Key to positive outcomes
by Jason Kraus
In today’s challenging healthcare environment, the time pressures to perform all the clinical tasks required for patient care may be causing practitioners to sacrifice one of their most important tools: effective communications.
Communication is the foundation of all human relationships, but it takes on even greater importance in healing relationships. The unique nature of healthcare puts an even greater emphasis on trust and empathy than on other types of social interaction. Positive physician-patient relationships are critical to the healing process and have been shown to directly impact patient outcomes.
Patient satisfaction and treatment compliance were shown by Kim and colleagues1 to relate directly to a physician’s empathetic behavior. The study surveyed 550 Korean patients and concluded that “affective empathy “ (the ability to relate to the feelings of another person) and “sense of partnership” had the strongest impact on patient satisfaction and compliance. By contrast, “cognitive empathy” (the ability to understand another person’s feelings) and “information sharing” had little effect on patient’s satisfaction and a negative effect on compliance.
Of the key determinants of satisfactory healthcare, communication skills rank a close second only to clinical skills in importance. At least, that is what your patients think, as reported in a 1996 study.2 In the same study, physicians ranked communication skills sixth in importance. This perception gap speaks loudly to the quality of practitioner-patient communications.
Effective communication not only plays a critical role in the proper treatment of patients, it also is a key component in making the proper diagnosis and treatment plan design. In order for physicians to make a proper diagnosis, they need to develop superior interviewing skills. The empirical data collected from a physical evaluation need to be correlated with information derived from effective interviews regarding the patient’s history, perceptions and other emotional characteristics.
In addition, the most carefully crafted, well intentioned treatment protocol will have no impact on your patient’s health if the patient becomes non-compliant with any part of the care plan. Practitioners’ ability to positively influence their patients to make the most appropriate decisions and behavior changes is a critical factor for successful outcomes. Since many diagnoses may lead to an array of different treatment options, successful plans need to take into account the patient’s goals and objectives, temperament, willingness to modify behaviors and the degree to which they may want to be involved in the decision making. The practitioner’s understanding of these variables depends on effective communication skills.
Practice makes proficient
Not unlike your clinical skills, the ability to develop and enhance effective communications proficiency requires careful study and extensive practice. While it is true that some people have an innate ability to communicate in an influential and effective manner, most do not. Like most skills, communication is something that can be developed and enhanced with proper education and commitment.
If you are willing to accept the definition of effective communication as “shared understanding,” then developing your listening skills is as important as your speech skills. The practitioner and patient each have to actively listen to the other and then share their understanding, feelings and beliefs. Only in this way can one achieve a shared understanding.
It is very helpful to first determine what your patients already know, or think they know, before discussing their prognosis and your proposed management plan. Many times, patients have already communicated with other practitioners, or have done research themselves, prior to placing themselves in your care. To avoid confusion and possibly negatively coloring their perceptions prior to new information being given, always find out what they know.
Next try to find out what they want to know. Not all patients want the same level of detail in the information they receive about their condition or treatment. This is not always apparent and may only be determined as the discussion unfolds. It may require direct questions, strategic silences and frequent checks on your part to determine if the information you’re presenting being comprehended. The nature of the questions that patients ask will often illustrate their understanding and need for detail. Continuing to provide further information is not always the best approach.
Once you have a thorough understanding of what your patients know and what they want to know, you can begin to present commentary on their diagnosis, prognosis and treatment plan. An emotional connection to your patient has great impact on their ultimate satisfaction. As such, empathy is a basic caregiving skill that needs to be developed to help you recognize the directly or indirectly expressed emotions of your patients. Careful questioning of your patients can help to reveal “how they feel” (emotionally) in addition to “what they feel” (physically). Once identified, these emotions should be acknowledged and further explored. Do not ignore or minimize patient feelings. Practitioners who acknowledge these feelings are less likely to be viewed by their patients as uncaring .3
When you are ready to present information to your patients, your objective should be an acknowledged understanding of the cause of the problem, the most probable prognosis and the acceptance of a treatment plan with the attendant risks. To achieve these objectives, a dialogue needs to evolve with you directing the flow and content of the information. Your ability to properly convey information and elicit the desired response from your patient is entirely dependent on your delivery, both verbal and non-verbal.
