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Communication Practices of Physicians With High Patient-Satisfaction Ratings | to pdf >> Introduction How do primary care physicians with outstanding patient-satisfaction ratings communicate with their patients? Which specific practices distinguish them from less effective communicators on the basis of measured performance? To answer this question, we videotaped 92 adult primary care visits in Southern California and Hawaii and interviewed both physicians and patients separately. Each participating physician and patient viewed the tapes of the visit and shared their perceptions of the communication aspects of the visit. We also audiotaped these debriefing sessions. To identify successful physician communication practices, exam room visit behaviors and comments from the postvisit debriefs were coded and compared with each physician's panel-level patient satisfaction. In the final section, we describe communication strategies reported by physicians with high patient-satisfaction ratings. The quality of physician-patient communication in primary care visits is related to patient satisfaction,1 adherence,2,3 litigation,4 quality of data collection,5 utilization patterns, and clinical outcomes.6 There is evidence that communications between physicians and patients are sometimes inadequate.7-9 In addition, disruptive communications reduce the quality of worklife for physicians. Thus, improvement in physician communication skills has great potential for both the quality of medical care and for the physician work environment. Methods Participants Patients: We videotaped 92 adult primary care visits with patients who were already scheduled to see these physicians during the time of filming. We invited patients to participate in a videotaped visit with their physicians. To respect privacy, the camera was covered during some physical examinations. Patients and physicians were informed that all comments would be completely anonymous.
Audiotaping
of Postvisit Commentary Narrative
Analysis Up to three sources of data were used for coding: researcher, patient, and physician perspectives. When two or three perspectives were present, it was possible to assess multiple perspectives on the same visit, ie, a form of triangulation.12 Sometimes the physician or the patient commented on a topic but not both. Occasionally the patient and the physician both commented on the same issue, but disagreed. In these cases, discrepancies were typically resolved in favor of the patient's opinion. For example, if the patient believed the physician explained well, but the physician or the researcher did not, the patient's opinion was used. Some categories were coded on the basis of researcher observations, such as the number of consecutive sentences of storytelling. Additional detail on sources of data and priorities for resolving discrepancies are found in Table 1. Further details on the definition of the coded practices are included in the findings section. A large database was used to record notes, large sections of the visit dialogue, physician and patient comments, and to assign codes. The coder had no information on the physician's patient satisfaction scores when performing the coding. Later the performance data was added to this database. Correlations
Between Practices and Patient Satisfaction Results Spearman rank order correlations between physician practices and patient satisfaction scores with correlations exceeding r = 0.35 (p .01, n = 45-55) are presented in Table 1. Twelve coded practices met this criterion. These practices were examined to look for higher order commonalities. After several iterations, five major categories of practice emerged that described the behaviors that discriminated between High, Medium, and Low Group physicians. The resulting model and the relationships between the categories are illustrated in Figure 1. The following sections describe the categories and practices found in Table 1. Quotations from the exam room visit are used to exemplify each practice found to be related to patient satisfaction.
Focus on the Patient's Agenda (Rather
than Focusing Primarily on Clinical Issues or Visit Management) In contrast, physicians from the Medium Group and, especially, High Group were focused much more on the patient. They attended fully to the patient's medical concerns, and also considered what the patient would need to move forward in the management of his/her condition(s). They were cognizant of the patient's history and barriers to progress. They assessed current patient concerns, affect, readiness for next steps, and tailored their actions to support the patient's development. In effect, they helped the patient be an active participant in their care. For example, the first remark by one High Group physician was "I do a lot of reassuring for this patient ... I think what she came in for is dialogue." Drawing Out the Story Use
Active Listening Responses During Patient Storytelling
Users
of active listening responses were generally unaware that they were
responding in this manner. When they listened to their videotapes,
some were surprised that they were saying "okay" or "uh
huh" so much. One physician wondered if it might annoy the
patient, but none of the patients in the debriefing sessions indicated
dislike for these responses. To the contrary, during those sections
of the visit, patients often mentioned that they appreciated that
the physician was listening.
Low Group physicians were more likely to either be silent throughout the storytelling or they might interrupt the patient to start the biomedical questioning. Listen to 3-5 Uninterrupted Patient Sentences Low Group doctors were more likely to interrupt the patient after only one or two sentences were communicated. High Group physicians typically left room for patients to relate three to five consecutive sentences during storytelling. (Active listening responses were not counted as interruptions.) Typically, sufficient listening required less than 30 seconds, consistent with time frames reported in the literature.5,13 Note that important storytelling did not always occur at the start of this visit. Often the first minutes were used in rapid dialogue about lab or test results. One or more stories of interest to the patient often came up later in the visit.
Some
Low Group physicians could not tolerate non-pertinent "digressions."
The patient would respond to having their question ignored by repeatedly
bringing up their issue, to which the physician would still not
respond.14 This situation was unpleasant for both parties.
One physician whose patient had multiple serious conditions objected,
"This is a waste of time here. I just wanted the chronology."
Another consequence of failure to listen effectively was observed among some of the Low Group physicians who failed to detect and/or address language barriers, cultural differences, or literacy problems that could have affected the relationship. Listening did not always open a Pandora's Box. Only a few of the patients took advantage of physicians who were good listeners. Even an emotional story could conclude in good time when the patient felt heard and understood. In the following transaction, a High Group physician noted: "If patients have a chance to say what is on their mind, they often return to the medical issues on their own," as illustrated in this dialogue with her patient. Physician:
"Well hello there. Good to see you. Patient: "We had a fire." Physician: "Oh my!" Patient: "I am living with my niece now. I was going to move, then the fire." Physician: "Oh!" Patient: "Everything turned out pretty good. Everything is put in place now. So, what was my blood pressure?" Physician: "It was 112. That is pretty good, much better ..." Give
Patients the Opportunity to Express Fears and Concerns Ask
Probing Questions, Especially Regarding Patient Concerns Despite positive patient perceptions of medical questioning, some Low Group physicians felt uncomfortable about patient perceptions of probing questions. Some assumed that patients disliked medical questions because it seemed like they were "interrogating" the patient or being too "nosy." Patients did not report objections to physicians asking questions. Use Physician Self-Disclosure (for Patient Education) Some of the High Group physicians were comfortable using self-disclosures to normalize, to teach, or to build a sense of commonality with the patient. For example, one physician shared that her husband was also on statins. She thought sharing that information would be more memorable than hearing a risk reduction percentage. Women physicians with children often shared this fact with patients. Patients often commented that they liked having their physician share personal information with them. These physicians were selective in their use of self-disclosure. The disclosures were always relevant to the patient's development. For those who used this approach, it felt natural and they were confident doing so. Demonstrate Understanding Investing a little effort to build a strong relationship with patients was typical among High Group physicians. There were three practices related to this concept: empathic responses, demonstrations of caring, and familiarity with patient's history. Respond Empathically Empathic responses were defined as remarks or actions that signaled to the patient that the physician understood what the patient was trying to communicate. The physician showed s/he heard the patient's message and/or recognized the implications of the patient's situation. Sometimes these were responses to patient's emotional reactions, but more often the patient was trying to describe a situation, context, barrier, or symptom that the patient believed the physician needed to understand. Responsive actions showing understanding of the patient's situation might be changes in body language, voice tone, deciding to order a test, or examining the patient. The High Group physicians were more likely to 1) detect an opportunity to respond to an important patient thought or feeling and 2) to respond to the clue, proving to the patient that the physician understands the patient's experience. Sometimes they missed the opportunity during the visit, but detected it in the tape. In contrast, Low Group physicians generally did not detect missed opportunities. Other times, there was evidence of intellectual understanding of the patient's situation, but they did not communicate the insight. For example, they might report their empathic understanding to the research assistant during the debrief, but did not share their insight and understanding with the patient.
Physician: "You had a colonoscopy a few years ago. That was good ..." Patient: "I don't want to be on the receiving end of one of those again." Physician: "Worse than the sigmoid?" Patient: "I handled that one better." Physician: "Okay then. We won't be giving you another one of those!"
Show
Caring Patient: "If you felt strongly, I would [do the stress test]. But, normally a company would be concerned about costs ..." Physician: "I want to have this conversation ten years from now ... I need to help you to stay as healthy as possible ... If you were my father, I would have you do it ... If you leave it to me, I would schedule it." Patient: "I will take your advice." High Group physicians often made statements that suggested they were concerned about their patients as individuals. They liked to make small investments in the relationship when there were special opportunities to build trust and a relationship and to improve adherence in the future. Some of the High Group physicians discussed communication approaches that contribute to a strong relationship.
