and to teach ways to gain the trust of the patient so they can form a partnership that allows for shared decision-making and management of patient expectations.”
From 2009 to 2015, 64 residents went through the program. Surveys administered before and after training showed a significant increase in residents’ mean knowledge of aging and older people and in their attitude toward older adults, as well as a decrease in their anxiety level when talking with older adults.
Charles Cornell, MD, professor and clinical director of the Department of Orthopedic Surgery at HSS, founded the program. Cornell sees communicating better with older adults as critical to the future of his specialty as the US population ages.
“Communication has been overlooked as a necessary skill in orthopedic postgraduate education,” Cornell said. “I have practiced alongside geriatricians who said conversations with elderly patients are often not straightforward. They may interpret what you say differently than what you intended. The word ‘stiffness,’ for example: To me, stiffness of the knee is a direct measure of how much the joint moves, but to the patient, it means an uncomfortable feeling.”
For the residents, the program is an exercise in self-awareness of their communication abilities, giving them a basis from which to assess their skills going forward, he said.
“Interviewing the patient is one of our most basic tools, and if the patient is not following what the doctor is saying, those tools are not being used correctly,” Cornell said.
Empathy in providers
Clinician empathy and emotional management ability have been linked to higher patient satisfaction scores.16 Studies have suggested practitioners’ ability to manage their own and others’ emotions can help improve empathy, relationships with patients, and teamwork and communication skills.17
If providers are short on empathy, some suggest, they might at least turn to professionalism to benefit their relationships with patients and boost patient satisfaction scores. A widely quoted 2008 article from The New England Journal of Medicine18 called for increased medical school and postgraduate training in “etiquette-based medicine” that would at least result in a respectful and attentive practitioner, if not a compassionate one. The author suggested using a checklist for clinician etiquette would systematically teach good manners and emphasize not how providers feel, but only how they behave.
For a health professional visiting a hospitalized patient, for example, the six items on the checklist are:
- Ask permission to enter the patient’s room;
- Introduce yourself;
- Shake hands;
- Sit down;
- Explain your role on the team; and
- Ask how the patient is feeling about being in the hospital.
Two 2013 observational studies of how often interns and hospitalists completed the checklist showed the practice had not caught on: In almost a third of 1000 patient encounters, the doctors failed to do a single one of them.19,20 It may be no wonder, then, that fewer than 25% of hospital patients can name their doctor.21
Beyond core skills
van Netten, lead author of a recent clinical note on the topic,13 said, “A shoe or brace may be ‘perfectly’ built or modified, but it is only effective if worn. As such, patients have an increased role in their own care, and patient perspective must be sought by the clinician.”
When patients believe their provider hasn’t understood them properly, they’re less likely to adhere to the footwear or device as necessary, he said.
“Orthotists and prosthetists might master the core skills necessary to produce therapeutic footwear, but we also need to learn techniques of communication,” van Netten said.
His group described two techniques for improving communication, person-centered communication, and shared decision-making.
“It’s most important,” he said, “to elicit the patient’s attitudes about their condition, and that requires making a personal connection by building a relationship in which they feel you are listening to them and understanding what they say. It’s important, for example, to repeat back to the patient a summary of what you hear them saying, and for the patient to relate back to you what they are hearing you say.”
Shared decision-making as part of the structured consultation, he said, means the practitioner and the patient are working together toward the best choices available for care by jointly negotiating and agreeing on treatment plans.
“In providing therapeutic footwear,” van Netten said, “the process should not proceed until the patient confirms that they are actively choosing the footwear, rather than passively accepting it but likely not wearing it.”
Clear language is also a helpful element in communicating with a patient. In one study describing a patient who was receiving prescribed footwear, the patient showed confusion and said, “The doctor seriously just kept talking, saying it is to protect your feet. I was left wondering, to protect them from what?”22
“This illustrates inaccurate assumptions and poor communication, both of which put the patient’s health at risk,”said van Netten.
Practitioners may use simple visual aids to help with communication.
“For example, to describe the fact that fifteen percent of people with diabetes will experience a foot ulcer, you could show a picture of one hundred people, with fifteen of them colored differently,” he said.
Communication tool kit
Communication aids can also improve practitioner-patient discussions on healthy footwear, as Farndon et al described earlier this year.23 The British group developed an online tool kit to assist in identifying and addressing barriers to patient acceptance of suitable footwear.
Torres-Hodges frequently uses visual communication aids in her practice to help explain a pathology and a treatment plan.
“I have handouts to augment the clinical conversation,” she said. “For instance, if a patient doesn’t understand what a bunion is, I have charts to illustrate that, or I draw it myself. It also helps with understanding if I explain concepts such as a biomechanical concept like pronation, by comparing it to something the patient is more familiar with, such as an alignment problem with their car, that if continued will lead to serious problems down the road.”
That analogy may help an adult understand the condition, but a pediatric patient may relate better with an example from a popular TV show or video game, Torres-Hodges said.
“That puts it on their level—though admittedly, teens and tweens are sometimes the hardest to develop a relationship with,” she said. “With them, I always start the conversation in the room with them first, then introduce myself to their parent.”
If a patient doesn’t seem to completely understand an explanation, Torres-Hodges asks if there is an accompanying relative or friend who can serve as a second set of ears. Alternatively, she emails important information to the patient and caregiver.
