The importance of effective physician-patient communication cannot be overemphasized. Before formal training in communication skills was available, physicians often learned to communicate with their patients by observing and adopting the communication style of an experienced physician or mentor. Recognizing the value of skilled communication in the patient encounter, medical schools now provide a variety of courses to students to help them talk to patients.
Arriving at the medical diagnosis, assuring patient compliance, and predicting the likelihood of a patient filing a claim or lawsuit against the physician are all influenced by the ability of the physician and patient to communicate. In addition, "Positive physician communication behaviors increased patients' perceptions of physicians competence and decreased malpractice claim intentions toward both the physician and the hospital." (1)
Physicians may struggle communicating with patients who have low health literacy, who are noncompliant with instructions, or who may have language or cultural barriers to overcome. This article focuses on the physician-patient interview and examines the techniques of professional interviewers — journalists — for ideas that may help make the physician-patient interview more effective.
The journalistic method
"Journalistic interviewers are not equal: Some get more than others. They do it not by clever questions or intimidating tactics. Quite the opposite. They get more by asking fewer questions, listening more intensely, and responding to what they've heard." (2)
Both physicians and journalists have similar goals for an interview — they each want to gather information. In a physician-patient conversation, asking fewer questions might mean affording the patient the uninterrupted opportunity to share information, opinions, and concerns about his or her medical condition.
Determine what details you want to take away from the interview and structure your conversation with the patient to help you obtain them. If the patient begins talking randomly, listen carefully to discern any important facts, then try to focus the patient's conversation with your questions. "The more you use your mind to evaluate, compare, and contrast the source's comments, the more you'll ask those kinds of creative questions." (2)
Journalists take notes or record their interviews. Physicians must also write notes for the medical record. Short-term memory of what took place at the interview deteriorates rapidly, so it is helpful to write notes during the interview. "Reporters often do not pay attention to comments made early in an interview" (2) because the comments are not in context. Later in the interview, when the reporter understands more, the comments become meaningful. If they have not been written down, however, they may not be remembered. The same holds true for the physician interviewing a patient.
Before conducting an interview with a source, journalists do their homework. Because they go into the interview knowing some things about their source, they are able to develop questions that will help them to better understand what their source has to say and any biases he or she may have. When a physician sits down with a patient, that physician will have the advantage of some previously supplied information. The patient may have completed a patient information form before the visit that provides the physician with information about his or her medical history and current complaint or the physician may review the patient's medical record. Due to time constraints in the office setting, the physician may only have time to quickly scan this information before sitting down with the patient. This can present a challenge. However, familiarity with this background information is beneficial to the communication process.
Active listening
Listening to and understanding a prepared speech is a very different experience from listening to and understanding information delivered in an interview. Prepared speeches follow a pattern with a theme and organized points. A conversation is a different type of communication and may be hard to follow. One must listen carefully for major points and endeavor to grasp the meaning of what the source or patient is saying. We speak at about 125 words a minute, and we listen at 375-500 words a minute. Use the lag time to think ahead and anticipate where the patient may be headed in the conversation. Think about what was said and listen "between the lines." For example, when your patient is answering a question is he or she blushing? Is the patient struggling to find the right words? Does that mean there is more that is not being said? What word choices are made? Word choice can reveal a lot about attitude and expectation. This kind of active listening can encourage exploration of an issue that may have been touched on but not directly stated. (2)
Many successful journalists are masters of active listening. Active listening is ". . . paying attention to the respondent's message. It means asking questions that will ensure that you understand the message. It means mentally juggling the many aspects of the interview in short-term memory so that your questions uniquely reflect what you've been hearing during the conversation. And it means coming away with a record of what has been revealed . . . " (2)
In the patient interview, active listening promotes better communication and helps establish a trusting relationship between physician and patient. "Studies have shown that when this relationship is based on mutual trust and good communication, the chance of a malpractice claim being filed after a poor medical outcome is greatly reduced." (3)
Eye contact, note taking, and head nodding all tell the patient that you are actively listening. Although the typical office visit lasts from 18 to 21 minutes and the interview may be a small part of that time, glancing at your watch while the patient is talking does not help the patient build confidence in the relationship. Posture also communicates the interviewer's level of interest. Choose to make eye contact with the patient. If you are recording the patient interview in an electronic medical record, you will need to turn your attention to the computer screen from time to time. It is helpful to tell the patient what you are doing so they understand you are still focused on them and the reasons they are in the office to see you. (4)
To elucidate, repeat back what the patient is saying during the interview. Use phrases such as "As I understand it, you mean . . ." or "You are saying . . ." Journalists use this technique to make sure they are grasping the point their source is trying to make. Listen for contradictory statements to clarify with the patient. Listen for supporting evidence to statements the patient is making. Actively evaluating what is being said can prompt you to ask more questions while the patient is in your office. (2)
For sources who have agreed to an interview with the journalist, the kinds of interviews that leave them with a negative impression are those where the interviewer asks a question, then settles back to record the answer without any kind of interaction with the source. Physicians can avoid this type of interview by offering encouragement and direction to the patient during the interview. Active listening requires one to interject confirming statements and to probe with additional questions.
