Effective Physician Communication Skills

Communication issues, whether patient-physician, nurse-physician, or physician-physician, are at the crux of many medical malpractice claims. A medical malpractice claim almost always fails to reveal the unseen emotional and psychological factors that triggered the patient’s visit to an attorney. The most common element in adversarial patient-physician relationships is failed communication.

Listening

Hearing and listening are dissimilar processes. Unlike hearing, which is the perception of physical stimuli to our ears, listening is the active, cognitive process of interpreting what we hear, evaluating that information, and deciding how it can be used.

The following 10 bad listening habits can lead to serious physician-patient misunderstandings and problems (1):

1. Dismissing the Subject Matter as Uninteresting: Effective listening requires attention, patience, and suppression of the urge to control the conversation.
2. Feigning Attention: Most people can sense when someone is pretending to listen or is merely showing superficial interest.
3. Avoiding Difficult Material: There is often a tendency to shy away from material that seems to demand more of our thoughts and time.
4. Allowing Distractions: When communicating with a patient, do not allow distractions that steal attention and make it difficult to listen effectively.
5. Finding Fault With the Speaker: Focusing on a patient’s mannerisms or physical characteristics can prevent you from focusing on what is being said.
6. Listening Only for Details or Facts: Medical training and examinations are geared toward facts and figures and fail to take into account the equally important emotions, behavior, and intentions of the patient.
7. Becoming Over-stimulated by Something the Speaker Says: Becoming enthusiastic about a speaker’s style or presentation can cause you to suspend judgment about what the speaker is actually saying and to misinterpret what is being said.
8. Allowing Emotion-laden Words to Arouse Personal Antagonism: Certain words or phrases can trigger negative emotional reactions in the listener and lead to distraction from what is being said.
9. Taking Notes: Although taking notes is essential to obtaining a patient’s history, it can distract your concentration or continuity of thought and increase the patient’s anxiety.
10. Wasting the Advantage of Thought-Speech Speed: Most people can assimilate 500 words per minute but can only speak at 125 words per minute. The extra time is often used to think of something other than what the speaker is saying. Communication is more effective if you focus only on what is being said.

Techniques to Sharpen Your Listening Skills

• Reflective Feedback: Ask questions, make statements, or offer visual cues that indicate whether you understand and agree, that you do not understand, or that you disagree with the message.
• Silence: Remain physically and mentally silent to focus on what is being said.
• Listen With Your Eyes: Stay attuned to what the speaker is saying through his or her body positioning, eye movement and contact, physical contact, and other body language.
• Positioning: Lean forward slightly and look at the patient while he or she speaks. This nonverbal communication says, “I’m interested in what you have to say. Please continue” (2).

Improving Verbal and Nonverbal Communication

• Tempo of Speech and Tone of Voice: To ensure that patients understand you, speak slowly and clearly.
• Pause for Digestion and Feedback: When your message is complex, pause frequently — even if you do not sense confusion in the listener. Repeatedly invite questions. There is nothing wrong with asking, “Do you understand?” To ensure that explanations or instructions are understood, ask patients to repeat what they have just been told.
• Tailor Your Language: Avoid complex terminology or medical jargon when simple words will suffice.
• Repetition: To improve retention, summarize the essential points of your message at the end of the consultation or examination.
• Request Written Questions: Encourage patients to write down their questions and to bring a list on their next visit.
• Body Language: Maintain eye contact with patients to hold their attention. Patients’ facial expressions and frequent nods will indicate how effectively you are getting your message across. A reassuring smile, a comforting touch, and a confident and caring attitude are indispensable ingredients for solid physician-patient relationships (2).

Improving Medical Team Member Communication

Communication among team members must be clear and complete. Faulty communication can occur in a variety of settings. For example, patient care may be jeopardized when the referring physician provides too little information to a consultant or when nurse-to-nurse or nurse-to- physician communication lacks critical data. Patients are also part of the team. Poor patient-physician communication has been identified as one of the root causes of medical errors (3). As the following cases illustrate, the fault generally lies with both parties.

Patients as Partners

A patient with psoriasis was evaluated because of worsening disease. Two topical steroids were prescribed: one very mild topical steroid for the face and a more potent steroid for the palms and soles. The patient was given instructions on how to use the two medications, but, because of time pressure, the physician wrote “use as directed” on the prescription for each steroid. The physician provided no other written support to his verbal instructions to the patient. The patient obtained the prescriptions but mistakenly put the potent steroid on the face and the mild steroid on the palms and soles. At the time of the next appointment, the patient had developed severe atrophy and striae. With discontinuation of the potent steroid on the face, the atrophy improved but the striae remained.

Time pressure impelled the physician to take a short cut in the prescription process by writing “use as directed” on the medications. Moreover, while it is true that the physician had instructed the patient in the correct application of the two topical steroids, by not reinforcing this oral instruction with written guidance on the steroid use, the possibility for misuse by the patient was left open. The concept of “teaching back” is essential in providing important medication information to patients.

This case reveals that patients need to know that they are essential to the planning of their care. Emphasis by the physician on the role the patient plays in his or her care is an important communication technique (4).

Clear Instructions Are Essential

A 39-year-old man was brought to the emergency room of a large hospital shortly after being struck in the head with a baseball bat. He was adequately evaluated and then discharged.

Eleven days later, the patient returned to the emergency room because of increasing lethargy. He was hospitalized, and a CAT scan raised the question of subdural hematoma. The physician wrote orders for the nurses to check the patient’s vital signs hourly. The physician did not give specific directions for monitoring the patient’s neurological status or to call the physician if any alteration occurred.

Nurses and physicians are trained to work in separate “silos.” The physician is focused on medical knowledge, whereas the nurses may be preoccupied with more immediate factors of care and are not fully aware of the physician’s overall treatment aims. The separate realities often lead to differences in priority setting, imperfect communication, and, sometimes, disastrous results (5).

The nurses were not alert to a progressive deterioration during the night. It was not until the patient was profoundly comatose at 4AM that a neurosurgeon was called. A craniotomy identified a subdural hematoma, and death occurred five days later.

At trial, several negligence issues arose, but the plaintiff’s attorney mainly concentrated on failed communications: failure of the neurosurgeon to give the nurses sufficiently clear instructions, and failure of the nurses to call the physician when the patient was obviously deteriorating. The jury returned a substantial verdict against the hospital and the neurosurgeon.

Critical Peer Comments

Communication skills become even more important when an adverse outcome occurs. A common catalyst in the chemistry of malpractice suits is an inadvertent or deliberate critical comment by a health professional concerning a colleague’s actions. Experienced defense attorneys estimate that 25 percent of all claims may be triggered by such an event.

Consider the case of a 19-year-old woman with lobar pneumonia who did not seek medical attention until she was critically ill. Her empyema required thoracotomy and drainage. Her care was excellent and she recovered fully. A year later, another physician asked about her obvious scar. When told it resulted from pneumonia, he responded, “I’d hardly expect that from a simple pneumonia.” The patient then consulted an inexperienced lawyer who filed a suit. The case was pursued for a year before being dropped. When confronted by the first treating physician, the second physician apologized, explaining that he meant only that the pneumonia must have been far from simple to require a thoracotomy.

In another case, competition was a key factor when a patient who had experienced less-than-satisfactory nasal reconstruction consulted one of two competitors who were located in the same building of a large metropolitan area. The second surgeon, though not directly critical of the first, clearly communicated by body language (frowning, sighing, raising eyebrows, emphatic “hmphs,” shaking his head) what he thought of the result. He then quoted a very high fee for a secondary surgery, stating that the case would be “much more difficult because someone else had been there before.” The resulting lawsuit was dropped after two costly years, and the first surgeon sued the second for slander.

If you are a consulting physician, particularly in a second opinion situation, you should make every effort to avoid communicating any criticism of a colleague by word or action. Since you were not present during the initial treatment, it is vital that you maintain the position that you don’t know why or how it happened.

The need to maintain a nonjudgmental stance is a caution that applies equally to office staff. A casual, innocent remark by an empathic aide preparing a patient for examination can be all it takes to trigger a claim. Thoroughly brief your staff to categorically refrain from such comments.

Communication techniques are a learned skill. Unfortunately, many health care providers discover this after an adverse event occurs.

References:

1. Nichols R. Are You Listening? New York, NY:McGraw Hill; 1957.
2. Morris D. Body Watching. New York, NY:Crown; 1985.
3. Meyer G, Arnheim L. The power of two: improving patient safety through better physician-patient communication. Family Practice Management. July/August 2002;9:47.
4. Mottur-Pilson C. Patient safety: the other side of the quality equation. Under a grant from the Agency for Healthcare Research and Quality. Available from www.acponline.org. Last accessed April 22, 2005.
5. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and the call for structure. Journal on Quality and Patient Safety. January 2007;33:38–39.