In a study published in the Journal American Board of Family Practice in 2002, Beck and colleagues reviewed primary care-based research from a 25-year period to determine which verbal and nonverbal behaviors on the part of the physician during the medical encounter could be linked empirically with favorable patient outcomes.4 The list in Table 1 (adapted from Beck and colleagues) outlines the identified verbal and nonverbal behaviors shown to influence patients’ responses.
Although many of the behaviors identified in the Beck study had been identified in other basic communications research, it is worthy to note the statistical verification of the impact of patient outcomes in more than 25 years of published studies.
Beyond familiarizing yourself with Beck’s findings, effective patient communication also requires attention to:
Tone: Patients expect and want their caregivers to be confident. It is important to convey this sense of confidence in both your verbal and nonverbal communications. Your body language, including posture, eye contact and positioning all help establish the tone of the interaction. Verbally, the choice of words, volume and fluidity all help to convey a sense of confidence, or lack thereof.
Volume: Generally speaking, your volume should be slightly louder than normal conversational volume. This will accommodate patients who are hard of hearing without appearing aggressive or dominant to those with normal hearing.
Decisiveness: Choosing the right words to convey your sense of confidence and conviction is crucial. Physicians and other caregivers should avoid words of an equivocal nature. While you don’t want to make any false guarantees, it is very reassuring for patients to know that you have a high level of confidence in the plan you are recommending. Words like “maybe or perhaps” make patients unsure, while words like “essential or critical” convey the importance of your plan. Describing the successful outcomes that previous patients have had under similar circumstances also helps to build confidence.
Pace: Slow down! In general, practitioners present information more rapidly than patients can process it. It may not feel that way when you are speaking, but it is usually the case. This is a result of the practitioner’s familiarity with the subject matter and the fluidity that develops after presenting the same information time and time again. To patients, however, it is generally all new, somewhat technical and usually the cause of some anxiety. These factors contribute to their inability to process what is being said quickly. It is helpful to pause periodically during the presentation and assess the patient’s understanding. Sometimes a nonverbal response will be enough. Other times, questions should be asked to determine the level of comprehension.
Association: An effective technique to assist patient understanding of a complex or unfamiliar subject is to associate it with something that is well understood. Lower extremity practitioners might use the example of eyeglasses as a way to understand the need for foot orthotics. Patients might have difficulty understanding the underlying biomechanical problem that is causing their feet to hurt, but they can grasp the idea of using orthotics to treat the pain in the same way that lenses are use to correct an underlying weakness in the eyes.
Contrast: To assist patients with making treatment decisions, it can be useful to compare and contrast the likely outcomes of various choices, and describing the consequences of partial or complete noncompliance. However, practitioners do need to be careful when using contrast to make their point. You do not want to frighten patients into compliance unless the likely outcome of a decision to refuse your treatment plan is truly frightening.
Honesty: Although practitioners always want to be sensitive and caring, it is important to convey the facts as you know them. Euphemisms should be avoided, even though they may seem to lessen the negative impact of what is being communicated. A sense of hopefulness is a better way to soften a difficult truth.
Published and anecdotal data strongly suggest that improved practitioner-patient relationships built upon effective communication can lead to better overall clinical outcomes. These skills are not formed simply by completing a degree or residency program. Like clinical skills, communication skills are strengthened over time and with ongoing practice.
Jason Kraus is executive vice president of Langer Biomechanics and former partner in the practice consulting firm SOS Healthcare Management Solutions.
1. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof 2004; 27: 237-251.
2. Laine C, Davidoff F, Lewis CE, et al. Important elements of outpatient care: a comparison of patients’ and physicians’ opinions. Ann Intern Med 1996;125(8):640–645.
3. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA 1997;277(8):283-287.
4. Beck RS, Daughtridge R, Sloan PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract 2002;15(1):25-38.