A journalist might engage in self-disclosure statements during the interview in an effort to appear friendly and to help their source feel comfortable in being candid. However, a recent study published in the June 25, 2007 issue of the Archives of Internal Medicine suggests that physicians who engage in personal disclosure during the patient visit wasted the patient's limited time in the office and did not enhance the doctor-patient relationship. (5) In another study exploring the relationship between physician self-disclosure and patient satisfaction with the office visit, results showed that primary care patients were less satisfied with the visit when doctors self disclosed while surgical patients were more satisfied when their surgeon made self disclosure statements. (6) With this intriguing information in mind, the patient-physician interview could be more productive if the topics of discussion were prioritized to make the best use of the time available.
Reduce your risk
Patients who have communication issues with their physician may be more likely to change doctors or to sue.
"Patients have identified three problems that made them consider changing doctors: physicians not giving understandable answers to questions; not taking enough time to answer questions; and not giving enough medical information." (3)
In a study comparing primary care physicians who have been sued with those who have not, communication played a key role. Physicians who prepare their patients about what to expect at the medical visit, encourage them to talk about their concerns and opinions, and who repeat information back to the patient are less likely to be sued. (3) These physician behaviors establish mutual respect and trust.
Another study compared the communication styles of primary care physicians who had reported malpractice claims with physicians who had never reported malpractice claims. The study demonstrated that ". . . no-claims primary care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and tended to use more facilitation (soliciting patients' opinions, checking understanding, and encouraging patient to talk). No-claims primary care physicians spent longer in routine visits than claims primary care physicians (mean, 18.3 vs 15.0 minutes), and the length of the visit had an independent effect in predicting claims status." (8)
In an article titled, "Reducing risk of malpractice suits by forging patient relationships" physicians are offered five tips. One of these is to "take a course on physician-patient communication." The author says "even if you think you are a fine communicator, it is helpful to get feedback from an unbiased observer . . . how well you listen and communicate is an area you can control and improve." (3)
Sources
- Moore PJ, Adler NE, Robertson PA. Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med. 2000; 173:244-250.
- Metzler K. Creative Interviewing. Allyn and Bacon.Third Edition 1997; 84-91.
- Mendelson R. Reduce risk of malpractice suits by forging patient relationships. AAP News. 2003 June;22:260.
- Rhoades, DR et al. Speaking and interruptions during primary care office visits. Fam Med. 2001 Jul-Aug; 33(7)528-32.
- McDaniel SH, et al. Physician Self-disclosure in Primary Care Visits: Enough About You, What About Me? Arch Intern Med. 2007;167:1321-1326.
- Beach MC, et al. Is Physician Self-disclosure Related to Patient Evaluation of Office Visits? J Gen Intern Med. 2004 September,19(9):905-910.
- Keating NL, et al. How Are Patients' Specific Ambulatory Care Experiences Related to Trust, Satisfaction, and Considering Changing Physicians? J Gen Inter Med. 2002; 17:29-39.
- Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA.1997;277:553-559.
Dana Leidig can be reached at
dana-leidig@tmlt.org.
