Wednesday, November 21, 2018

Sonoma Medicine

The magazine of the Sonoma County Medical Association

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Improving Physicians’ Communication Skills

Mark Klein, MD

We physicians spend a lifetime communicating with our patients—some 120,000 to 160,000 medical interviews during the course of an average physician’s career.1 The numbers are staggering to think about, not only for the amount of time spent and the number of people encountered, but also for the importance of these office visits in providing effective care. How we communicate—first understanding, then seeking to be understood—plays a large part in our patients’ satisfaction, compliance with treatment plans, and outcomes.

The medical interview has been described as “the most powerful, … sensitive, and versatile instrument available to the physician.”2 This view is much different from one that sees the physician as primarily a deliverer of technology (or, in some cases, an obstacle to its delivery). Between these extremes, I think most of us believe our office visits are important, but we find that time constrains us from putting all we can into them, or getting all we can out of them. Yet, these encounters shape the texture of our daily lives.

Physician-patient communication has been studied extensively over the past several years, in journals as diverse as JAMA, Surgery, and Social Science and Medicine.3-5 Sixteen out of 21 studies yielded positive correlations between effective communication and good patient health outcomes.6 One study found that educating, counseling, and negotiating during visits predicted patient satisfaction, but doing exams or tests or providing medications did not.7According to a public opinion survey, the most important attributes of a physician are:

  • A caring attitude and good communication skills (85% of participants).
  • Ability to explain complicated medical procedures (77%).
  • Good listening skills (76%).8

Physician satisfaction is more difficult to assess. Compensation, recognition, control over one’s daily schedule, and many other factors affect satisfaction; but when primary care physicians were surveyed, their overall satisfaction most closely related to the quality of their physician-patient relationships.9

We know that a solid fund of knowledge, diagnostic acumen, therapeutic skill, and experience enable us to practice the science of medicine. But the art of medicine requires that we understand the context in which illness occurs in our patients’ lives: that is, the impact illness has on them, the expectations they have, and what they are willing and able to do to make things better.

Sometimes patients tell us the context (“I sprained my knee, and it’s not getting better—I’ll do whatever I need to play tennis again”). But sometimes we have to look a little deeper:

Patient: I’ve already taken two different antibiotics. They helped a little, but I still have this ache in my groin. It’s not bad, but it won’t go away.

Doctor: What are you most worried about with this pain?

Patient: Can I give this disease to my wife? or My dad died of prostate cancer. or A guy I knew in college had testicular cancer.

We don’t know the context until we draw it out. The context tells us whether to revisit the sexual history in more detail, whether further testing may help, or whether a brief exam, simple education, and a little empathy may settle the issue.

In short, improving communication skills can sharpen diagnostic accuracy, build trust, and help determine which treatment is most likely to succeed for each individual.

Communication style is not who we are. Instead, it is a way of expressing—of bringing out—who we are. We can learn to develop different communication skills or strengthen the ones we already possess.

Communication skills are part of the curricula of many medical schools, and there are several courses available for practicing clinicians (e.g., American Academy on Physician and Patient; Bayer Institute for Health Care Communication). The example with which I am most familiar is the Four Habits model developed by Drs. Terry Stein and Richard Frankel for Kaiser.10

The term “habit” is used to denote an organized way of thinking and acting during a clinical encounter. The four habits divide the office visit into four parts, each with its own goal:

Invest in the Beginning

When you invest in the beginning, you create rapport quickly by:

  • Introducing yourself to everyone in the room.
  • Acknowledging the wait, if any.
  • Making a social comment or asking a nonmedical question to put the patient at ease.
  • Conveying some knowledge of the patient’s history or your preparation for the appointment (“So Dr. Jones asked you to see me“ or “I understand you’ve been having a problem with your urination”).
  • Eliciting the patient’s concerns with open-ended questions (“Is there anything else?”). Whether the patient has one problem or a laundry list, they should be stated early.
  • Planning the visit with the patient—even a 10-minute visit (“I’d like to ask you a few more questions, then we’ll do a brief examination and go over the options of where to go from here. Does that sound okay?”).
  • Prioritizing when necessary.

Elicit the Patient’s Perspective 
By eliciting the patient’s perspective, you facilitate the effective exchange of information by:

  • Identifying the context (“What worries you most about this problem?” or “How is this affecting your work? Your family life?”).
  • Eliciting specific requests (“How were you hoping I could help you most today?”). Sometimes a patient may think a specific test or treatment may help; sometimes he or she just wants to be heard.
  • Considering cross-cultural factors (“Are these dietary recommendations consistent with your religious beliefs?”).

Demonstrate Empathy
Look for an opportunity to make a brief empathic comment. If you’re not sure, name a likely emotion (“That sounds pretty scary”). If you don’t guess right, the patient will tell you the emotion once he or she senses you are willing to hear it. Sometimes a facial expression, a pause, or a touch may be helpful in conveying your empathy.

Invest in the End
You can increase the likelihood of treatment adherence and positive health outcomes by:

  • Framing your diagnosis in terms of the patient’s original concerns and, if possible, using his or her own language.
  • Explaining the rationale for tests and treatments.
  • Explaining options and listening for the patient’s preferences.
  • Checking for comprehension and assessing the patient’s willingness to commit to the plan.
  • Setting limits respectfully (“I can understand how getting that test makes sense to you, but since the results won’t help in diagnosis or treat your symptoms, I suggest we consider this one instead”).
  • Asking for final questions.
  • Assuring the patient of follow-up (“We’ll work on this together”).

Asking patients to tell us all their concerns at the beginning of the visit can be a little scary, especially when we are running behind in the office. In a classic study, however, most patients took less than a minute to express their concerns fully (if not interrupted), and no patient took more than two and a half minutes. Certainly we can all think of patients who could go on for days if left to their own devices, and direction is needed then. But these are usually rare, and in most cases we can safely let the patient speak for more than the 18 seconds the physicians in the study allowed before interrupting.11

The Four Habits course—in which I have been a participant, a facilitator, and eventually a teacher—begins with didactic presentations of the four habits, followed by videos of physicians inter-viewing actor “patients.” The video physicians present a range of communication skills from poor to excellent, and the participants discuss how they might handle the modeled situations differently. Plenty of time is allotted to practicing different approaches, with facilitators and participants playing out different encounters. Sometimes a facilitator acts the part of a particularly troublesome patient in a physician’s practice.

The classes often begin with some trepidation, but they quickly become fun. Perhaps the most important event is the sharing of wisdom. I’ve never taught a Four Habits course in which I didn’t learn something valuable.

Given the plethora of communications courses offered across the country, doctors naturally wonder how effective the courses are. One-day courses seem to help physicians more confidently manage “problem” patient encounters (e.g., angry patients, drug- seeking patients, “clingy” patients).12 Improvement with the full spectrum of patients in a practice (as measured by patient satisfaction surveys) is more likely with a several-day course followed by periodic feedback from patient surveys, self-assessment tools, and/or refresher sessions.3,6,13

In my experience, the response to a one-day course, a several-day course, a noon conference, or personal coaching is very much “operator dependent.” The physician’s success depends on mo-tivation, sincerity, and a sustained willingness to believe in positive change.

Two further questions are often asked:

  • Can we change our communication style but still remain authentic in ourselves?
  • Does improving our communication skills actually improve the health outcomes of our patients?

If we try to use the various communication skills as “tricks” to improve scores on patient surveys or to construct an acceptable “mask” for our public, we won’t feel authentic, and our patients will sense the changes as insincere and manipulative. But if we can use these same skills as springboards for connecting with what is already in us—to bring it out more fully—we become more authentic in expressing ourselves. We translate what we learn into our own experience and make it our own.

Translating these skills into our own experience builds a sense of trust in our therapeutic relationships. In turn, this trust can make a difference for a patient in following through with a chosen therapy or relying on our opinion about the validity of tests or Internet research.

