Abstract

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a national annual report that surveys patients and rates health plans on a variety of metrics, including claims processing, customer service, office staff helpfulness, and ability to get needed care. Although physicians may feel they have no immediate control over many aspects of this questionnaire, there is an important area of the survey where they do have direct control: “how well the doctor communicates.”

It is well established that effective physician–patient communication has beneficial effects not only on physician and patient satisfaction but also on adherence to medical advice, diagnostic accuracy, and malpractice risk. The creators of the CAHPS survey developed and incorporated four questions seeking to ascertain the patient’s impression of the physician’s communication skills. These questions assess how well the physician listened carefully to the patient, how often the physician explained things understandably, how often the physician showed respect for what the patient said, and how often the physician spent enough time with the patient.

Many excellent clinical communication models exist that touch on aspects of the CAHPS topics, but it behooves physicians to be mindful of the exact survey questions. The ALERT model of communication was developed to facilitate physicians’ recall of these measures. By incorporating key verbal and nonverbal communication skills, clinicians can address and improve their scores on this important area of the CAHPS survey.

Introduction

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is an evolving and comprehensive family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care.1 The CAHPS program is funded and administered by the US Agency for Healthcare Research and Quality. The survey covers topics of importance to consumers, including accessibility of medical services and physician and clinician communication skills. The CAHPS program seeks to assist organizations, purchasers, and consumers in assessing the patient-centeredness of care, comparing health plan performance, and ultimately improving the quality of care. Since 1999, the National Center for Quality Assurance has required CAHPS survey results from health plans (including Kaiser Permanente (KP)) seeking accreditation and submitting data as part of the Healthcare Effectiveness Data and Information Set.

Although the CAHPS Health Plan Survey (Versions 3.0 and 4.0) are extensive and cover many important areas pertaining to the delivery of care, individual physicians may feel that much of the survey content is out of their immediate influence. Fortunately, the portion of the survey covering physician–patient communication is clearly under the direct control of the clinician. As the CAHPS family of surveys has continued to evolve and expand (such as the development of HCAHPS for hospitalized patients as well as Adult, Child, Commercial, Medicaid, and Dialysis Center-specific surveys to name a few), the elements pertaining to physician communication have remained consistent. In addition, the CAHPS survey questions assessing effectiveness of clinical communication align well with other survey tools currently in use, including Art of Medicine, used by the Colorado Permanente Medical Group. If physicians are aware of the exact questions on the CAHPS questionnaire that focus on clinical communication, they will be better able to hone their skills to address these important metrics.

Here, we explore the four CAHPS questions in the “How Well the Doctor Communicates” section of the survey and highlight ways of improving these skills on the basis of existing research. The four CAHPS questions focus on the patient’s perception of how often the physician listened carefully to the patient, how often the physician explained things understandably, how often the physicisn showed respect for what the patient said, and how often the physician spent enough time with the patient. The ALERT model was developed to aid physicians and clinicians in recalling the CAHPS questions:

• Always:

• Listen carefully

• Explain things understandably

• Respect what the patient says

• Manage Time perception

Clinical Communication

It is well established that excellent physician–patient communication enhances a variety of important metrics, including improved physician and patient satisfaction,2,3 better patient compliance,4 reduction in medicolegal risk,5 and improved health outcomes.6 Medical schools and residency programs across the US are developing and employing innovative communication curricula for physicians in training.7 Banking on the assertion that good communication skills are “learnable, teachable, and improvable,” many practicing physicians participate in communication workshops to improve these important skills.8 Even the American Board of Medical Specialties is partnering with CAHPS to develop and incorporate clinical communication assessments into the physician Maintenance of Certification process.9 Fortunately, many excellent models exist to assist physicians in enhancing their clinical communication skills, including the “Four Habits”10; “Inviting, Listening, Summarizing”11; and others.12,13 There are also online resources available with skills training and research services, including those provided by the Institute for Healthcare Communication and the American Academy on Communication in Healthcare (www.healthcarecomm.org and http://aachonline.org, respectively). Thus, by using existing communication models and resources to better understand the CAHPS questions focusing on physician–patient communication and recalling the ALERT mnemonic, physicians can address and improve these skills.

The ALERT Model

Always

Because we do not know which patients will receive CAHPS questionnaires, excellent clinical communication must be used consistently with all patients. The CAHPS report provides information as to whether the patient felt that the physician never, sometimes, usually, or always used the specific communication skill. Understandably, physicians often score higher when usually and always are combined in terms of grouping survey results, and the scores tend to drop when always is the lone standard. That is, we often use effective communication but do not always do so. It is our hope that clinicians will use these skills always and not only when convenient. Practice and awareness will facilitate consistency.

Listen Carefully

The art of listening is a critical piece of physician effectiveness. From auscultating a cardiac murmur to listening to a dictated radiology report to hearing the story of a patient’s illness, active listening is one of the key ways in which we take in clinical information. The CAHPS survey seeks to ascertain the patient’s perception of whether the physician listened carefully. How is it that we can take in verbal information used to make critical decisions yet give the impression that we are not actually listening? Physician and author Fred Platt, MD, has gone so far as to say that “inaccurate and ineffective listening leads to diagnostic and therapeutic disasters and convinces our patients that they are in the hands of incompetents.”14p14 Indeed, active listening is necessary and important across the entire spectrum of care, from the simplest office visit15 to the most complicated inpatient scenario.16

Effective listening requires awareness and participation on the part of the clinician. We must express to the patient that we are listening by being fully present. This can be demonstrated in the following ways:

• Maintaining eye contact while the patient is speaking

• Sitting down, leaning in, and keeping an open and receptive body posture

• Using reflective statements such as paraphrases and summaries (“What I hear you saying is that ... ,” “Let me make sure I understand ...”)

• Avoiding interrupting the patient’s story--being quiet and paying attention

• Avoiding multitasking, such as shuffling papers or typing on the computer

• Avoiding unnecessary interruptions when possible (door knocks, pager, cell phone)

Physicians’ use of these simple concepts will allow patients to more fully tell the story of their illness and thus feel listened to, heard, and understood.

Explain Understandably

The initial part of a clinical interview typically centers on relationship-building and information-gathering; the latter part is steeped in information sharing. According to Frankel and Stein,10 investing in the end of the clinical encounter emphasizes delivering diagnostic information, providing a clear rationale, exploring potential barriers to adherence, and providing support. The CAHPS survey question is again asked from the patient’s perspective: “Did the doctor explain things understandably?” As clinicians, we may feel that we have explained things very clearly, yet from the patient’s view, this may not be the case. It is incumbent on physicians to ensure that patients can understand all diagnostic and therapeutic options as clearly as possible. A recent study of Permanente physicians from the Hawaii and Southern California Regions found that those with the highest patient satisfaction ratings offered more detailed and effective explanations to patients using simple language than did physicians with low ratings.17

Many clinicians have had the uneasy feeling that what was just explained to a patient or family was not well understood. Reasons for poor comprehension may include fear, mistrust, dementia, hearing impairment, time factors, language barriers, health literacy issues, and overuse of medical jargon. It is estimated that more than 90 million Americans cannot adequately understand basic health information, and this obstacle affects people of all ethnic groups and income and education levels. Former US Surgeon General Richard Carmona has stated that clinicians must “communicate in plain simple terms and take the time to confirm comprehension.”18

Patients perceive that their care is thorough and appropriate when they have received enough information to understand the problem and options relating to treatment. Effective explanations can be enhanced by doing the following:

• Explaining the rationale for tests, treatments, and consultations (“I’m ordering this blood work to see if we can find a reason for your fatigue.”)

• Using simple, easy-to-understand terminology whenever possible

• Speaking slowly, clearly, and at an appropriate volume

• Avoiding medical jargon and abbreviations

• Discussing treatment goals and outlining expected course of recovery

• Exploring barriers to compliance (eg, cost, travel, work schedules)

• Providing resources (handouts, diagrams, after-visit summaries)

• Checking for understanding, comprehension, and agreement

• Asking if there are additional questions or areas needing clarification.

A useful technique for assessing patient comprehension is the “teach back” method, in which patients are asked to restate the rationale and plans in their own words. This should be done in a supportive and nonthreatening manner so as to not embarrass the patient or family. The physician could say, for example, “Okay, Mr Jones, I know that when you get home, your family is going to want to know what we talked about today in terms of your knee pain. What are you going to tell them?”

Respect What the Patient Says

The CAHPS question asking how often the physician showed “respect for what you say” can be confusing to some clinicians and potentially offensive to others. Aren’t we the medical experts? Isn’t the patient in the office to hear what we have to say? Perhaps in a bygone medical era, physicians could give their point of view without considering the patient’s thoughts or wishes. However, we are now in an information era, in which many patients have very definite ideas about their care plan. With the emergence of the Internet, direct-to-consumer advertising, and a host of other readily available medical-information sources, patients are showing up on our doorsteps more informed (and occasionally misinformed) than ever. Many patients want to collaborate with the care team and be actively involved in decision making. It is incumbent on physicians to be accepting, even welcoming, of patients’ points of view pertaining to their care. The CAHPS question seeks to ascertain whether the physician respected what the patient had to say and thus the patient’s point of view. It is important to note that respect does not necessarily imply agreement; simply put, it means acknowledgment of what the patient has to say. Interestingly, a 2007 Consumer Reports survey of 39,090 patients found that of those who rated their physicians as “excellent,” 77% felt that their doctor treated them with respect.19

