skill in interpersonal communication and relationships is a component
of health care so important that patients may both seek and select health
care practitioners on the basis of this skill.
published in the medical literature illustrate the importance of good
communication and interpersonal skills for achieving effective, satisfying
health care encounters and episodes of care. Humaneness is the first
patient priority for general practice care,1 and patients
rated communication in the top three out of seven aspects of patient
care.2 Patients' rates of adherence to recommended treatments
were increased 2.6-fold when a physician's knowledge of a patient "as
a whole person" was strongest.3 The trust level between
patient and physician predicted self-reported adherence at six months.4
In addition, higher patient satisfaction occurred when patients received
any one of three nontechnical interventions--education, stress counseling,
or negotiation--as part of the medical care.5 Meeting patient
expectations for diagnostic tests did not have an important effect on
satisfaction. A patient's perception of a clinician's humanity did correlate
with satisfaction.6 Of five distinct communication patterns
in primary care practice, patients were most satisfied with the psychosocial
pattern (inclusion of psychologic, social, and personal questions and
information).7 A review article on communication and health
outcomes concluded that "most of the studies ... demonstrated a
correlation between effective physician-patient communication and improved
patient health outcomes."8:abstract The outcomes most
affected were patients' emotional health, symptom resolution, functional
status, physiologic measures, and pain control.8
Satisfaction Survey and Database
"Art of Medicine
Survey" of Patient Satisfaction
since 1992, Kaiser Permanente Northwest (KPNW) has evaluated the communication
and interpersonal relationship skills of physicians and affiliated clinicians
by using the Art of Medicine Survey (AOM), a data collection tool developed
in 1992 by Karl Weiss, President, HealthCare Research, Inc (HCR).9
The survey, routinely distributed in a single mailing to KPNW Health
Plan members who recently visited a health care clinician, asks patients
about their satisfaction with their care as delivered by a specific
clinician. The mailing achieves about a 35% response rate, and differences
in response rate are not related to survey score. More than a million
AOM surveys received from patients in multiple KP Regions have been
analyzed, and both validity and reliability of the survey have remained
constant.9 The number of surveys mailed in the NW has been
large enough to obtain 75 completed questionnaires for each clinician
every six months. The survey was administered in six-month cycles (during
1995 and 1996) and in 12-month cycles (in 1997 and 1998), thus producing
six data sets spanning four years.
Survey asks patients seven questions to assess positive attributes of
clinicians' communication skills9 (Table 1).
1992 and 1999, Northwest Permanente Medical Group (NWPMG) has administered
the AOM survey to patients seen by 400 physicians and 200 affiliated
clinicians over seven years. In spring of 1999, survey data collected
at KPNW from 1995 through 1998 were comprehensively analyzed.
Highest Rated Clinicians:
2000-2001, clinicians who consistently scored in the top 10% in the
AOM Survey--specifically, the "overall satisfaction" question--were
interviewed to learn what they say, how they behave, and what they believe
are the reasons why patients rate them so highly. From the six data
sets collected from 1995 through 1998, this high rating was achieved
by 35 clinicians.
Pilot Study of Clinicians
A pilot study was conducted in fall 1999 after a recognition dinner
held for the 35 clinicians. Twenty-one clinicians attended, and after
the dinner, the clinicians were asked, "Why do you feel that your
patients rate their interactions with you so highly?" The clinicians
responded with the following kinds of comments:
introduce myself; I shake their hand; I acknowledge their presence."
talk to them as a person."
explain things, and involve them in decisions."
conscious of what it takes to please people."
the patient where they are."
am with them when they are with me."
study participants included all those physicians and affiliated clinicians
in the highest rated group who responded to a request for an individual
interview about their patient interactions. Twenty-six clinicians (74%)
of the highest rated group agreed to participate (Tables 2, 3).
The qualitative method used in the interviews is sometimes called "conversation
with a purpose." Data were collected on specific, research-defined
topics by means of a conversational interview in which participant's
responses influenced the sequence of questions as well as the probes
used to explore issues more deeply. The study used an interview guide
were conducted by one of the authors (NV) and by three other interviewers
trained in qualitative methods. Interviews were conducted in the clinician's
office and lasted between 30 and 60 minutes. With the clinician's permission,
all interviews were both audiotaped and transcribed for analysis.
focused on features of good practice identified by clinicians and on
perceptions of the role of intuition in their practice. The interviewers
and Dr Vuckovic read a sample of the transcripts and developed coding
based on the interview questions and themes that emerged in the transcripts.
The Coding Elements
coding elements were included: reason for high rating; what patients
value; connection to patient; finding
at work; intuition; listening; time; respect; nonverbal communication;
caring about the patient. These codes were applied to the remaining
transcripts using Atlas ti (Scolari/Sage), a software program
for text-based data analysis. This software enables electronic labeling
of sections of text with codes and retrieval of coded segments.
statements were recorded verbatim because these personal narratives
most specifically convey the main themes highlighted by the coding.
From clinicians' stated beliefs about what patients value, four common
respected as a person and an individual.
listened to and heard by the clinicians.
presence and undivided attention of the clinician.
cared about and cared for.
1. Respect for Patient
uniformly reported that respect for the patient as a person and an individual
was both a fundamental aspect of their interactional style and an aspect
of their practice of medicine that patients valued. Individual clinicians'
ways of demonstrating that respect varied but had in common a desire
to both recognize the patient as a person and minimize social distance
between patient and clinician.
try to treat people like I'd want to be treated."
value that I treat them with respect."
I come in the room ... I always try to shake their hand, just to establish
a touch contact."
such an imbalance of power for one person to be naked and the other
to be wearing an extra lab coat over their clothing."
just a two-second personal interjection:
'I'm sorry. I'm running late.' Just acknowledging that yeah, their time
is not going unnoticed either. It's a big deal for them. It translates
into showing some mutual respect."
Another aspect of their practice that participants believed patients
valued was the attempt to listen to patients' concerns. Some participants
described nonverbal strategies they used to communicate to patients
that they were attentive to what the patient had to say.
they tell me they value the most is when I take the time to listen to
give them time to address whatever problems they have. I don't start
by telling them things. What I say is, 'How are you doing?'"
most times they say 'You know, you're the only person who listens,'
or 'You're the only person who cared,' or 'I feel like you're going
to get to the bottom of it.' That type of thing."
I go into a patient's room, I always sit down to talk with them ....
People just get this sense that you're listening to them longer, or
something, if you're seated than if you're standing by the door."
need to look directly at them when you talk to them. If you're typing
on the computer, then you're not really listening, at least in their
Several participants also described a style of focused attention--which
we have termed "presence"--that contributed to patients' sense
of ease and satisfaction. The essence of this practice was to let go
of events or thoughts that have preceded or that will follow an encounter
and to focus on the moment and on the person in the exam room.
even if it's not very long,
you've given them a sense that you're just there for them, to listen
to them .... And even if I'm really, really rushed, when I walk in the
patient's room I really try hard that they never know that's going on."
I'm talking to them, I'm talking to them, and everybody else is out
of the picture for the time being."
don't appear rushed. Even when I am. So when I go in that room, that
is their sacred time."
4. Caring About Patients
most participants, the behaviors described above were motivated by a
sincere liking for patients, not merely techniques applied to improve
satisfaction scores. For some clinicians, their enjoyment of patients
as people was the most meaningful part or their work.
pretty much like all my patients. I think it's important that you find
something to like about them."
really care about my patients and I think that probably comes through
in the conversation and I think they realize it then."
know, first and foremost, that I actually, really do care about them,
and I will help them in any way I can."
enjoy my patients. I wouldn't keep doing this if I didn't enjoy them."
wonderful. In fact, that's the most rewarding part of it."
Intuition: A Transpersonal
were interested in the phenomenon of intuition as it relates to clinician-patient
interaction. This interest arose from our familiarity with the anthropology
and transpersonal psychology literature. In these disciplines, intuition,
as a part of the communication process has been explored more explicitly
and deeply and is recognized as a potent and effective way to gain information
without sensory input.
When posed to participants, our question about use of intuition in medical
practice elicited responses that classified intuition into three categories:
that comes from experience;
that comes from being open to information from multiple sources,
from other (spiritual, paranormal) sources.