“It’s so important that the patient understands and participates in the decisions,” she said. “You’re getting them involved in their own healthcare. It’s our responsibility to advise and guide them—to make sure someone with plantar fasciitis, for example, understands that it’s necessary to stretch before taking the first step from bed in the morning, wear supportive shoes, and take their anti-inflammatory medication. If I’m not conveying the message understandably, I haven’t done my job. We have to engage, bond, and maintain open a line of communication with those who entrust us with their care.”
Patient-centered communication has been associated with closer adherence to treatment recommendations and improved health status and patient and provider satisfaction.24-27 However, research suggests that outcomes from a clinic visit may be affected more by the patients’ perception of the quality of the encounter than by the providers’ visible behaviors.28-30
A recent study conducted at Baylor College of Medicine in Houston, TX, found patients’ perception of the quality of providers’ communication quality is influenced by sociodemographic and health-related characteristics, including patients’ healthcare access, age, race, and education.31 For this study, the researchers analyzed data from the Health Information National Trends Survey (HINTS), a nationally representative survey administered by the National Cancer Institute. HINTS asks patients how often their health professional gave them the opportunity to ask questions, addressed the patient’s feelings, involved them in decisions, gave clear explanations, allowed sufficient time, helped with uncertainty, and made sure the patient understood the next steps.32
Based on their analysis of almost 8500 respondents from the 2011-2013 iterations of HINTS, the results indicated most people in the US have positive perceptions of the quality of their providers’ communication. Respondents aged 65 years and older, those who had had cancer, retirees, homemakers, students, and those in excellent/very good health tended to rate the quality of their providers’ communication positively; those who were unemployed, in fair/poor health, and who didn’t have a regular healthcare provider or health insurance gave their providers’ communication lower ratings.
Also interesting were the findings that respondents with at least a college degree were more likely to rate the quality of their provider’s communication as poor, compared with those who had less than a high school education. Unexpectedly, they found non-Hispanic black respondents were more likely to report that their providers always allowed time for questions and made sure that they understood what would happen next.
“Our study yields very important results about associated characteristics of perceptions and of communication between patients and providers,” said Kiara K. Spooner, DrPH, MPH, CHES, the study’s lead author and a research fellow in the college’s Department of Family and Community Medicine. “However, we did not have data on patients’ rationale for their perceptions. We hope to one day extend our research on patient-provider communication by qualitatively examining it from the perspective of both the providers and patients. This may help us gain a better understanding of patient-provider communication, as well as how it can be improved to achieve a higher quality of care.”
VanPelt, the Dallas-based foot and ankle surgeon, sees a lot of barriers to good communication, including growing diversity among patients with regard to language and culture, an increase in the number of advanced professionals involved in patients’ care, use of computers while interviewing, and the pressures for efficiency that leave less time for each clinician-patient encounter.
“But it’s the job of the doctor to educate the patient and build a trust that will lead to a partnership that can develop and follow a treatment plan,” VanPelt said. “Gaining that trust through shared decision-making or other techniques is vital. Patients are more interested today in researching their own condition, and encouraging that allows the patient to participate more fully in the conversation.”
Hank Black is a freelance writer in Birmingham, AL.
- Levit L, Balogh E, Nass S, et al, eds. Patient-centered communication and shared decision making. In: Delivering high-quality cancer care: charting a new course for a system in crisis. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population; Board on Health Care Services; Institute of Medicine, 2013.
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- De Haes H, Bensing J. Endpoints in medical communication research, proposing a framework of functions and outcomes. Patient Educ Couns 2009;74(3):287-294.
- Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA 2005;293(9):1100-1106.
- Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49(9):796-804.
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- Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277(7):553-559.
- Morin ML, Hoopes DM, Szalay EA. Positive communication paradigm decreases early recurrence in clubfoot treatment. J Pediatr Orthop 2014;34(2):219-222.
- Suarez-Almazor ME, Looney C, Liu Y, et al. A randomized controlled trial of acupuncture for osteoarthritis of the knee: effects of patient-provider communication. Arthritis Care Res 2010;62(9):1229-1236.
- Hsiao-Wei LG, Balasubramanyam AS, Barbo A, et al. Link between positive clinician-conveyed expectations of treatment effect and pain reduction in knee osteoarthritis, mediated by patient self-efficiency. Arthritis Care Res 2016;68(7):952-957.
- van Netten JJ, Francis A, Morphet A, et al. Communication techniques for improved acceptance and adherence with therapeutic footwear. Prosthet Orthot Int 2016 Jun 8. [Epub ahead of print]
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- National Surgical Patient Safety Summit. Nontechnical skills matter too. American Academy of Orthopaedic Surgeons. http://newsroom.aaos.org/media-resources/news/surgical-safety-patients.htm. Published August 5, 2016. Accessed August 24, 2016.
- Weng, HC, Steed JF, Yu SW, et al. The effect of surgeon empathy and emotional intelligence on patient satisfaction. Adv Health Sci Educ Theory Pract 2011;16(5):591-600.
- Arora S, Ashrafian H, Davis R, et al. Emotional intelligence in medicine: a systematic review through the context of the ACGME competencies. Med Educ 2010;44(8):749-764.
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- van Netten JJ, Dijkstra PU, Geertzen JHB, Postema K. What influences a patient’s decision to use custom-made orthopedic shoes? Use of custom-made orthopedic shoes. BMC Musculoskelet Disord 2012;13:92.
- Farndon L, Robinson V, Nicholls E, et al. If the shoe fits: development of an online tool to aid practitioner/patient discussions about “healthy footwear.” J Foot Ankle Res 2016;9:17.
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