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Vol. LX, No. 22
October 31, 2008
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Change Is Coming
Grand Rounds Spotlights Patient-Doc Communication

On the front page...

A guy walks into the doctor’s office. “Listen, doc,” he says. “I got this terrible pain.” That’s the setup for an old gag with a million punchlines. But when a physician has only 15 minutes per patient visit, time spent listening may seem like a luxury, if not impossible. And that’s no joke.

A change is coming, says Harvard Medical School’s Dr. Elizabeth Rider, who recently traveled to NIH for Clinical Fellows’ Grand Rounds. In “Difficult Conversations: Evidence-Based Methods for Improving Outcomes,” she made the case for enhancing communication skills in medical encounters.

“Why do we care?” she asked the audience in Lipsett Amphitheater. “It’s not cell receptor communications. It’s interpersonal.”

Continued...


  Dr. Elizabeth Rider argues for better patient-doc talk.  
  Dr. Elizabeth Rider argues for better patient-doc talk.  

And now it’s regulatory. Residents must demonstrate and document interpersonal and communication skills, deemed a core competency by the Accreditation Council for Graduate Medical Education as well as the Joint Commission on the Accreditation of Healthcare Organizations, various medical schools, fellowship programs, specialty and licensing boards.

Here’s the background. Studies show that when physicians interact with patients:

  • They prevent patients from completing their opening statements around 75 percent of the time.
  • They respond to patients’ cues less than half of the time in both surgery and primary care.
  • They fail to elicit over half of patients’ complaints.
  • They use jargon.

Studies also show that enhanced communication improves health care outcomes, symptom resolution, patient adherence and compliance and both patient and physician satisfaction.

It also builds a sense of alliance, a factor affecting patients’ decisions to participate in clinical trials.

Meanwhile, in malpractice suits, ineffective communication is a factor.

“Hundreds of studies,” Rider said, “show that [effective communication] is not just being supportive.” And it’s a mistake to assume you’ll automatically learn it effectively as you go along.

Video clips offered several takes of doctor-patient duos in role-played conversations. The audience was invited to critique each version.

Enhanced communication can affect patient decisions to participate in clinical trials, Rider said.
Enhanced communication can affect patient decisions to participate in clinical trials, Rider said.

Depending on the culture and institution, Rider noted, there are many paradigms for communicating with patients and families. She offered two evidence-based models for physicians to use or adapt in their work.

In the Kalamazoo Consensus Statement framework, now implemented at Harvard Medical School, the physician completes 7 essential elements and 23 sub-competencies, including:

1) Build a relationship (“show interest in the patient as a person”).

2) Open the discussion (“allow patient to complete opening statement without interruption”).

3) Gather information (“begin with patient’s story using open-ended questions”).

4) Understand the patient’s perspective (“elicit patient’s beliefs, concerns and expectations”).

5) Share information (“explain using words that are easy for patient to understand”).

6) Reach agreement (“ask about patient’s ability to follow treatment plans”).

7) Provide closure (“ask if patient has questions”).

The Four Habits model is more compact: 1) invest in beginning/set the agenda; 2) elicit patient perspective; 3) demonstrate empathy; 4) invest in the end.

Eliciting the patient perspective can be surprising. To illustrate, Rider showed a slide of a bear up a tree—in closeup.

What is the bear’s perspective? What’s he up to? Looking for honey? Next slide: a wider shot of the same bear, clinging to the branch, while at the foot of the tree stands a stroppy orange cat with a major attitude.

“This was a news item,” Rider said. The cat, a domestic shorthair, had treed the bear, which now seemed somewhat...less than fierce.

So now what’s the bear’s perspective? The moral of the story: Take time to see things from the patient’s point of view.

The audience had questions. Isn’t writing a prescription often the most efficient way of ending an interaction with a patient?

You still have to communicate, Rider said. She described the real-world scenarios where parents request an antibiotic prescription, even when their child just has a cold. (Viruses don’t respond to antibiotics). You need to be flexible, communicative and to use your “differential self,” as she called it. “You respond differently with different patients” depending on the patient’s needs.

Now a pediatrician and communication specialist, Rider began her career as a clinical social worker and therapist, where the focus is interpersonal relations. She acknowledged that while there’s “a large and useful literature” on communication in social work and nursing, the physician has additional responsibilities and “physicians use [their own] clear models.”

For an M.D., she admitted, it’s tough to find the time to communicate fully with patients and their families. But it’s worth it.

“It will make people happier,” said Rider. “It’s better care and more efficient.” NIHRecord Icon

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