Health Systems

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Caring for Patients One Conversation at a Time:
Musings from The Interregional Clinician-Patient Communication Leadership Group | to pdf >>
By Terry Stein, MD; Vivian Tong Nagy, PhD; Lee Jacobs, MD

Recognizing that excellence in clinician-patient communication can improve the medical care of patients and provide strategic benefits to a health care organization, KP's Interregional Clinician-Patient Communication Leadership Group regularly assembles some of the best leadership and communication expertise from across KP to enhance the day-to-day communication skills of our clinicians. This article describes the importance of excellent clinician-patient communication, and the membership, goals, and activities of this interdisciplinary group.

Introduction
Once a month, Kaiser Permanente clinicians, educators, and researchers from across six time zones meet by phone to talk about clinician-patient communication. We grapple with such questions as:

• Our primary care departments are switching to team-based care. What communication skills will be needed by the clinicians to explain changes in their role, make smooth referrals, and use the telephone as an alternative to in-person visits?
• As health care outcomes, quality, utilization, and patient satisfaction are more closely monitored, many clinicians are becoming concerned about their increasing professional and financial accountability for their practices. How can improved communication skills make a difference?
• Available time for medical visits seems to be decreasing. What specific skills could help clinicians manage time pressures?
• Some clinicians have good technical skills but do not relate well to patients. What resources are available for these clinicians?
• We need clinicians with excellent patient communication skills. How can KP recruit more clinicians with superior "people skills?"

These types of issues are addressed by our Interregional Clinician-Patient Communication Leadership Group during monthly conference calls. Our multidisciplinary group represents every Permanente Medical Group in the organization (Table 1). Because we are geographically scattered, we function primarily as a "virtual" group. Our group works under the leadership of Terry Stein, MD, Director of Clinician-Patient Communication in TPMG in Northern California, with sponsorship provided by Jill Steinbruegge, MD, Associate Executive Director of Physician Development of The Permanente Federation.

Impetus for the Group's Formation
The need for convening this group became clear to Dr. Stein after the CME workshop, Thriving in a Busy Practice, was introduced to KP clinicians in North Carolina, Colorado, the Northwest, Texas, the Northeast, and Hawaii: she realized that coordinating efforts and sharing ideas about clinician-patient communication across the Program could be productive, cost-saving, and fun. In fact, when the group met for the first time in November 1996, we were impressed that our needs were remarkably similar.

Acknowledging that excellence in clinician-patient communication can improve the medical care of our patients "one conversation at a time" and provide strategic benefits to KP, we created a mission statement to show how our interregional group is prepared to leverage the leadership and expertise from across the Program to enhance the communication skills of our clinicians:

The mission of the Interregional Clinician-Patient Communication Leadership Group is to ensure that excellence in clinician-patient communication becomes a distinguishing feature of care delivery throughout Kaiser Permanente, is accepted as a critical aspect of clinical practice, and is recognized as a major contributor to organizational success.

Patients Don't Care How Much You Know Until They Know How Much You Care
George Engel said that "the interview is the most powerful, sensitive, and versatile instrument available to the physician ..."¹ Despite the emphasis on new technologies and new medications, the medical interview with the patient remains one of the most important tools available to health practitioners. "Before anything else, a good doctor must be a good communicator."² The interview is also our most common clinical procedure: a physician conducts more than 150,000 medical interviews during a practice lifetime.³ Clinician-patient communication is a critical element of Permanente Medicine and reflects our values as caring people.

However, despite the acknowledged importance of good communication with patients, many clinicians believe that their communication skills can be improved. For example, in a 1997 national survey, 61% of 230 primary care physicians agreed that they were not well prepared by medical school or residency for the challenges of physician-patient communication.⁴

The increasing sophistication of consumers means that skills such as attentive listening and collaborative decision-making between clinician and patient are becoming even more essential. As stated recently by Richard Barnaby, KFHP/H California Division President, "Our challenge is to continue to treat each patient as an individual by listening and caring. We're doing it well, but the bar of expectations keeps rising."⁵