Knowledge That Comes From Experience
participants described intuition, or "gut instinct," as the
result of years of experience in medical practice. A clinician might
sense that something is wrong with a patient because the clinician has
lived through other, similar situations.
think a lot of what seems like intuition is actually observation,
a lot of training, and a lot of just repetition and judgment that
you've learned from making mistakes before."
don't know that it's really intuition. I think a lot of it is experience
and it's training. You learn to interpret and observe people very
something that I didn't just have off the bat. It's something that
came after a few years."
Being Open to Information
other participants, intuition about how to act resulted from being aware
of and open to sensory information beyond clinical tests and standard
diagnostic procedures. This information could be visual (eg, how a patient
looks or acts) or embedded in information given by the patient.
knows that there's an instinct thing and that some people are good
at it and some people aren't. I don't know if certain people are just
more open. You go in and you just get a feeling of how that person
looks and is moving around and acting. You know, I'll come up and
say 'I just didn't get a good feeling.' It's hard to quantify."
know, when a car goes by and you just know it's a Chevy. You just
know. It's hard to put into words."
3 Information from other
(spiritual, paranormal) sources
experience of intuition was identified by only a few participants. For
these clinicians, intuition came from a source outside the individual
and was not seen as a cognitive process. This form of intuition was
not the result of clinician experience, skill, or being open to other
sensory information; the clinician only needed to be receptive to it.
sounds really crazy, but sometimes I do feel it's more spiritual where
you almost feel like at some point, somehow, something tells you to
do something . You don't know why you did the right thing at the right
time, but you did."
closest thing I can even relate it to is almost like a psychic phenomenon.
You know, something just enters your mind as if another voice was
telling you information."
has nothing to do with you."
constraints were the most frequently named hindrance to practicing medicine
in a caring, attentive way. Clinicians said that they often chose to
ignore appointment time limits to give patients the time they needed
and that patients were willing to wait to receive this kind of attention:
way behind a lot of the time, but mostly they'll say 'It's worth waiting
for. I know you're going to spend the time that I need with me, so
it's ok to wait.'"
acknowledged that providing extra time for patients extracted a personal
cost from clinicians who chose to do so:
is a challenge, though, with our schedule, to provide that time. I
think it's a big issue that if you do provide the time, it's usually
your own time and not company time. That has a lot of problems, because
what I've found is that a number of the really good doctorswho have
provided that timeend up burning out and then they're not there."
results indicate that, as perceived by clinicians, qualities that patients
find important in interpersonal health care encounters are consistent
regardless of medical specialty, gender, years with Kaiser Permanente,
practicing as a physician or affiliated clinician, or schedule (ie,
whether seeing patients part-time or full-time).
physicians and clinicians would naturally be keyed to what patients
think is important by focusing on the questions of the AOM survey, these
attributes were initially chosen as important characteristics of overall
patient satisfaction. HRC has validated that these six attributes individually
show high correlation with overall satisfaction.9 Clinicians'
results on the "overall satisfaction" question were used to
determine the most highly rated cohort.
believe that what they do to satisfy their patients so highly and so
consistently is about interpersonal relations, not simply about ordering
the right test. Fundamentally, it is about listening, whether passively
(ie, by being quiet) or more actively (ie, by hearing patients' words
as well as by divining the meaning behind the words). The interpersonal
relationship skills necessary for patient satisfaction also include
being so attentive as to hear the person within the patient, being a
person within the professional, and being present in the moment enough
to share a personal moment. An ultimate demonstration of personal regard
is listening deeply and being present fully, as if the world is only
communication skills transferable, or do they just represent innate
ability that only a few elite professions possess? Observations made
in a Seattle public fishmarket confirm our belief that many people can,
with practice, learn to communicate in this effective way.10
How employees of the fishmarket interact with customers demonstrates
that people can learn presence. Paying attention and being present in
the moment have "street value," so to speak. These concepts
are illustrated by sample quotes from fishmarket employees:
have to always be there. I mean, being aware of what the customers
are saying. Actually dealing with them face to face."
