Introduction
Communicating with patients has become tougher. Visits are briefer, yet patients want more face time; patients arrive armed with dubious medical advice from the Internet; and physicians are challenged to try to relate to patients while typing into the electronic medical record (EMR).
"Today's healthcare environment creates many communications challenges," William R. Branch, MD, MACP, Fellow of American Academy on Communication in Healthcare (www.aachonline.org), and professor and director of the division of General Internal Medicine at Emory University School of Medicine, Atlanta, Georgia. "The biggest is time pressure; it means that doctors have less time with patients, and also have a less developed relationship on which to build communications."
Poor communication can lead to missed diagnoses, patient resentment, noncompliance, and a greater chance of being sued. An often-quoted study published in the Journal of the American Medical Association in 1997 showed that the 2 factors leading to a malpractice suit are bad outcomes combined with poor physician-patient communication.[1]
Conversely, better rapport makes the patient visit more gratifying for both parties. "Patients are more likely to keep appointments, take their medicine, accept your medical advice, and not sue," says Dr. Branch.
"On a personal and moral level, when communications are satisfying, you can feel that you're doing more good and feel much more rewarded by the whole process. Additionally, some evidence indicates that patients who have a positive, trusting, therapeutic relationship with their doctor do better in a genuine concrete way," adds Dr. Branch.
To improve rapport during patient visits, physicians need to identify situations that undermine communication; adopt tactics to correct those problems, and enrich their own communication skills.
Determine Whether a Problem Exists
Patients may feel that communication is flawed, but they'll rarely tell the physician.
"There are 2 quick ways for doctors to know if there's a problem," says Judy Bee, medical practice management consultant with Practice Performance Group, LLC, La Jolla, California. "First, ask your checkout person or front desk receptionist how often patients come out of the examination room and say, 'what am I supposed to do?' or comment, 'that was ridiculous, he sat there for all of 2 minutes.' That can give you an answer.
"Another way is to track the kind of phone calls your practice is getting," says Ms. Bee. "You should primarily be hearing from patients calling for an appointment. If you have a high incidence of patients calling 24 to 48 hours after their appointment to ask questions about the visit, then you're not being clear in the office."
Asking your staff for patient feedback can unearth problems. Patients more readily complain to a nurse or receptionist than to the physician. Use your staff as team members to improve patient relations, and show appreciation when office personnel convey negative patient comments. "Office staff sometimes says the doctor shoots the messenger, so they clam up," says Ms. Bee.
Asking questions that patients ignore, or that don't elicit concrete responses is fruitless. Patient satisfaction surveys can help physicians pinpoint areas for improvement, adds Ms. Bee. She provides tips for developing a survey that can provide important information to help improve patient communications ( Table ).
Mary Ann Bauman, MD, Integris Family Care Central, Oklahoma City, Oklahoma, said that she used feedback to improve her patient communication techniques. Dr. Bauman said that when she was in a time crunch, her efficient nature kicked in and she became more businesslike during patient appointments. "Scores said that patients felt I was technically a very good doctor, but not very warm," she said. Dr. Bauman changed her attitude during patient visits, let more of her personality come through, and patient satisfaction scores rose.
Expand Your Communication Skills
Because patient visits are fairly brief, finely honed skills are vital. "You've got to be able to have intense interactions in a few minutes," says Dr. Branch. "You can do a good job building relationships and communicating with patients even under today's conditions if you're not seeing an excessive numbers of patients, and if you have the skills.
"Effective communication starts with attitude," Dr. Branch says. "Examine your mindset toward seeing patients.
"If you believe that practice is no fun because you don't have time to relate to patients and build relationships, that's not going to lead to good relationships," says Dr. Branch. "If you say, 'I'm going to have a good relationship no matter what,' your relations with patients will be very different."
The right techniques can also heighten patients' perception of the physicians' concern for them. Elizabeth A. Pector, MD, Spectrum Family Medicine, Naperville, Illinois, says, "The body language, eye contact, and nonverbal aspects of communication are very important. How you say something is often more important than what you say.
"Sit at a patient's eye level. Assume an appropriate respectful posture," says Dr. Pector. "If a doctor has her hand on a doorknob as the patient is talking, she's telling the patient the visit is over and she's thinking about moving on."
Patients are very aware when you're paying close attention to them. A few minutes of friendly, unbroken eye contact makes a huge impression. Adds Dr. Branch, "If you start with sustained eye contact, people say it feels like you spent a long time with them."
Physicians can also enhance communications by letting their personality come through so that patients get a sense of the person as a human being, not just as a physician. An appropriate balance allows physicians to maintain professional boundaries while letting patients feel like they've related on a personal level.