Myth #1 The problem isn't my communication skills. The problem is that I don't have enough time to spend with my patients. Time pressures can be enormous and truly can impede the best intentions to communicate well. There simply needs to be enough time with each patient to sit down, to focus and listen attentively, and to discuss diagnosis and treatment. Well-honed communication skills are even more important for interacting with patients, because time constraints make every second count. Skills such as setting patients at ease rapidly, eliciting patients' concerns at the outset, and using empathy won't add time to the day, but these skills will help visits go more smoothly and can enhance patient and physician satisfaction.1 How much time do "patient-centered" listening skills take? On average, less than one extra minute, according to one study.2 The quality of the interaction can affect patients' perceptions of time. In a classic study by Barbara Korsch, MD,3 patients who were satisfied after a visit tended to overestimate the time the doctor had actually spent. In contrast, patients who were dissatisfied complained that the doctor had seemed in a hurry, even when visits were long. 1. Weinberger M, Greene JY, Mamlin JJ. The impact of clinical encounter events on patient and physician satisfaction. Soc Sci Med [E] 1981;15:239-244. 2. Stewart M, Brown JB, Weston WW. Patient centered interviewing, part III: Five provocative questions. Can Fam Physician 1989;35:159-161. 3. Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. I. Doctor-patient interaction and patient satisfaction. Pediatrics 1968;42:855-871.

What Difference Does Good Communication Make?
A growing body of literature shows that the way clinicians relate to patients has a major influence on patient behavior and health, clinician and patient satisfaction, and the number of malpractice actions. Multiple research studies have shown this impact on critical aspects of care such as diagnostic accuracy, adherence, and health outcomes. For example, when clinicians communicate effectively, patients are more likely to convey their main concern,⁶ to adhere to prescribed medication regimens,^7,8 and to follow instructions.⁹ Communication also influences clinician and patient satisfaction as well as medical-legal risk. This impact on multiple dimensions of care is underscored by the fact that in mid-1998, Index Medicus listed more than 100,000 articles on the topic.

After reviewing 21 studies on communication and health outcomes, one author¹⁰ concluded that "most of the studies ... demonstrated a correlation between effective physician-patient communication and improved health outcomes." The outcomes most affected were patients' emotional health, symptom resolution, functional status, physiologic measures, and pain control.¹⁰ As an example, in one of the studies,¹¹ patients reported a reduction in emotional distress for as long as six months (compared with a control group) after their physicians attended an eight-hour communication training program. In another of the studies,¹² hypertensive patients who were coached successfully to ask more questions during visits had lower blood pressure, and diabetic patients who received this coaching had improved glucose levels.

Studies also show the connection between communication with patients and clinician satisfaction. The American College of Physicians recently studied internists in managed care and showed that "the doctor-patient relationship is the main reason internists are satisfied with their careers."¹³ Another study found that the relationship with patients topped the list of factors that contribute to the satisfaction physicians feel after conducting an office visit.¹⁴ Visits that used humor were particularly satisfying.¹⁵ Doug Morgan, MD, an internist in the Colorado Permanente Medical Group, observed, "I thought that if I really worked hard to listen effectively, interact personally, and respond empathetically, the patient would leave happier. What I discovered is that I, too, leave the exam room happier."

Enhanced clinician-patient communication is also highly correlated with improved patient satisfaction. Jill Steinbruegge, MD, commented, "Patients judge our competence primarily on how effectively we interact with them." Many studies have analyzed medical interviews to determine which specific communication behaviors lead to high ratings. Discussing psychosocial issues, providing health education, and offering adequate information on treatment makes a difference.^16,17,18 Use of encouraging nonverbal signals has also led to more satisfying visits, suggesting that even subtlety of body language can impact the way patients experience the office visit.¹⁹

Another well-documented observation is that improving patients' perceptions of the clinician-patient relationship reduces the volume of malpractice litigation. Whereas poor treatment outcome is the primary cause of malpractice actions, poor communication has also been a factor in about 75% of cases.²⁰ The presence or absence of certain communication behaviors differentiates primary care doctors with prior malpractice claims from those without such claims.²¹ In addition, considerable anecdotal information indicates that a good physician-patient relationship might deter patients from suing, even in situations where medical error is the cause.^22,23 Communicating empathy and respect can reassure patients that clinicians have patients' best interests at heart.²⁴

What's in it for Kaiser Permanente?
Our own KP research shows that improving clinician-patient communication skills has important strategic benefits for our clinicians and our patients. On the business side, effective communication is linked to our competitive strategy and our continuing success as a health care provider.

