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 doctor-patient 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 that information can be used. On average, patients are interrupted 18 seconds into explaining their problems, and less than 2 percent of them get to finish their explanations.¹

The following 10 bad listening habits can lead to serious doctor-patient misunderstandings and problems.²

1. Dismissing the subject matter as uninteresting
   A subconscious resistance to listening becomes more pronounced as we get tired or bored. Moreover, it is easier to dismiss new information as a bother than to analyze or assimilate it. Effective listening requires attention, patience, and suppression of the urge to control the conversation.
   
   
2. Feigning attention
   We learn to look attentive as a protective mechanism at dull and boring meetings or to act polite during conversations that do not interest us. Feigning attention is risky while talking with patients. Most people can sense when someone is pretending to listen or is merely showing superficial interest.
   
   
3. Avoiding difficult material
   The incessant media bombardment of our psyche competes for our attention by plying us with a professionally prepared “listening-made-easy” approach. As a result, there is often a tendency to shy away from material that seems to demand more of our thoughts and time.
   
   
4. Allowing distractions
   The physician’s office environment permits interruptions that make it difficult to listen. If possible, do not allow distractions that steal attention when communicating with a patient and make it difficult to listen effectively.
   
   
5. Finding fault with the speaker
   Instead of listening to what the patient says, there is a tendency to become distracted by how the patient looks or behaves. Focusing on a patient’s mannerisms or physical characteristics can prevent you from focusing on what is being said. Distraction can be avoided if you learn to concentrate and analyze content rather than to focus on style and mannerisms.
   
   
6. Listening only for details or facts
   Medical training and examinations are geared toward facts and figures. Consequently, doctors often fail to take into account the equally important emotions, behavior, and intentions of the patient.
   
   
7. Becoming overstimulated 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. For example, if you are told “you were just too busy for me,” you’re likely to feel antagonistic toward the person making the emotionally charged statement. Such words or phrases 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. It’s best to listen and make eye contact with the patient until a clear message is detected regarding the information. Even then, it’s best to jot down only important key words or phrases that can help you reconstruct the conversation within the context.
   
   
10. Wasting the advantage of thought-speech speed
    Most people speak at approximately 125 words per minute but are capable of assimilating 500 spoken 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: This technique indicates to the speaker whether his or her message is being understood. This is accomplished by asking questions, making statements, or offering visual cues that indicate: 1) whether you understand and agree; 2) that you do not understand; or 3) that you disagree with the message. Withhold criticism or judgment until you clearly understand what the patient is trying to say. This technique also shows that you are listening carefully.
  
  
• Silence: By remaining physically and mentally silent when a patient is speaking, you are less likely to prepare or rehearse your response while you are listening. Instead, focus on what is being said.
  
  
• Listen with Your Eyes: You can 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: Your own body language or positioning is a powerful communicator of attentiveness. For example, too relaxed a posture can reflect disinterest while crossed arms often signal defensiveness. Some doctors avoid sitting behind a desk to remove any semblance of a barrier. If you 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.”³

Improving Verbal and Nonverbal Communication

• Tempo of Speech and Tone of Voice: Some of us have a tendency to speak rapidly or to economize on words. To ensure that patients understand you, speak slowly and clearly. Often, the stress that physicians experience in their daily practice is reflected unconsciously in their tone of voice. For example, the phrase “you should have called me” can be said in an empathetic, solicitous manner, or in an impatient, accusatory way. The effects the two styles have on a patient can differ dramatically.
  
  
• Pause for Digestion and Feedback: When your message is complex, pause frequently—even if you do not sense confusion in the listener. A break in speech allows the patient to either digest what you are saying or ask for clarification. In addition, repeatedly invite questions. The resulting dialogue reinforces the patient’s feeling that he or she is participating in his or her health care. There is nothing wrong with asking, “Do you understand?” or questioning the patient about specific instructions or education to determine his or her level of comprehension. You can also ask the patient to repeat what he or she has just been told.
  
  
• Tailor Your Language: A common complaint in patient attitude surveys has to do with physicians’ use of complex terminology or medical jargon when simple words will suffice. And when you describe a procedure, choose words that do not produce anxiety. For example, “excise” might be misunderstood, yet “cutting it out” sounds painful. “Removing it” is a better way to convey the message without inducing stress.
  
  
• Repetition: Various studies have shown that the average patient retains only 35 percent of what he or she is told. To improve retention, summarize the essential points of your message at the end of the consultation or examination. Repetition strongly reinforces what you have said.
  
  
• Request Written Questions: A visit to the doctor can cause anxiety that makes a patient forget important questions or information until he or she has left your office. Encourage patients to write down any questions that occur to them and to bring a list on their next visit. If your patient already has a list, patiently answer the questions.
  
  
• Body Language: Body language is as important when speaking as when listening. While much has been written on the subject of body language, relatively little has been said about its role in the doctor-patient relationship.
  
  In speaking, as in listening, eye contact is critical—it is the essence of understanding. 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.
  
  Do not permit your own emotions or frustrations to affect the patient. In some cases, a patient’s visit to an attorney has been triggered by an innocent sigh, a raised eyebrow, or a look of skepticism when evaluating a colleague’s results.
  
  Likewise, remember that a reassuring smile, a comforting touch, and a confident and caring attitude are indispensable ingredients for solid doctor-patient relationships. Positive rapport can weather all sorts of treatment failures and complications.

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 doctor 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-doctor communication has been identified as one of the root causes of medical errors.⁴ 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.⁵

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 doctor did not give specific directions for monitoring the patient’s neurological status or to call the doctor 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.⁶

The nurses were not alert to a progressive deterioration during the night. It was not until the patient was profoundly comatose at 4 a.m. that a neurosurgeon was called. A craniotomy at 6 a.m. 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 neurosurgeon when the patient was obviously deteriorating. The jury returned a verdict against the hospital and the neurosurgeon.

Deliberate Critical 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 doctor apologized, explaining that he meant only that the pneumonia must have been far from simple to require a thoracotomy. Perhaps a better way to have asked the question would have been to say, “How did pneumonia cause a scar?” Instead of assuming, ask for more clarification.

Beyond Carelessness

Unfortunately, such remarks often go beyond mere carelessness. Sometimes they are made deliberately and stem from strong therapeutic biases, ego problems, or interpersonal conflicts. For example, a prominent, highly skilled orthopedist was known for his strong bias toward the procedure he had perfected. He was openly critical of colleagues using alternative methods. Either by word or action, he often communicated his disapproval to patients who consulted him upon receiving less than optimal results. He quickly became the fountainhead of a stream of lawsuits related to his specialty.

Peer Criticism

Competition was a key factor in a case in which 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.

It is not necessary for physicians to verbalize disapproval to reveal sentiments. 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.

Do Not Conceal or Assume

Refraining from uninformed comment does not imply or suggest deliberate concealment. If, for example, a retained sponge is identified, the patient must be told. Most situations are not so sharply defined, and the consulting physician should carefully avoid coming to a conclusion without knowing all the facts. Obviously, a thorough review of medical records is mandatory. A direct call to the first physician can provide important insight into the situation. Perhaps the patient inadvertently or deliberately omitted significant information.

In Conclusion

Communication techniques are a learned skill. Unfortunately, many health care providers discover this after an adverse event occurs. If this is the case in your facility, turn that negative experience into a positive teaching tool by asking these questions:

• What can we learn from this?
• How can we prevent a recurrence?
• Is there anything we can do now to alleviate the situation?

The team approach works well as a follow-up activity. If internal changes will prevent repetition, make the changes as soon as possible. To document education for this change, have all personnel sign the new policy.

An additional tool that will help you to improve your skill is the patient questionnaire. Its use in small increments will be accepted and completed more readily by patients.

J4238B 9/07