The Low Group physicians were less likely to effectively demonstrate their caring to patients. After viewing his tape, one physician expressed his disappointment that he "didn't seem warm and fuzzy" with the patient. He was unsure how he could change this perception. Low Group physicians were also more likely to make remarks that were insensitive or otherwise detracted from the relationship. Some facts can be hurtful if shared insensitively. For example, one physician told his patient that she was 80 pounds overweight in an offhand manner on the way out the door. The patient reported her surprise and distress in the debriefing. Show Familiarity with the Patient's Medical or Social History
Provide Detailed Explanation Explain What is Happening and Why Patients of all educational levels sought detailed information about what was happening to them and why. "I'm lucky to get him back," a patient of a High Group physician remarked. "You picked a good person to study. He takes the time to explain. Not all doctors are willing to do that." Medium Group and High Group physicians tended to offer more detailed explanation to patients using simple language than Low Group physicians. Some of their approaches are described below.
A patient described how a High Group physician provided the "personal touch."
Explaining well requires explaining effectively and handling all issues that the patient raises (although some issues were negotiated to a later visit for some patients).
Present
Options to the Patient High Group physicians typically built a case for a new medication over several visits and repeated information. Several physicians explained that patients want to understand why they need a medication or they would not take it. For example, one High Group physician worked with the patient as an advocate, empathically confirming that the patient did not like medication, and hoping that diet and exercise would work instead, then asking the patient's perspective. Patients complained about physicians who prescribed medication without explaining the reasons for the drug, the side effects, and/or did not seek their perspective. They reported that they did not use those prescriptions and they did not inform the doctor of their decision not to adhere to the plan. One High Group physician was able to collaboratively work with a patient on psychosocial and health issues. After the patient complained about his relationship with his wife, the physician supported the patient's decision-making process. Physician: Is this something you need help on? Patient: We tried that ... We saw a marriage counselor ... My wife is defensive. She says, 'He smokes too much; he drinks too much.' It didn't work. Physician: Right. Patient: Everything wrong is my fault. I can't get her to open up. We have various counselors. One said 'Get rid of her' ... quote unquote. Physician: What do you want? Patient: I can't afford to divorce. Physician: There is a person who comes here, if you want to start with yourself. And then she can recommend what comes next. Patient: Also I learned she hates to admit to doing something wrong. Physician: The problem is that all these stresses affect your overall health. Patient: I know where you are coming from ... [Other discussions followed, including smoking cessation.] Physician: So on the counseling, you want to hold off or try that? Patient: I have to do something. I am tired of being the bad guy ... Physician: See you back in four months. Patient: Check my ears for wax before you go? [quick exam] Physician: Bingo ... You have some now ... Use these drops. Patient: I think I covered all the bases. I accomplished a lot.
Complete the Patient's Agenda Delivering
what was Promised; Responding to Questions Patients were pleased when the physician agreed to pursue an issue that was of interest to the patient, but not the physician. The following is an example with both the physician and patient comments on the interaction. Physician: "When he mentioned the tingling, I thought carpal tunnel. He was worried about it being a side effect of the drug. I was sure it was carpal tunnel ... but I did the full exam and I think he is satisfied. He brought it up, so he is worried about it." Patient:
"He has a lot of knowledge and he expresses it to help you
know what is going on ... It's great ... He sets my mind at ease.
Either it is not as bad as I think it is or I am not thinking right.
I was worried that I was doing more damage ... He explains things
in detail ... Nothing is left out ... I bring a list usually and
we go down the list and he and I discuss everything on the list
... I like that he spends enough time on each issue and does not
push you through. He makes you aware of what he is going to do.
You feel a little more at ease."