Myth #2 If I just give the patients what they want (tests, drugs, referrals, work excuses), then I'll score better on satisfaction surveys. Logical enough! But research shows a more complicated picture. One study1 found that if physicians asked for patients' requests and then listened attentively, patients were more likely to be satisfied regardless of whether their requests were granted. Another study2 looked at patients who expected medical tests to be ordered during an upcoming visit. Their satisfaction as reported after the visit correlated not with whether tests were actually ordered but with the extent of their physician's humanistic qualities. These studies suggest that the interaction between physician and patients regarding patients' requests can have greater impact on satisfaction than simply saying "yes." 1.Tuckett D, Boutlon M, Olson C, Williams A. Meetings between experts: an approach to sharing ideas in medical consultations. London: Tavistock; 1985. 2.Froehlich GW, Welch HG. Meeting walk-in patients' expectations for testing: effects on satisfaction. J Gen Intern Med 1996;11:470-474.

One of the most important research findings has been that clinicians' subjective experience of practicing medicine can be enhanced by learning better communication skills. Research on two interventions offered in KP-Northern California assessed clinicians' perceptions of patient interactions after the clinicians received specialized communication training. In the first study, three months after participating in the one-day CME Workshop Thriving in a Busy Practice, clinicians from more than 20 programs (n = 911) reported having fewer frustrating patient visits (p < .05).²⁵ In the second study, several months after participating in the five-day Communication Skills Intensive Program, clinicians described more enjoyment when seeing patients, despite the ongoing time constraints. After attending the Communication Skills Intensive Program in 1997, Mira Kaplan, MD, Chief of Allergy at the KP Medical Center in Oakland, reported: "I've found that I'm able to express more of who I am with my patients and not be as removed as I thought I had to be. I get more satisfaction out of the visits now. Thanks to all the practicing we did in the course, when I encounter a difficult patient, I say to myself, 'I've seen this before,' and I know that I'm going to be able to get through it."

Another KP study underscored the importance of training and feedback as a means of giving clinicians insight into the level of their communication skills. In a study of 261 diabetic patients and their 44 personal physicians, questionnaires were distributed immediately after office visits. A direct correlation was seen between how patients perceived the communication and patients' overall satisfaction, but patients and physicians did not agree on the quality of communication that had just taken place. These findings suggest that although patient satisfaction is linked to their perceptions about quality of communication, physicians may require training or feedback to help them determine how well they are relating to their patients.²⁶

Patient satisfaction has also been shown to increase when clinicians receive feedback on their communication skills. Al Mehl, MD, from the KP-Colorado Region, tracked Art of Medicine scores for ten physicians who participated in an individual feedback process in which actual visits with patients were observed and specific suggestions for improvement were provided. In each case, scores improved during the next six months (Mehl A, personal communication, August 1998).^a Similarly, for the Communication Skills Intensive Program in KP-Northern California, during which clinicians receive detailed feedback on patient interviewing, member survey scores were significantly better (p < .01) in the six months after taking the course than in the six months before taking the course (Stein T, unpublished data).^b

Improving communication skills may result in fewer patients voluntarily terminating their membership because of dissatisfaction. In exit interviews with members who voluntarily left the Kaiser Foundation Health Plan (KFHP), dissatisfaction with their personal physician was cited by nearly one in four members (Hughes E, August 1998, personal communication).^c

Expert clinician-patient communication may also provide a distinct competitive advantage for KP. If managed care organizations in time achieve parity on premium costs and documented quality measurements, some experts believe that the factor differentiating these organizations may be the level of service perceived by purchasers.²⁷

Finally, honing communication skills can be important for KP's public image. Amid the prevalent consumer fear that close ties with physicians are being lost in this era of managed health care, community awareness that KP is actively fostering and improving clinician-patient interactions can greatly boost our public image.

