Patient Engagement

Time to Start Using Evidence-Based Approaches to Patient Engagement

Article · March 28, 2018

Seasoned clinicians have vast experience in patient interactions, through which they have learned many helpful techniques. But in this era of evidence-based medicine, we should be more discerning. Would you trust a surgeon who told you, “I haven’t had any formal training for this procedure, observed any experts, nor received feedback on my skills, BUT over the course of time, through trial and error, I think I’ve found what works for me”? That is essentially how physicians were “trained” in communication skills for decades. Even though most of us know that it is the right thing to communicate effectively, humanistically, and compassionately, fewer of us know that over the past quarter-century or so, patient-clinician communication has become a prominent field of scientific research. Important findings from these data affect almost every patient interaction we have.

Overall, effective communication leads to increased patient and clinician satisfaction, increased trust with the clinician, and functional and psychological well-being. Effective communication also leads to improved outcomes in specific diseases, including a small but significant absolute risk reduction of mortality from coronary artery disease, improved control of diabetes and hyperlipidemia, better adherence to antihypertensives, bereavement adjustment in caregivers of cancer patients, and higher self-efficacy of adherence to HIV medications. Patients with medically unexplained physical symptoms (the kind that lack easily identified biomedical diagnoses) report significantly higher levels of satisfaction when their clinicians use effective communication skills. A recent review found that a strong patient-clinician relationship has a beneficial effect on overall health care outcomes with an effect size approximately equal to taking a daily aspirin for 5 years to prevent myocardial infarction. What’s more, unlike aspirin, good patient-provider relationships do not cause GI bleeding.

Data also show that clinicians do not communicate as effectively as they think. There are certainly systemic factors that interfere with the way that most clinicians would like to practice optimally. Even so, there is still a gap between what we think we’re doing and what we’re actually doing. We do not elicit the full spectrum of patient concerns so as we prepare to leave, we need to wrestle with “doorknob” questions that make us less efficient. We redirect patients after 18–23 seconds and rarely allow them to return to their thoughts. We unreliably seek patients’ perspectives of their illnesses and inadequately address their emotions, which further wastes time in medical encounters. We incompletely attend to cultural differences. We use incomprehensible jargon and don’t confirm that our patients understand their diagnosis and treatment plans.

The negative outcomes of our ineffective communication are measurable: Outpatients do not return to clinicians with poor communication skills, and readmission rates for inpatients are higher. What’s more, perceived failures in communication, or patient experiences of humiliation by poor communication from clinicians, are associated with more malpractice claims.

There is good news. Clinicians who elicited the patient’s full list of concerns and prioritized the agenda for the encounter reported an increased sense of control and enjoyment. Explicitly addressing patients’ emotional cues appears to save time. Participants completing a mindful communication program had higher well-being and attitudes toward patient care. Clinicians who underwent a daylong communication skills course showed higher patient experience scores, increased empathy scores, and lower burnout scores when compared with those who did not.

It’s tempting to search for a “quick fix” to help clinicians with low patient experience scores. But as chief medical officers and patient experience staff have begun to discover, one can’t acquire proficiency by attending a 30- or 60-minute lecture. There is a dramatic difference between learning a concept and learning skills. Whether you were on a soccer team or in an orchestra, you know that skill improvement and achieving mastery requires deliberate practice and feedback. No one would ever expect a proceduralist to attend an hour-long didactic and then immediately perform a new procedure with complete proficiency. For communication skills expertise, we must note the complex needs, desires, histories, approaches, stories, assumptions, and psychology that every individual patient brings to a relationship. Data on effective communication skills programs show that they are typically full-day trainings, start with learners’ goals and needs, and focus on application of learnings to clinical practice.

Skills-based exercises, including role-play, in small groups or through individualized coaching, are more effective than isolated didactic presentations; specific feedback on communication skills is the most important element that contributes to heightened patient experiences of care. Specifically, at the Academy of Communication in Healthcare, we teach an educational framework and rationale for communication skills, followed by a demonstration of how the skills apply to a typical clinical case. Then, in small group skills sessions, rather than using canned patient scenarios, we invite participants to volunteer their own clinical cases to adapt these skills to their particular practices.

For example, Dr. Hospitalist might invoke a case of an inpatient admitted for pneumonia, whom another group member will portray. In a skills session using the framework of agenda-setting, we will carefully set up the scenario so that Dr. Hospitalist will succeed in eliciting the patient’s full list of topics to discuss. Once the short scenario is completed (typically in less than 5 minutes), we will ask Dr. Hospitalist to reflect on how effectively she used the skills, and then we will ask other group members for feedback. In a diverse group of providers, cases can range broadly, including those that involve inpatient and outpatient circumstances, medical and surgical procedures, and general, specialty, and subspecialty-based professionals. Our experience in using this learner-centered method is that the vast majority of clinicians find the skills helpful in their everyday practices and feel renewed dedication and energy in their careers.

While communication skills training is not a health care panacea, it can reliably improve quality of care, patient outcomes, and patient and provider experience. In some instances, the data have existed for well more than a decade, yet only recently have market forces, such as value-based purchasing and emphasis on patient experience, started to exert influence on these most interactive — and human — of provider behaviors. Though there are some glimmers of hope at places that have adopted provider communication training — such as Mayo, the Cleveland Clinic, and several other health systems across the country — we still have a long way to go. As recent technological advances drive people toward interacting with devices rather than directly with others, in the health care setting, interpersonal communication skills have never been more important. In the high-stakes setting of health, well-being, and wellness, a trustful, caring relationship between patient and clinician leads to better outcomes for both.

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