are being with them. You are, like, just with them. Things are going
on all around, but you are taking care of just them."
with the people from moment to moment."
are 95% of the time present from moment to moment. You have to keep
bringing yourself back to being present now and do what you have to
full presence is important to customer satisfaction in a commercial
encounter, how much more important it must be in situations where health
care is the purpose of the encounter! The health care encounter should
provide an enhanced opportunity for the clinician to be attentive and
present. The encounter is a private, personally important, and meaningful
moment for patients because it relates to their health, their body,
their emotional well-being, and sometimes their survival.
elements of what clinicians think is most important about satisfying
patients in interactions are well-known and are taught in communication
courses. Clinicians with high patient ratings have not necessarily taken
these basic elements to a level of social sophistication or high intelligence
but have deepened the communication experience between two people to
create a highly respectful, personally meaningful, highly important
studies such as ours often identify new hypotheses for future exploration
and may confirm or explain hypotheses on the basis of previous work.
One such hypothesis is that clinician awareness of, and reliance on,
intuition in medical practice can influence both the process and outcome
of care. Further controlled studies will be necessary to understand
this phenomenon and its implications for education and practice.
Intuition and Intention
anthropology and transpersonal psychology literature demonstrate that
information flows between people in both sensory and non-sensory ways.
"Intuition" is a term used commonly to describe the knowledge
a person gains through this process. "Intention" is a conscious
and compassionate act of mentation intended to benefit the physical
and/or emotional state of another.11-13
hypothesis for this study was that in the highest-scoring clinicians,
intuition and intention were factors in creating patient satisfaction.
Patients were consistently highly satisfied because the clinicians better
knew what the patients needs were (intuition), and patients' felt more
cared about and cared for (intention).
and intention can have powerful therapeutic effects, especially in the
context of the clinician-patient interaction. These processes can result
in a therapeutic momentan intuitive moment in which patient and clinician
share knowledge of need or concern. A caring act of intention may initiate
the treatment process before the first pill is swallowed; or this caring
act may become the treatment itself (for example, validation of a self-care
approach that could work in place of a prescribed pill).
responses given during interviews grouped intuition according to one
of three themes:
that comes from experience,
that comes from being open to information from multiple sources;
from other (spiritual, paranormal) sources.
are trained mainly from a physical science perspective and from scientific
belief systems where knowledge is derived three ways: from collecting
and analyzing quantifiable, tangible, sensory data; from use of physical
techniques; and from applying physical agents and procedures. Clinicians
are taught that with time and clinical experience, they will develop
"clinical judgment," which is part of the art of medicine.
Given this orientation, the comments of this first group may be expected.
The clinical encounter is a vehicle for gathering historical and physical
examination information from a patient; for presenting therapeutic options;
and, more recently, for implementing a shared-decision process. However,
only a mental health therapist would view the encounter primarily a
group of clinicians, either because of their personality, holistic belief
system, or both, understands that the clinical practice of medicine
requires a broader perspective than physical science alone. These clinicians
are open to other information, value this information, and use it. They
admit that "non-scientific" (ie, subjective) knowledge is
not publicly acceptable to the medical community and do not discuss
this knowledge with colleagues or patients.
group of clinicians is willing to admit (at least confidentially in
an interview) to having a belief system that includes existence of "another
source" of information or to admit that people can know things
in ways that extend beyond usual sensory processes, even though these
ways are not understood. These clinicians state a belief that this way
of knowing could represent spiritual or psychic phenomena.
important to us as investigators is not to advocate for replacing current
interpersonal communication processes with intuitive and intentional
processes. Instead, we believe that creating awareness and some understanding
of processes that may be at work in the clinician-patient interaction
could benefit both patients and clinicians.
the sample size for this study was small, it represents 74% of the cohort.
However, other questions remain that were not addressed by this study.
First, the participants were not interviewed by a clinician; might clinicians
have solicited different responses or prompted deeper exploration of
some areas? Or would clinicians, acting as interviewers, have introduced
question merits additional research: On a scale of overall patient satisfaction,
what is the natural point of differentiation between competent and superior
patient communication during clinical interactions? The study does not
answer this question.
the main data is second or third derivative: 1) clinician intent and
attitude; 2) clinician behavior; 3) high KP patient satisfaction; 4)
clinician (self-perception) recall and description of clinician attitudes
and behavior. Something these clinicians do makes patients satisfied,
but it is not clear the clinicians themselves best know what that is.
Neither can we characterize structural or environmental factors at play.
we relied on face-to-face interviews with clinicians only.
now conducting research now in which we videotape the physician-patient
interaction and then interview patients and physicians about this interaction.
This research will deepen our understanding of highly successful interactions,
communication, and relationships.
health care delivery system, we must not only find ways to guide low-performing
clinicians toward greater competence. To substantially improve clinician-patient
interactions, we must elevate competent performance to high performance.
The learnings from this study give us guidance and tools for developing
this competence. The fish market employee's communication and service
behaviors are one example of how these skills are broadly transferable
and not just the purview of a select few.
successful tools for improving communication skills include CME courses,
tutorials, and coaching sessions, in addition to the "Four Habits
Model" (Table 5) the importance of which is confirmed by this study.13
Of particular note, a new video training tool is now available from
The Permanente Medical Group Physician Health Department, "Mindfulness
Practice for Busy Doctors and Healthcare Professionals," featuring
Jon Kabat-Zinn.14 With practice clinicians can integrate
minfulness (being fully present in the moment) into their patient interactions
and into interactions with their care teams.
service and commitment to the highest medical quality, are what we and
patients both want; patients view medical quality through their perception
of service quality. We must therefore enhance the work environment,
while providing sufficient time to be fully attentive to patients and
meet their highest expectations. We must also be willing to provide
the leadership direction , resources, and training to promote these
goals. Excellent communication is an aspect of excellent service that
distinguishes practitioners in the health care marketplace and can become
a hallmark of Permanente Medicine, thereby producing a sustainable competitive
advantage to enhance the health and well-being of our patients and our
Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review
of the literature on patient priorities for general practice care.
Part 1: Description of the research domain. Soc Sci Med 1998 Nov;47(10):1573-88.
McBride CA, Shugars DA, DiMatteo MR, Lepper HS, O'Neil EH, Damush
TM. The physician's role. Views of the public and the profession
on seven aspects of patient care. Arch Fam Med 1994 Nov;3(11):948-53.
Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking
primary care performance to outcomes of care. J Fam Pract 1998 Sep;47(3,):213-20.
Thom DH, Ribisl KM, Stewart AL, Luke DA. Further validation and reliability
testing of the Trust in Physician Scale. The Stanford Trust Study
Physicians. Med Care 1999 May;37(5):510-7.
Brody DS, Miller SM, Lerman CE, Smith DG, Lazaro CG, Blum MJ. The
relationship between patients' satisfaction with their physicians
and perceptions about interventions they desired and received. Med
Care 1989 Nov;27(11):1027-35.
Froehlich GW, Welch HG. Meeting walk-in patients' expectations for
testing. Effects on satisfaction. J Gen Intern Med 1996 Aug;11(8):470-4.
Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles W, Inui TS. Communication
patterns of primary care physicians. JAMA 1997 Jan 22-29;277(4):350-6.
Stewart MA. Effective physician-patient communication and health outcomes:
a review. CMAJ 1995 May 1;152(9):1423-33.
Weiss K. Measuring the reliability and validity of the Art of Medicine
Survey. Denver (CO): HealthCare Research, Inc January, 2001.
Fish! Catch the energy, release the potential [videotape]. Burnsville
(MN): Charthouse Learning Corp; 1998.
Dossey L. Reinventing medicine: beyond mind-body to a new era of healing.
San Francisco: HarperSanFrancisco; 1999. p 166-202.
Radin DI. The conscious universe: the scientific truth of psychic
phenomena. New York: HarperEdge; 1997. p 127-56,191-3,296.
Frankel RM, Stein T. Getting the most out of the clinical encounter:
the Four Habits Model. Perm J 1999 Fall;3(3):79-88.
Mindfulness practice for busy doctors and health care professionals
[video-tape], Oakland (CA): TPMG; 2001.