Effectively treating patients requires more than good clinical skills. Just as important is learning how to listen.
William Clark was frustrated. Soon after he’d finished his residency and began working at a practice in Boston, the internist realized he didn’t know the first thing about communicating with his patients.
“I didn’t have any active ways to respond to them,” says Clark, recalling his stress as a young physician. “Conversations with patients didn’t feel at all natural to me. I just didn’t know what to say, especially when they were angry about something. Or if they were sad, that was hard for me to hear and cope with. I wasn’t doing a very good job.”
The result? Clark’s patients balked. The newly minted physician, then in the process of joining Harvard Medical School’s faculty, noticed the nonverbal signs - a frown, an eye roll, patients looking annoyed or just keeping quiet themselves. They responded to his uneasiness with uneasiness of their own.
“I suffered quite a bit,” Clark recalls.
But rather than passively accept his communication shortcomings in the exam room, Clark decided to do something about it. He connected with other colleagues in academia who were feeling the same way. Together, they commiserated about their own limitations, compared notes, and decided to seek out and attain better communication skills, vowing to pass what they learned to their own medical students. They formed the American Academy on Physicians and Patients.
That was 35 years ago. The organization is now called the American Academy on Communication in Healthcare (AACH), but its mission remains the same. AACH members published a textbook on doctor-patient communication in 1995, and now the academy offers detailed instruction online (www.aachonline.org/doccom) for physicians who have trouble talking to their patients. As for Clark, he now works in a private practice in coastal Maine, and he’s a lot happier with his interactions in the exam room. So are his patients.
“It was very hard work, but I became a lot more comfortable with patients, and they became a lot more comfortable with me,” he says.
Clark, who currently travels the country giving seminars to other physicians on how to enhance their listening skills, is a pioneer in a movement that’s picking up steam these days. More medical schools are adding communication courses to their curricula, requiring students to work with actors simulating troubled patients while faculty look on and offer guidance. Medical associations are sponsoring more and more seminars for residents and older doctors on how to better connect with patients and support staff.
For example, AACH and its regional affiliates offer long-term coaching for physicians who want to be better listeners. And individual practices are sending uncommunicative doctors to these seminars to learn effective listening skills, sometimes requiring the doctors to either reduce their number of patient complaints or lose their job security. In addition, journals continue to churn out studies examining the importance of the doctor-patient relationship. In one, researchers videotape physicians interacting with patients in the exam room, afterward analyzing the quality and quantity of their communication, down to counting and sorting each sentence exchanged.
At the core of all this effort is the goal of learning to be a good listener, which many physicians say plays an important clinical function in both diagnosis and therapy.
Paging Dr. Welby
It seems that over time physicians have somehow lost that Marcus Welby vibe.
“Doctors used to be trusted friends; they came over, they wanted to hear the stories and spend the time that was needed to help the family,” says Reid Blackwelder, an internist and professor of family medicine at East Tennessee State University. He teaches listening skills to first-year medical students. “The art of medicine is really about bedside manner, but today we’ve lost that skill,” says Blackwelder. “Now doctors are super-stressed. Many just say, ‘Here’s the treatment,’ and that’s the end of the visit.”
A recent study in England demonstrated that when patients send cues indicating they want to be listened to, many physicians tend to resist. Avoidance mechanisms include changing the subject, interrupting, being directive or making a plan, reducing shows of sympathy, and modifying body language.
When called upon to return to the Welby way - at least when it comes to interacting and listening to patients - today’s physicians often counter that there’s no time for that during ever-shortening patient visits. But Debra Roter, a professor in the Department of Health Policy and Management at Johns Hopkins University School of Hygiene and Public Health, disagrees. She quotes studies that have shown the length of patient visits increasing by two minutes over the past 10 years. But Roter also acknowledges that today’s physicians are responsible for accomplishing far more in that time frame.
Blackwelder says that’s all the more reason to employ better communication skills during the short time patients and physicians have to interact. He points to literature that suggests physicians tend to conduct patient exams backward, putting themselves in the position of having to guess what’s wrong by using the small bits of information they elicit from patients. He says doctors can draw on a larger, more fruitful body of information on which to base decisions by simply letting their patients talk.
“If you step back and ask more open-ended questions at the beginning of the exam, like, ‘Tell me what’s going on,’ ‘Will you tell me more about that?’ and ‘What else would you like to tell me?’ instead of many directed questions like, ‘Is the pain right here?’ and ‘Has it been going on for a few weeks?’ you get a lot more information quickly,” says Blackwelder. “You avoid the kind of visit where the patient answers all your pointed questions and you get nowhere until the end, when they say, ‘Oh, by the way …’ and then you’re there for another 10 minutes getting the real story, the valuable info.”
“It may take a few minutes to sit and listen like that, but those minutes are a great investment that will return big dividends,” agrees Lidia Schapira, a Boston oncologist.
Schapira has been delivering better-listening talks to other oncologists since 1999, when she and a patient made a film on their interactions with one another. The film attracted a lot of attention at an American Society of Clinical Oncology symposium. Since she began consciously working to become a better communicator in her busy practice, Schapira says things have really changed.
“I am a far better physician than I used to be, and I get much better feedback from patients and nurses,” she says.
Minus any systematic training on communication skills, research indicates that physicians typically develop idiosyncratic ways of communicating (or not communicating) with patients and support staff. The good news: Studies have also shown that if physicians have a specific model to follow - one they can practice and use, helps them build better rapport with cohorts and patients, and that allows them to subsequently collect more meaningful data during exams and professional encounters - then the new behavior becomes self-reinforcing. That is, its effects are so pleasing, so satisfying, that doctors can’t help but repeat it with each patient.
But how do physicians accomplish this, short of going back to med school or signing up for coaching sessions?
Schapira says it must start with a genuine curiosity about your patients; you can’t fake it by simply nodding vacantly as they speak. You have to truly care about the details they give you, and you must translate that sense of caring during an exam.
But reluctant MDs should not rush into what many of them perceive as an entirely new method of patient interaction. If they don’t come naturally, such skills must be learned.
“Doctors who come into the [hospital] room and just stand over the bed looking at their watch and looking like they want to leave are not encouraging you to tell your story,” says Blackwelder. “But if a doctor comes in and sits in the chair, looks straight at you, and seems like he has all the time in the world, the quality of the visit is different - better. You don’t actually have to spend extra time - just use your time differently.”
To do this, says Barry Egener, an internist in Portland, Ore., and the medical director of the Northwest Center for Physician-Patient Communication, it’s helpful to reframe listening as an active - rather than passive - activity. And then work to be “present” with the patient.
“Before going into the exam room, get yourself ready to be with the patient, rather than being distracted by how busy you are, or thinking of the last patient,” Egener instructs. “That takes a lot of concentration, but it helps you more quickly decipher what the meaning is behind the patient’s story.”
Verbal cues are crucial during the medical interview, says Roter. Simply saying things like “uh-huh” and “mmm” as the patient tells his story is critical to active listening. It signals to the patient that he is being heard. Simply sitting silently while taking notes can have the opposite effect.
After the patient tells you what’s going on (and you have listened intently), it’s helpful to restate to the patient the gist of what he said, says Egener. That way, the patient knows you understand what he’s trying to convey, that you’re focusing and concentrating on him, and that you are attempting to collaborate with him regarding his care. Egener adds that most docs quickly discover that paraphrasing prevents patients from repeating the same things over and over.
Roter also advises physicians to be quiet. “A great way to engage patients is by lowering verbal dominance - simply shutting up, allowing more room in the conversation,” she says.
Nonverbal cues that convey receptivity are also very important. These include making and keeping eye contact, nodding, and leaning forward. Egener recalls a particular patient of his, an alcoholic who was experiencing terrible headaches. The patient wanted Vicodin to ease the throbbing pain, but Egener didn’t want to give it to her because of her addiction. They continued arguing about it, until, Egener says, he stopped the conversation, leaned forward, and told her he wouldn’t give it to her because he cared about her. The patient’s anger evaporated on the spot, and she understood the root of her problem. Looking back, he credits his body language more than his words in effectively communicating with this patient. The visit was a turning point for them both - the patient went on to kick her addiction, and Egener saw just how powerful nonverbal communication could be.
But these types of exchanges and breakthroughs aren’t commonplace among patient visits. A study by Roter and colleagues at Johns Hopkins in 1997 scrutinized the visits between 127 physicians and 537 chronic patients. They concluded that many medical exams (32 percent) were characterized by closed-ended medical questions and biomedical talk with only moderate levels of psychosocial discussion. Only 8 percent of visits were characterized primarily by psychosocial exchange - even though that was the style of visit that produced the most patient satisfaction.
Most experts in doctor/patient communication agree that after you’ve asked the open-ended questions in the exam room that Blackwelder suggests above, you should be willing and able to subsequently respond to a patient’s emotions. If a patient starts crying, gets angry, or seems fearful, put aside the more technical portions of the medical interview and deal with the feelings at hand.
“It’s important to the patient that you attend to the relationship as an important goal separate from the medical issue,” says Egener, adding that this establishes you as an empathic listener and builds trust with the patient.
And don’t be afraid to bring forth a flood of emotions, says Blackwelder: “I see a lot of doctors making the choice not to ask the deep questions when they see the patient is hurting and they know that a specific question will make them cry. But the more you deal with their stress and issues, the less you are just offering Band-Aids. So much about health and disease is about personal choice and stress.”
But if you sense that a patient’s emotional outpourings could go on and on, well into your next scheduled visit, you needn’t fear that, says Schapira. “Most people don’t go on forever; they will stop talking after a few minutes,” she explains. “If they don’t, though, you can respectfully redirect them, and say, ‘In order to make sure all your questions about treatment are answered, we need to stop and focus on what brought you here. But we can pick up next time on this issue.’”
Then there’s anger. If a patient is mad at you, don’t shrink from it. Blackwelder recommends acknowledging the anger rather than automatically getting defensive. “Most of the time, they appreciate that you’ve acknowledged their emotion and then open up and tell you what’s underlying the anger - and you’ll see that the anger usually isn’t about what you think it’s about. They may say, ‘Well, I’m not mad because you were late - I’m mad because no one’s telling me what’s going on.’”
Clark says taking time to work on improving the quality of your interactions with patients, colleagues, and staff shouldn’t be a peripheral issue that you “might” get to one day. It should be the front-and-center issue you start working on right now - for their sake and yours. “If you’re not paying attention to your communication and relationship skills, you can’t advance your opportunity to do a better job - and isn’t that what all of us want to do?” asks Clark.
If all physicians made improving their communication skills a professional priority, Blackwelder says the impact on medicine would be profound. “We spend more and more money each year on our heathcare system, and outcomes are getting worse,” he says. “If we just took a little more time to listen and help patients figure out how to handle the issues behind their issues, we likely wouldn’t need all the drugs we do today. And outcomes would definitely be better.”
Suz Redfearn is an award-winning healthcare writer living in Falls Church, Va., who has written for a variety of publications including The Washington Post and Men’s Health. She can be reached via firstname.lastname@example.org.
This article originally appeared in the July/August 2006 issue of Physicians Practice.