Examples of Permanente Educational Workshops and Programs Video Visits: A set of one-hour interactive programs designed to stimulate group discussions about communication with challenging patients. The set includes eight video vignettes, a facilitator guide, and a participant workbook. Thriving in a Busy Practice, Part 2: A one-day workshop focusing on medical interviewing skills, nonverbal communication, and dealing with conflict. The workshop includes interactive discussions and small group practice sessions with actors, short lectures, and demonstrations. Appointment With Success: A one-day workshop focusing on the medical interview process and some challenging clinician-patient interactions. This program uses actors to simulate individual cases so that physicians can practice new strategies. Director Observation Tutorial: A focus on the communication skills of individual physicians. A physician's interaction with patients in the examination room is observed by a consulting physician for half a day. Feedback on the observed behavior is reviewed in a subsequent consultation. Video Coaching: A half-day program to refine the communication skills of individual physicians. A physician's interaction with an actor-patient is videotaped, and the interaction is subsequently reviewed and discussed with a trained interaction coach. Communication Skills Intensive: A five-day residential program with four-month follow-up. The content focuses on specific communication behaviors, including videotaped practice with actors, and on how personal and family history can affect interactional style. Thriving in a Busy Practice, Part 3: Communicating for Health Behavior Change: A one-day workshop that presents a collaborative approach for discussing with patients their lifestyle and adherence issues according to patients' readiness to change. *For more information about these and other programs, contact your representative from your Medical Group [See Table 1]

How We Work: Leveraging Learnings and Services
An underlying premise of our interregional communication efforts is that clinician-patient skills can be successfully taught to clinicians²⁸ and that these skills can be retained for a long time.²⁹

We believe that one of our most important functions is to provide a forum for sharing our learning and solving problems. We collect from our Medical Groups issues, questions, and concerns such as those listed in the introduction to this article and hear how others are struggling with the same or similar topics. We discuss the successes and failures that others have experienced with these same issues. This approach rapidly transfers learnings throughout the organization--a function that is essential to Permanente improvement initiatives.

One product resulting from our shared learnings is an Inventory of Education and Service Resources for improving clinician-patient communication. This Inventory describes programs and efforts developed throughout the KP Program (see sidebar). The Inventory is available to all administrative physicians as well as to others in the Medical Groups. As the Permanente community has become more aware of these resources, we have received an increasing number of requests for assistance and guidance. For example, when the North Carolina Permanente Medical Group needed rapid implementation of team-based training in communication, we were able to direct the inquiry to our Leadership Group's members in the Northeast and Georgia Permanente Medical Groups who had experience in this area. We have also observed an increasing number of requests for referrals to the most appropriate training programs offered within the organization to address specific communication needs of individual physicians, physician groups, and health care teams.

To determine best practices and to identify issues that are common throughout the Program, we are also looking for similarities and differences among responses to our Medical Groups' patient satisfaction surveys.

Future Directions
Over the past two years, our monthly telephone discussions have helped us identify ways to advance clinician-patient communication skills. Our priorities for the next year or two include validating the quality of our learning resources, augmenting these resources, addressing the communication needs of teams and individual clinicians, and investigating effective ways to recruit and retain clinicians who have good communication skills.

We intend to accelerate current efforts to evaluate the effectiveness of our primary educational programs and interventions. This process will include examining how well we transfer programs to the workplace and assessing evidence of long-term improvement in Permanente clinicians' communication skills.

As we continue to better understand how clinicians learn communication skills, we plan to expand our repertoire of learning opportunities by supplementing our classroom-based workshops with opportunities for self-directed learning (eg, CD-ROM, distance learning, Internet programs). In addition, to optimize quality and cost-effectiveness, our group may sponsor development of some of these initiatives and then disseminate the products throughout the Permanente community.

We are becoming increasingly aware of new types of clinicians, other health care practitioners, and health care delivery teams that have different communication needs and challenges. Some examples are the hospital-based specialist and the health care teams emerging from primary care redesign efforts. These practitioners will constitute new audiences for our efforts to improve clinician-patient communication skills in our Program.

In addition, we intend to help identify and implement the best methods of recruiting and retaining clinicians who have superior communication skills. Our group will work with medical group leaders to find strategies for attracting and retaining clinicians who are highly motivated and skilled in effective communication.

Finally, because customized care requires effective communication, we will be a resource to the organization as it implements the new KP Promise.

Conclusion
These are challenging and exciting times for Kaiser Permanente. As we move into the next millennium, we must return to the core skill of our medical practice and focus on enhancing communication with patients, one conversation at a time, in order to attain a high level of excellence throughout KP. By improving the medical care we give, increasing our work satisfaction, and enhancing our community image, this focus on effective communication can provide us with a major competitive advantage. The Interregional Clinician-Patient Communication Leadership Group strives to be a valuable resource to our organization by 1) highlighting the impact of communication skills on medical care and on our major business imperatives, 2) designing effective communication interventions, 3) coordinating implementation of these interventions across the Program, and 4) addressing future communication needs. In these ways, we hope to realize our vision of excellence in clinician-patient communication.