Some situations may require more advanced communications skills. Physicians can expand their ability to convey bad news, discuss end-of-life issues, and deal with difficult patients through courses at the American Academy on Communication in Healthcare, at http://www.aachonline.org.Focus the Patient Visit
"Uh, doctor, by the way -- there's another thing...."
Spoken as the physician is leaving the examination room, those words can throw off the whole day's schedule. Alternatively, the new subject may get short shrift. To avoid that scenario, it is wise to extract the patient's concerns up front, without seeming abrupt.
Dr. Pector says she asks questions to set the tone and elicit any hidden agenda. "I often ask, 'Why did you decide to come in about this now?'
"A patient may have what looks like a harmless nothing on their skin," says Pector. "It turns out their best friend just had a horrible skin cancer; then you understand why they're concerned." If a patient comes in for a consult, Dr. Pector asks about their time frame and what they hope to gain. "Some people have trips they want to go on, or a wedding coming up. You can sense whether a patient wants a diagnosis, or just wants reassurance."
Some patients have too many surprise issues to address in one visit. In those cases, it's best to have them come back another time to take care of separate large concerns.
Ms. Bee suggests this diplomatic stance: "Oh, Mrs. Jones, it's such a shame we didn't realize you have a number of issues. I wouldn't want to cut you short, and I didn't schedule that way. What are the most important issues? Then we will schedule a longer time and have you back and we'll deal with these others."
This approach also lets a patient know that it's important to tell the scheduler about all the problems the patient wants to discuss.
Dr. Bauman suggests making every moment with the patient count by increasing patient communication time without lengthening the visit. "I have a little dressing area in each examination room. While the patient is changing, I am at the computer asking questions," says Dr. Bauman. "They can tell me about their kids; I'm listening while I type.
"I asked patients whether they like that approach. Response was very positive. They said they feel they have so much time with me," says Dr. Bauman.
Flexibility can also help with communication, especially for distressed patients.
"Some patients want to get in and get out, while others have emotional health-related issues," says Dr. Branch. "If you're really good, you'll figure out right off the bat who needs time to talk about things that are problematic, and who wants to get out quickly. You can see one patient for 20 minutes and another for 3 minutes, and they can both feel satisfied."
Deflect Misleading Internet Health Advice
"Doctor, I got this from a Website, and it's different from what you said."
Many patients show up with pages of printouts from Google searches. "Often their information has no relevance to their condition, or they've found it on some horrible site I've never heard of," says Dr. Pector.
Dr. Bauman concurs, "Patients come in and tell you what they believe from the Internet, and I ask, 'You would believe that more than you believe your doctor?' It's frustrating and takes time to deal with. It adds a level of complexity, and we don't have control over it."
Physicians can dethrone anonymous Internet "experts" by providing handouts that tell patients how to evaluate medical sites. Physicians should include a list of their own recommended sites. Patients can also be referred to the US Food and Drug Administration Web page article, "How to Evaluate Health Information on the Internet," which can be found at: http://www.fda.gov/oc/opacom/evalhealthinfo.html
If the patient bristles and defends the nonscientific sources, physicians should stick to their guns, says Dr. Bauman. "I won't necessarily prescribe what they want if I don't think it's what right for them."
Conquer the EMR
Squinting at a keyboard while trying to make eye contact with a patient is a ticket to patient frustration. This challenge is becoming increasingly common; a 2008 survey by SureScripts, the largest network provider of e-prescribing services, shows that 34% of office-based physicians now use EMRs.
Physicians who hunt-and-peck with 2 fingers can still make the EMR less intrusive. However, doing so may require planning and practice.
"I have set up my computer so I almost glance over the top and I can see the patient," says Dr. Bauman. "I also make a point to look up and make eye contact.
"When I started doing EMR, I asked my patients, 'is this distracting? Is this okay, do you feel like I'm not paying attention?" Patient response has been positive, not only to the EMR, but to being asked to give input on Dr. Bauman's practice habits.
"Sometimes, if I have a skeptical patient, I'll read back what they wrote. Patients feel I'm really getting down what they say," she says.
If necessary, it's never too late to beef up one's typing skills. One free online touch-typing tutorial with practice lessons is at http://www.typingweb.com/.
Despite today's patient communication challenges, physicians can become better at developing rewarding patient relationships. The key is to get feedback -- from patients, staff, and colleagues; act on their input; and never relinquish one's own goal of creating a satisfying rapport with patients.
Source : http://www.medscape.com/viewarticle/587906
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