How do physicians demonstrate respect for the patient’s point of view? In response to the Consumer Reports survey findings, Caleb Alexander, MD, of the MacLean Center for Clinical Medical Ethics at the University of Chicago, stated that “physicians have to establish a climate of trust and safety where patients’ concerns are heard in a nonjudgmental fashion” (emphasis added).20 Clinicians need to be sensitive to patients’ frame of reference and be careful not to devalue their health beliefs. Patients respond best to physicians who are genuinely curious about them, and they shut down when they feel they are being viewed in an overly generalized, stereotypical way.21 Although many variables can add to the complexity of the demonstration of respect (differences in age, culture, sex, education, experience, and personality, to name a few), in the simplest terms, to be respectful is to be humble. Respect is manifested by behaviors that reinforce a patient’s dignity.22

Demonstrating respect for what the patient has to say can be accomplished by using skills outlined in habit 2 (elicit the patient’s perspective) of the Four Habits model10:

• Ask for the patient’s ideas about his or her illness (“What do you think might be causing this problem?” “What worries you the most about this?”)

• Elicit specific requests from the patient (“How might you and I work together to solve this problem?” “I see you’ve been downloading information from the Internet. Tell me what you’ve come up with so far, and I’ll share my thoughts with you.”)

• Explore the impact on the patient’s life (“How this is affecting your ability to get through your workday?”)

It is critical to the establishment of a trusting and therapeutic alliance that we discover patients’ beliefs and theories about their illness. We must be willing to discuss and respect their beliefs even if we disagree with them.

Manage the Perception of Time

Perhaps one of the most pervasive complaints of both clinicians and patients is a lack of time. Feeling rushed or hurried is frustrating to all parties. Indeed, with an ever-increasing emphasis on value and efficiency in health care delivery, quality time between physician and patient is an increasingly valuable resource.23 The CAHPS survey asks, from the patient’s point of view, whether the physician spent enough time with him or her. One solution for this problem would be to add more time to all visits, but research suggests that simply increasing the length of each appointment may not necessarily improve the patient’s perception of time spent. The aforementioned study involving KP patients and physicians found that patient satisfaction ratings were not significantly related to the length of the visit.17 The challenge is thus for the physician to manage the perception of time. This can be accomplished with careful attention to good clinical communication skills.

While studying patients’ “entitlement” to time with their physician, Pollock and Grime found that it is the perceived quality of time, rather than just quantity, that is critical to patients’ experience of office visits.24 What improves the quality of the time spent? Research suggests that when patients have their emotional needs met--when they feel listened to and understood--regardless of the actual time spent with the physician, they are satisfied not only with the visit but also with the visit length. Furthermore, those satisfied with the quality of the visit are more likely to comply with medical advice.25 In short, physicians can create the sense of more time through the process of improved listening and understanding. Patients who are left feeling that a visit was too short may say more about the content of the visit than the time on the clock.

Clinicians concerned that slowing down, listening, and uncovering patients’ emotional needs might actually lengthen the visit and cause them to run late can take comfort in the findings of a study involving visits to primary care and surgical specialists.26 In these audiotaped encounters, physicians who responded empathetically to patients’ emotional needs had visits that averaged 2.5 minutes shorter than the visits of those who ignored the emotional needs. That is, careful listening and appropriate empathetic responses actually saved time for the physician and likely improved the perception of the quality of time for the patient.

To enhance the patient’s perception of time spent with the physician, try the following:

• Focus on demonstrating listening, empathy, concern, and understanding

• Sit down during the interview

• Maintain eye contact

• Avoid appearing rushed or hurried; don’t look at your watch or the clock

• Use open-ended questions to allow the patient time to speak

• Avoid rapid-fire and closed-ended questions

• Keep patients apprised of wait times and delays.

Remember that although we may not be able to add minutes to the clock, we can affect the patient’s perception of time by improving the quality of the time.

Conclusion

Clinician awareness of the CAHPS survey areas looking at communication in the examination room is an important step toward improving scores in this area. The metrics of listening carefully, explaining understandably, respecting what the patient says, and improving the patient’s perception of time can be easily remembered by recalling the ALERT mnemonic. Careful consideration and consistent use of the skills embedded in these areas should enhance patients’ perception of our clinical communication and lead to improved CAHPS scores. Most importantly, however, improved physician–patient communication leads to healthier patients, better medical outcomes, and happier physicians.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

We thank Scott Smith, MD, Associate Medical Director for Primary Care and Service for the Colorado Permanente Medical Group, as well as the Primary Care Leadership Team for their invaluable input and support regarding this work.

Katharine O’Moore-Klopf of KOK Edit provided editorial assistance.

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