In a recent editorial, Dr. Abraham Bergman observes, “The ability to listen is arguably the most important clinical skill in medicine.”14 I wouldn’t always have agreed, but I first became profoundly interested in physician-patient communication after an experience with empathic listening.

I’m a urologist. A patient of mine, whom I’ll call Lester, was wheelchair-bound from a neurologic problem that had also compromised the use of his hands and arms. I was following him for a related voiding problem and on this day thought he looked a little down.

Lester had been a horse trainer until the last few years, and we shared a love of horses. I asked him whether he still went out to look at horses, to be around them. He sighed, looked down at his uncooperative arms, and said, “No, I’m pretty worthless now.” I looked down at my own hands and tried to feel what it would be like to be unable to use them. When I looked up at Lester again, it was as if I saw him for the first time, and I knew he was thinking of killing himself.

I asked him about it, and he said, yes, he was. That moment of empathy allowed me to see Lester fully; and I think it was what allowed him to accept my help.

On less dramatic occasions, patients still benefit from “knowing you really care how it is” for them. Sometimes they need to know we’ve “gotten it” before they are ready to listen to advice about test or treatment options. As Stephen Covey writes, “Unless you’re influenced by my uniqueness, I’m not going to be influenced by your advice.”15

When patients do feel heard, when we can reflect back to them their deepest concerns, something relaxes in them, and they are ready to move on.

When I work with physicians in my capacity as a “communications consultant,” I realize there is nothing I can give them that they don’t already have. Every physician I have ever met, without exception, has an inner core of “practical idealism.” Communications courses, exercises, and techniques may serve as a reminder, a catalyst, a stimulus, an inspiration, or an irritant—it doesn’t matter. What matters is whether the physician can pick up these tools, tap into what is inside, and bring it out in his or her own unique way.

I would like to express my gratitude and indebtedness to Drs. Terry Stein and Robert Tull for their teaching, humor, and fellowship.


  1. M Lipkin et al, “Performing the interview,” in M Lipkin et al, eds, The Medical Interview: Clinical Care Education and Research, Springer-Verlag (1995).
  2. G Engel, “How much longer must medicine’s science be bound by a 17th-century world view?” in K White, ed, The Task of Medicine: Dialog at Wickenburg, Kaiser Family Foundation (l988).
  3. R Squire, “A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships,” Soc Sci and Med, 30;3:325-339 (1990).
  4. W Branch and T Malik, “Using ‘windows of opportunities’ in brief interviews to understand patients’ concerns,”JAMA, 269;13:1667-1668 (1993).
  5. W Levinson and N Chaumeton, “Communication between surgeons and patients in routine office visits,” Surgery, 125:127-34 (1999).
  6. M Stewart, “Effective physician-patient communication and health outcomes: a review,” Canadian Med Assoc J, 152:1423-1433 (1995).
  7. D Brody et al, “Relationship between patients’ satisfaction with their physicians and perception about interventions they devised and received,” Med Care, 27:1027-1035 (1989).
  8. Am Assoc Medical Colleges, Public opinion research: Issues facing medical schools and teaching hospitals (June 1999).
  9. A Suchman et al, “Physician satisfaction with primary care office visits,”Med Care, 31:1083-1092 (1993).
  10. R Frankel and T Stein, “Getting the most out of the clinical encounter: the four habits model,” Permanente J, 3;3:79-88 (1999).
  11. H Beckman and R Frankel, “Effect of physician behavior on collection of data,” Ann Intern Med, 101:692-696 (1984).
  12. T Stein and J Kwan, “Thriving in a busy practice: physician-patient communication training,” Eff Clin Prac, 2;2:63-70 (1999).
  13. J Brown et al, “Effect of clinician communication skills training on patient satisfaction: a randomized, controlled trial,” Ann Int Med, 131;11:822-829 (1999).
  14. A Bergman, “Learning to listen,” Arch Ped and Adol Med, 157;5:414-415 (2003).
  15. S Covey, Seven habits of highly effective people, Free Press (1989).

Dr. Klein is a urologist and a physician-patient communications consultant at Kaiser Santa Rosa.

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