In another visit, a male patient asked his doctor about his father's (a previous patient) problem with blood in the urine. The physician took a minute to share some advice. The patient thought highly of his doctor for taking the time to help him understand. The patient said, "I appreciate her answering my question about him, her explaining the reason. She seems quite concerned. I am very comfortable with her." The physician remarked, "I spent time on this issue. His father used to be my patient. Men don't talk about these things. This must bother him a lot to share this with me." High Group Physicians Describe Their Communication Strategies During the debriefing sessions, the physicians were not asked about their philosophies of patient care or strategies for interacting with patients, but many of the High Group physicians volunteered general approaches to working with patients. As a group, the Low Group physicians offered little information about their communication strategies. The approaches they did mention seemed to be less differentiated. For example, some emphasized only the importance of maintaining eye contact with the patient. Some of the Low Group physicians believed that when they had problems communicating with patients, they should be more direct with patients. In the previous section, the practices that correlated with patient satisfaction were discussed. The following section summarizes the communication strategies volunteered by the High Group physicians. The following is a list, not ordered by frequency of mention by the physicians. Use of these practices may or may not be correlated with patient satisfaction. The High Group physicians mentioned the following approaches to interviewing patients: Personalized Greeting As one physician explained, "I spend time greeting and acknowledging each patient. You have to look at each person. Each person is a little different." Listening
Feedback Being Responsive/Flexible The High Group physicians tried to respond to inquiries that were important to the patient (even if these were not the most pressing clinical issues)
Teaching and Explaining Some of the educational strategies mentioned by High Group physicians included:
Covering Topics of Interest to the Patient High Group physicians tried to be comprehensive, covering questions that were important to the patient, even though these might not be the most pressing clinical issues. Handling Psychosocial Issues Many of the High Group physicians wanted to be sensitive to patient fears and work to help patients with their concerns. Approaches to psychosocial issues included: active listening, reassuring, and reviewing what has been done and what actions can be taken. One physician discussed how a depressed patient was handled. "Her husband died a couple years ago. They were childhood sweethearts, married since their teens. He died of cancer ... She has been depressed since the death. She was hesitant to try antidepressants. We clarified some issues through talking about her daughter (who is doing well on antidepressants). It was a window of opportunity. There were many fears to address. "As a physician, you may think you have it all wrapped up. But there is what we know and there is communicating it to the patient. We are educators and we are like salespeople. I think it will make her feel better. This is trying to change behaviors. I am trying not to seem judgmental. She feels guilty about being depressed. It took a lot for her to come in today with all that is going on ... I am sharing what I hear her saying. I acknowledge the pain. There are options [for her]." Nonverbal
Communication
Patients often expected a physical examination. Some of the High Group physicians believed that touching was a natural and important element of communication for them. They touch patients on the arm, hand, or shoulder or hug them. One physician explained, "I use a lot of hand gestures. I am not just talking. Otherwise, they lose interest. It helps." Physicians were sometimes surprised how much they gestured. Patients seldom mentioned gestures, but they did notice whether the physician was looking at them and sitting down in contrast to standing over them or reaching for the door. Use
of the Exam Room Computer
Discussion The importance of physician-patient communication is well established. From our analysis it is clear that High Group and Low Group physicians communicated differently with their patients and that these differences are noticeable to patients and clinicians. The findings suggest an approach to improving physician communication with patients. The general theme emerging from this research is the importance of the patient's agenda. First, identifying the patient's agenda needs to be part of the physician's agenda. The physician draws out the patient's agenda with active listening responses, allowing the patient time to describe their concern(s) and to express their fears, and then asks the patient questions. During this time, a personal connection can be built using empathic statements and showing familiarity with the patient's history, both of which tend to add depth to the relationship and contribute to the patient's perception and feeling of being cared for. Next the physician returns to the patient with details to normalize or explain the reasons for the problem and how it might be addressed. The physician explains any options for managing the problems. Finally, the physician verifies that the items in the patient's agenda were addressed or negotiated to a future visit. Neglected issues interfere with the relationship and the flow of the visit and frustrate the patient and physician. These findings are compatible with the Four Habits Model,15,16 which has been widely used within KP to train providers in physician-patient communication skills. The four major categories of the model (invest in the beginning, elicit the patient's perspective, demonstrate empathy, and invest in the end) are well represented in the study's correlational findings and in the communication strategies shared by the High Group physicians. The study findings show specific ways that KP physicians apply the Four Habits.
Additional research with a narrower focus could be conducted to replicate specific findings of interest suggested by this exploratory research. Acknowledgments The authors would like to thank the physicians, staff, and members of the Southern California and Hawaii Permanente Medical Groups and Permanente Health Plans. We extend special thanks to Edward Thomas RN, MBA, Director of the Garfield Memorial Fund for his assistance with the project. References
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