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Thursday, March 18, 2004 - Page updated at 04:41 P.M.
Information in this article, originally published March 17, was corrected March 17. Dr. Larry Mauksch, who teaches communication skills to medical students, residents and doctors, said that studies show doctors typically interrupt patients after about 20 seconds of explanation of what brought them into the exam room. A previous version of the story mistakenly said 20 minutes.

Good medicine begins with a good doctor-patient relationship

By Carol M. Ostrom
Seattle Times staff reporter

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When the elderly patient and her daughter were ushered into the doctor's office at a Seattle clinic, the doctor didn't look up.

Behind his desk, he was hunched over, staring at the screen of his laptop computer. "I'll be with you in a minute," he mumbled.

It was a long minute.

Finally, he looked up, focused on his patient and her daughter, both of whom he'd seen several times before. "And who are you, again?" he asked the daughter.

Building a good doctor-patient relationship — the doctor's part


What a doctor can do to help build the doctor-patient partnership:

Let the patient complete his or her opening statement.

Elicit the patient's full set of concerns, perhaps adding your own. "Let's be sure to address both of our chief concerns and do justice to them today."

Establish and maintain a personal connection: Read the chart before you come into the room; shake hands, establish eye contact, sit down and don't act hurried, even if you are. Consider jotting down a personal note for the next visit so you can ask, "How was the vacation?" or "How's your mom doing?"

Actively listen (eye contact, words of encouragement, repeating back what you heard from the patient).

Use open-ended questions when appropriate, and remember that "tell me more about it" can be a faster way of getting the history and concerns than playing "20 Questions."

Plan and prioritize together: "How can we best use our time together?"

Understand the patient's perspective; explore contextual factors such as culture, spirituality, expectations about health and illness.

Express empathy, demonstrating that you have heard and understood the patient. ("Wow, sounds like your dad's death was pretty tough for you.")

Use information the patient can understand, and check for understanding. Encourage questions.

Encourage the patient to participate in decisions to the extent he or she desires; identify and enlist resources and support.

Provide closure: Ask whether the patient has other issues or concerns, summarize agreement with plan of action, discuss follow-up.

Sources: "Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement," Academic Medicine, April 2001; "Improving Satisfaction for Physicians and Patients: Managing Patient's Perceptions of Appointment Time," Dr. Paul Fletcher, Group Health Permanente; "Provider-Patient Communication Workshop: Communication Procedures — Time Efficiency Suggestions," Daniel O'Connell, Bayer Institute for Health Care Communication.

The good news: This doctor was learning how to operate a computer, a new tool of his trade that might help him improve communication with patients.

The bad news: His patient gave him an "F" in "Bedside Manner," shorthand for the skills health educators increasingly believe play a major role in two key areas: achieving good health outcomes for patients and heading off lawsuits.

The notion that empathy, communication and building rapport with a patient are important doctoring skills isn't new. But recent research is connecting dots, and some of them connect straight to places doctors don't want to go.

At Vanderbilt University Medical Center, internal guidelines for doctors spell out an uncomfortable connection in a pointed way: "Patients frequently tell us the reason they went to a lawyer was because their health professionals showed no concern, no warmth, wouldn't listen, wouldn't talk or wouldn't answer questions" when bad outcomes occurred.

Hard data hard to ignore

It doesn't take a rocket scientist to hypothesize that patients who feel dissed would be more likely to sue when something goes wrong. But in recent years, researchers have given the medical profession more "scientific" evidence of the connection.

Dr. Gerald Hickson, a Vanderbilt University pediatrician, published research in the Journal of the American Medical Association two years ago showing that doctors whose patients complained about them more were also more likely to be sued.

Patients who complained said things like "no one would answer my questions," or "they didn't use language I understood." In general, Hickson said, those who complained "felt as though they were not respected as human beings."

"One of the great tragedies we have is that so many medical professionals believe that litigation is sort of 'luck of the draw,' and there's little that they can do," said Hickson, recently named to head Vanderbilt's Center for Patient and Professional Advocacy, which opened last year.

In fact, lawsuits don't track with technical incompetence, Hickson's and others' studies show, but with the lack of a good doctor-patient relationship, something vital to promoting "good, safe, high-quality health care," said Hickson.

Dr. Bob Crittenden, chief of Harborview Medical Center's Family Medicine Service, is a firm believer that good communication can head off problems. He recalled a mistake he made early in his career: a tubal ligation on a patient with a lot of infection in which he took out the wrong "tube," a round ligament.