^aColorado Permanente Medical Group, Boulder, Colorado
^bThe Permanente Medical Group, Oakland, California
^cDirector, Risk Management, Kaiser Permanente Walnut Center, Pasadena, California

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References
1. Engel GL. How much longer must medicine's science be bound by a seventeenth century world view? In: White KL, editor. The task of medicine: dialogue at Wickenburg. Menlo Park (CA): Henry J. Kaiser Family Foundation; 1988. p. 133177.
2. CohenCole SA. The medical interview: the three function approach. St. Louis: Mosby Yearbook; 1991.
3. Glass RM. The patientphysician relationship: JAMA focuses on the center of medicine [editorial]. JAMA 1996;275:147148.
4. Take time to talk: barriers to patientphysician communication. Kalamazoo, Michigan: Take Time to Talk Advisory Council; Dec. 1997.
5. KP Reporter 1998 Jul 14;1(15):1.
6. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984;101:692696.
7. Coleman VR. Physician behaviour and compliance. J Hypertens Suppl 1985;3:S69S71.
8. Garrity TF. Medical compliance and the clinician-patient relationship: a review. Soc Sci Med [E] 1981;15:215222.
9. Becker MH. Patient adherence to prescribed therapies. Med Care 1985;23:539555.
10. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ l995;152:14231433.
11. Roter DL, Hall JA, Kern DE, Barker R, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress. Arch Intern Med 1995;155:18771884.
12. Kaplan SH, Greenfield S, Ware J. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27:S110127.
13. Gesensway D. A look at physician satisfaction in a time of change. ACP Observer, Mar 1998.
14. Suchman AL, Roter D, Green M, Lipkin M. Physician satisfaction with primary care office visits. Med Care 1993;31:10831092.
15. Weinberger M, Greene JY, Mamlin JJ. The impact of clinical encounter events on patient and physician satisfaction. Soc Sci Med [E] 1981;15:239-244.
16. Brody DS, Miller S, Lerman C, Smith D, Lazaro CG, Blum M. The relationship between patients' satisfaction with their physicians and perceptions about interventions they desired and received. Med Care 1989;27:10271035.
17. Robbins J, Bertakis K, Helms J, Asari R, Callahan E, Creten D. The influence of physician practice behaviors on patient satisfaction. Fam Med 1993;25:1720.
18. Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med 1995;40:903-18.
19. Bertakis K, Roter D, Putnam S. The relationship of physician interview style to patient satisfaction. J Fam Pract 1991;32:175181.
20. Cohn B, Ehrhardt ME, Phillips M. Protecting yourself from malpractice. Patient Care 1990 Aug 15;24:536,63-6,69-70,78-80.
21. 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;277:553559.
22. Bartlett EE. Injury prevention vs. patient communications. Risk Manage 1991 Jan;38(1):4043.
23. Mangels LS. Tips from doctors who've never been sued. Med Econ 1991 Feb 18;68:5658, 60-64.
24. Shearn D. Communicating for quality care: new tips for an old and proven medical procedure. Calif Physician 1994 Jan:6063.
25. Stein TS, Kwan J. Thriving in a busy practice: physician-patient communication. Submitted for publication 1998.
26. Hall JA, Stein TS, Roter DL, Reiser N. Patients' and physicians' views of the patient experience: discrepancies between physician and patient and interrelations among physician and patientrelated variables. Submitted for publication 1998.
27. Koop CE. Patientprovider communication and managed care. Group Pract J 1998 May;47:57-8.
28. Smith RC, Lyles JS, Mettler J, Stoffelmayr BE, Van Egeren LF, Marshall AA, et al. The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann Intern Med 1998;128:118126.
29. Levinson W, Roter D. Effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med 1993;8:318324.

Quotes from the National Quality and Learning Conference, November 1997 "Ultimately, the two dimensions of quality--the technical, medical kind that we're used to focusing on and the human experiential kind that's in some ways even harder to deal with--must be brought together." --Francis J. Crosson, MD, Executive Director, The Permanente Federation "We're going to get tugged and pushed in all sorts of directions, and we always have to ask ourselves, 'Does the way we're doing it enable us to provide superior medicine to individuals in a supporting, caring, even loving way?' That's what we're about. That's our challenge together--to hold ourselves to that standard." --David Lawrence, MD, Chairman and CEO, Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals