Techniques for better physician-patient communication, patient outcomes and profitability.
In recent years, a great deal of attention has focused on HCAHPS scores and efforts to improve them. Unfortunately, it is easy to become mired in the measures of today’s healthcare world and lose focus of the true “why” behind efforts to improve the patient experience.
As physicians, what drives us is providing high quality care and improving clinical outcomes for our patients. Effective physician-patient communication is critically important to these efforts. Research has repeatedly shown there is a clear link between how well we communicate and patient outcomes.
Research has demonstrated the connection between better communication scores and improved patient adherence, lower readmission rates, improved mortality rates, lower malpractice risk and reduced cost per case. No other area of medical knowledge or technical skill has a greater impact on our patients.
In addition to the significant patient benefits, other advantages to improved communication with patients include improved physician job satisfaction, improved market share and reputation, and reduced medical errors and patient safety events. The best part is, better communication does NOT require more of the physician’s time nor additional costs.
But as physicians are pushed to be more productive and take on more responsibility, it’s human nature to get caught up in focusing on tasks, routines and job requirements. When that happens, communication can break down, and we can come across as less caring.
We need practice - and discipline - to get it right. Thankfully, like any medical procedure, good communication is something that can be taught, learned, assessed and improved. Here are nine strategies to help you refocus and enhance your patient interactions.
Your patients will draw their first impression of you within the first few seconds of your appointment, so having a practiced ritual is key. That ritual might include announcing your entrance, smiling and making eye contact. Proceed by addressing your patient by name, introducing yourself and offering a handshake or other appropriate touch. Acknowledge all visitors, sit down if possible and start the conversation with something nonmedical to establish rapport.
Once rapport has been established, elicit your patient’s expectations or goals and ensure there is an opportunity for all of his/her concerns to be shared. You can ask questions such as “What were you hoping we’d accomplish today?” and “Is there something else you’d like to talk about?” Once you have the patient’s agenda, summarize it by listing the issues. A 2011 studyshowed that collaborating on an up-front agenda did not increase visit length or the number of problems addressed per visit, but it did reduce the likelihood of patients bringing up new complaints or information late in the visit.
In our hectic environment, we are very task oriented. We walk around with our to-do lists flooding our brains. It’s no wonder that patients sometimes perceive us as talking at them instead of with them. When we practice being present, we encourage our patients to really engage with us in that moment. Consequently, the overall quality of the interaction is better, and we often hear things in a different way than when we are multitasking.
To practice being present, take a deep breath, quiet your racing mind and bring your attention to the moment. Turn your body so you are fully facing the patient, open your palms and lean forward, smile and maintain eye contact. Make the human being in front of you the only priority in that moment. Do not think about what you are going to do the rest of the day.
To communicate positive intent, use the words “for you” and “with you” as often as possible. Consider the difference: “I will call your family to update them” or “I will call your family for you to update them.” Similarly, see the difference between “I am here to make sure your care is coordinated” versus “I am here with you to make sure your care is coordinated.”
Also make a point to show appreciation. Say thank you, pay a compliment or express your thanks to your patients while they are going through a potentially difficult and challenging experience. For example, “Thank you for coming in today,” or “I appreciate all the effort you are investing in your recovery.” Patients often do not expect gratitude, and that makes expressing it particularly heartwarming.
Emotions and feelings are most likely to be conveyed and observed through nonverbal communication, e.g., facial expressions, tearing up, hand movements or foot tapping. If we pay attention to nonverbal communication, we increase our awareness of what messages we send to others and what messages others send to us. Research shows the most important nonverbal actions that help a patient feel connected to their clinician are eye contact and touch.
Open-ended questions elicit the patient’s story. That may include, “Tell me what happened,” “Go on,” or “Help me understand.” At the beginning of the visit, we cast a wide net of open-ended questions to build rapport, create a dialogue and gather information. As we begin to understand the problem or concern, we can shift to closed-ended questions to fill in the gaps in our understanding and construct a differential diagnosis.
Engaging with a patient means making a connection, first and foremost, as a person who is hearing the issue from someone else’s perspective. Empathy requires listening intently and focusing on the patient to understand their experience, particularly when feelings or emotions are expressed. Empathy provides the patient with validation of their experience and communicates, “I see you, I hear you, I understand you and I accept you.”
Empathy also saves time. It’s estimated that patients provide numerous clues about their concerns during conversations with physicians. When physicians miss those clues, patients tend to repeat themselves until they feel they have received the appropriate response. According to a study published in JAMA, primary care appointments with missed clues lasted 20.1 minutes compared to 17.6 minutes without missed clues, and in surgery visits those with missed clues were 14 minutes versus 12.5 minutes in length.
As you near the end of a visit, use the technique of ask-tell-ask to customize your message. Start by asking the patient to describe her understanding of the issue. Then tell the patient in straightforward language what you need to communicate: the bad news, treatment options or other information. A useful guideline is not to give more than three pieces of information at a time and avoid medical jargon. Finally, ask the patient if she understands. You may also consider asking the patient to restate what you said in her own words, which will give her a chance to ask any additional questions and indicates whether you need to elaborate or repeat anything.
Buy-in is a critical element of shared decision-making. It’s an invitation to the patient to collaborate in decision-making around the goals, options and plans for treatment. Patients who are consulted and engaged in their care report enhanced satisfaction, understanding and confidence in their physicians’ decisions.
Developing shared goals for treatment will also help motivate patients to adhere to the treatment plan. Through education and shared decision-making, patient anxiety decreases, there’s a stronger physician-patient partnership and more satisfying relationships for both parties.
How you end a visit is as important as your first impression. During the visit, it is helpful to continually orient the patient to the process of care. Think ahead to the conclusion of the visit. Summarize diagnosis, treatment and prognosis and then review next steps: future visits, phone calls, communication of test results and handoffs. End the visit with an expression of optimism or hope, such as, “I hope you will be feeling better soon,” or, “hang in there, we are making progress,” to bring the visit to a satisfying conclusion.
Considering all of the above tactics at once can seem overwhelming. I encourage you to pick two or three things and start them today. Then use those skills with everyone, everywhere until they become habits. From there, you can continue incorporating other tactics on your journey to better patient communication. Your patients will thank you, and you will derive more meaning from your work.
Rohit Uppal, MD, MBA, SFHM l is a practicing hospitalist and the Chief Clinical Officer, Hospitalist Services, for TeamHealth and is a certified instructor for patient experience programs IHC E4 program, Heart-head-heart, Crucial Conversations.