As soon as he realized what had happened, he confessed his error to the patient, with whom he had built a good relationship. He explained how it had been hard to tell the ligament from the fallopian tube, that he'd made a mistake, and he offered to redo the surgery.

"I lost sleep over it," he recalled. But he firmly believes that having established a good relationship with the patient paved the way toward a straightforward conversation about his mistake, instead of a lawsuit. "If the person trusts you, you can explain things to them, and they will listen," he said.

In Crittenden's case, the patient accepted his offer, he did the second surgery, and the story ended well. In other cases, the story didn't end so well.

Gary Morse, spokesman for Physicians Insurance, the largest physician-malpractice insurer in the state, recalls a survey his company did several years ago of patients who had successfully sued their doctors. The company asked them why they'd chosen to go to court.

"The answer, in so many words, was, 'I just didn't feel like I was getting an explanation,' " said Morse.

Better health outcomes

Staving off lawsuits is important, of course, but health educators say there are even more important reasons for the resurgence of interest in the nontechnological skills involved in doctoring. Much of it is fueled by increasing recognition of the role good communication skills can play in health outcomes: Hearing what a patient has to say can make for a better diagnosis. And a patient who trusts the doctor will be more likely to follow medical advice.

"Communication is one of the most important things doctors and patients do with one another," said Dr. Eric Larson, former medical director of the University of Washington Medical Center and now the director of Group Health's Center for Health Studies.

In the past couple of years, new enterprises have been started to focus on the subject.

"We're saying that communication can be studied like any other thing can be studied," said Dr. Robert Arnold, director of the year-old "Institute for Doctor-Patient Communication" at the University of Pittsburgh School of Medicine.

This year, for the first time in 40 years, all medical students will be required to pass a hands-on test of these abilities to be licensed to practice medicine. More than 25,000 medical students are expected to take the full-day "Clinical Skills" examination in June at five sites around the country.

The exam, 15 years in the making, is the first time since 1964 that medical students have been required to pass tests of such skills. The test takers will face 11 or 12 "standardized patients," actors with scripted material, interviewing and examining them, diagnosing and charting their findings. Among the skills the test will examine are the ability to listen, establish "rapport" with the patient, and communicate effectively.

Julie Gunther, a third-year medical student at the University of Washington, said she's not really worried about the test. Her UW education has already focused on these skills, always emphasizing "remembering and honoring the uniqueness of your patients, being attentive to their needs," she said.

"It's a huge emphasis of our training," said Gunther, who plans to specialize in some type of primary care. "The people they've chosen to be our teachers are examples of that; they're almost uniformly that way."

In many ways, experts in this field say, what's happening is a resurgence of interest in skills that may have been overshadowed by the bright lights of high-tech, the amazing discoveries of molecular biology, the ever-more complex scans and diagnostic tests.

"The explosion of technology, which is so useful, if we're not careful, has the potential to drive a wedge in between patients and doctor, because more time is spent testing, with less time to sit and gather information from patients," said Dr. Erika Goldstein, who chairs the "Introduction to Clinical Medicine" courses for medical students at the UW School of Medicine.

"We're returning to the essential skills of physicianhood, of a good clinician."

A teachable skill

So what exactly is "good bedside manner," and how does a doctor learn to do it? And can patients gently nudge doctors who need help?

How to coach your doctor


If your doctor isn't exactly The Great Communicator, can you help her or him along? Yes, say experts. Here are some tips:

Be prepared: Write your questions and bring the list.

Have a pen and pad handy so you can take notes if you need to.

Ask questions if you don't understand something.

Give your doctor praise when he or she does something you like: "It really helps me when you take the time to explain things like that," suggests one expert.

Ask questions about the doctor's thought process: "Why are you thinking that?" "Do you understand why I'm concerned about this?"

Always fill out patient-satisfaction surveys; be specific about what you liked and didn't. If there's no survey, take time to write a letter to the clinic or hospital about what was good or bad; those messages are taken seriously, say those who know.

Don't wait until the end of the interview to bring up the difficult or embarrassing subject; for example, sexually transmitted disease or erectile dysfunction.

Know what to ask about prescription drugs: Are there side effects, interactions with other drugs, other drugs, generic drugs or nondrug remedies that might treat the problem?

Stick to your concerns without going overboard on emotions. Ask questions before you jump to conclusions.

If you're dissatisfied with your doctor's approach or recommendations, voice your concerns in a straightforward and tactful way.

If you're going to leave your doctor because you think his or her communication skills stink or for other concerns, be honest about it: "I'm going to a new physician, and here are the reasons why." ... "The people who answered the phone were really rude." ... or "You never took the time to listen."

Sources: Dr. Erika Goldstein, University of Washington School of Medicine, Dr. Paul Fletcher, Group Health Permanente; "Talking with Your Doctor: A Guide for Older People," National Institute on Aging.

Some experts, such as Dr. Larry Mauksch, who teaches communication skills to medical students, residents and doctors practicing in the community, object to vague terms such as "bedside manner" or "the art of medicine."

They're not descriptive, said Mauksch, a clinical associate professor in the UW's Department of Family Medicine. And worse, such phrases suggest it's simply a matter of the doctor being "caring" — a personality issue, rather than a matter of discrete skills that can be learned.

"People used to say, 'Either you can communicate or you can't; that's the job of the admissions department to get (medical students) in who can do that,' " said Goldstein. Now, teachers know this is something that can be learned even if a student doesn't start with it. Either way, though, it needs to be focused on, reinforced and nurtured, she said, "or it will atrophy."

In fact, there are specific phases of doctor-patient interactions, Mauksch said, and each has a specific set of skills and "microskills" that can be identified, practiced and incorporated into day-to-day life, even by doctors who are shy or more comfortable with lab rats than with human beings.

For example, there's the patient interview.

Studies show that doctors typically interrupt patients after about 20 seconds of explanation of what brought them into the exam room that day, Mauksch said.

"Only about 25 percent of primary-care interactions involve patients being able to put out their full agenda," he said. "Doctors cut the patients off, then they go into a diagnostic dive to discuss the specific problem ... and then they get bitten at the end (of the appointment) because patients on the way out say, 'Oh, by the way ... ' "

Too often, the "by the way" involves something serious ("I've been having these chest pains,") or something that's seriously troubling them ("I'm worried that my headache may mean something awful; my father died of an aneurysm").

"What we know from repeated research is that doctors do not regularly ask patients about all their concerns; they focus on what they're most concerned about, or the first thing. But the first thing may not be the most important thing, or it may be part of a much bigger thing," said Mauksch.

As part of a team of teachers, Mauksch teaches medical students these "clinical skills," using videotape and "very specific feedback" to help them get from "normal behavior" to "better behavior."

Mauksch also teaches the skills to doctors, and finds it helps open the door if he tells them about research showing that if they get better at detecting "clues" from patients, it will actually save time.

So if communication, relationship-building, empathy and all those things are so good — time-saving, even — why don't more doctors do them?

"We know that most physicians do not incorporate those practices into their repertoire, in how they interact with patients," said Mauksch. "But what we haven't done until now is ask 'why?' We've done a lot of physician bashing in ways that are unfair."

In the past, communication and empathy have been treated more as innate talents, he said. Even when specific skills have been introduced in medical school, when doctors move into the day-to-day experience of seeing patients, where they develop their "clinical personalities," said Mauksch, "an organized way of teaching and reinforcing these skills is for the most part absent."

Vanderbilt's Hickson agrees.

"We've never given (doctors) feedback," he said, with the exception of perhaps exhorting them to "show empathy" or something vague like that.

Doctors' typical reaction to that: "They think they're doing it," Hickson said.

Help for the distant doctor

As more and more medical centers realize what's at stake, they've invited Hickson and his colleagues to coach doctors identified by patient complaints as being "at risk" for problems. Hickson's group has done interventions with 400 doctors, showing them how they are perceived by patients, how they rank relative to their peers — and how they can change.

Sometimes, it's just a particular type of patient that sets a doctor off — for example, one who arrives with a foot of material pulled off the Internet. "Some doctors don't respond well to that," he said. "The important thing is to understand that about yourself, and figure out a more constructive way to respond than 'Who is the doctor here, me or you?' " said Hickson.

Group Health Cooperative, which employs about 1,000 doctors, offers three levels of training, including a class on the "basics of communication," using interactions with paid actors and a coach, a shadowing by a trained coach during actual office visits, and a four-day retreat which gets into deeper issues, such as "family of origin" and authority issues.

For example, for a superscientific-type doctor who might come across as a little distant, a coach might say: "How about, before you come to a conclusion, describe what you heard from the patient, and how you're coming to that conclusion?" said Dr. Paul Fletcher, associate medical director for performance improvement at Group Health Permanente, the doctors' group.

Some doctors are resistant to training at first, but they quickly warm to learning these skills once they realize the benefits, said Fletcher.

"We motivate doctors by saying, 'You can have better health outcomes, be less likely to be sued, have more fun, and patients are going to like you better.' "

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com


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