For many thousands of years, medicine had little to offer patients in the way of diagnosis and treatment. Early healers were limited to a listening ear, a caring touch, and an empathetic voice. With the transition to evidence-based medicine and its resulting explosion of medical knowledge, physicians focused ever more on learning and practicing interventions based in physical biology. Unfortunately, despite the great benefit of clinical understanding, some of what was good in medicine has been lost.
Skilled communication can help lower A1c, cortisol levels, heart rate, and blood pressure, all of which result in measurable relief of suffering and reduced dependence on the varied chemical supplements we are all too fond of prescribing.
Conversely, patients can show improvement in clinical measures yet also suffer anxiety, loneliness, fear, and pain, which may aggravate and even endanger an otherwise positive prognosis.
Patients today need physicians who practice both the science of medicine and the art of healing. A positive patient experience is strongly correlated with positive clinical outcomes, financial performance, and an inverse relationship to lawsuits. Longitudinal patient experience data represents the effectiveness of a therapeutic relationship, not the impression of a single visit.
Transforming the patient experience requires relationship-building and communication skills, which can be taught just as clinical exam knowledge is. The value of these skills is in relieving emotional suffering and building a therapeutic relationship. Patients are more likely to comply with therapy and continue care when they trust us and feel safe.
While the term “ritual” may feel uncomfortable in the world of randomized controlled trials, ritual is in fact a primitive checklist — in this case, a series of steps that, when repeated consistently, serve to create feelings of safety and trust between client and caregiver.
Abraham Verghese, MD, has pointed out that the clinician’s white coat of today is purely a ritualistic symbol, and continues to be worn despite its negative impact on infection control. The stethoscope has attained similar symbolic status. Just as these symbols help to inspire confidence, clinical and business literature on communication reveals that there are also specific actions that, when consistently performed during a patient encounter, foster feelings of trust and safety. These include sitting down, making eye contact, being cognizant of nonverbal cues, reflective listening, proper computer etiquette, and the use of a patient agenda.
At Hawaii Pacific Health, in January 2016 we began applying an evidence-based approach to the art of healing. From a list of best practices culled from literature searches and direct observation of high-performing physicians, we created a checklist of steps for physicians to consistently perform during patient office and hospital visits. While our physicians were not required to perform the entire list, they self-identified those items they already practiced, and then were asked to select at least two more from the checklist. In some cases, exam rooms were modified to allow proper performance of the checklist, such as moving handwashing stations to just inside the door so this could be the first action upon entering the room, or replacing fixed wall mounts with tethered computer carts to allow physicians to sit facing the patient.
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Our system’s overall performance on the CGCAHPS physician communication composite score improved from the 54th percentile to 75th percentile over a period of one year for a group of 200 physicians, 50 of whom received coaching for communication skills.
Physicians selected for coaching were identified from the 30th to 75th percentile according to Press Ganey national rankings, as they were felt to be actively engaged but possibly lacking in knowledge of clinical communication skills. These physicians were encouraged to choose one or two new skills from the list and incorporate them until they could perform them consistently and sincerely in each office visit, with scripting if necessary. However, physicians at the low end of the Press Ganey performance data who volunteered for coaching also received training, sometimes with dramatic results. The most important criterion was a willingness to learn.
Though we may not normally think of the modern patient-physician encounter as a ritual, it is in fact susceptible to the same process improvement that use of a checklist has demonstrated in the operating room and the airline industry.
Physicians with good relationship skills have lower rates of burnout, experience greater career enjoyment, and can apply these skills in building relationships with their colleagues and staff. Communication skills that reduce pain, relieve anxiety, and create understanding help transform the dry term of “patient experience” into a therapeutic relationship, in which both the provider and patient benefit.
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Barbara Andrews
Thank you for this resounding vote for strong clinician-patient communication skills! The Institute for Healthcare Communication, a nonprofit based in New Haven, Connecticut, has been teaching exactly these skills since the 1980s. People often ask if such skills truly make a difference—here is some evidence of measurable improvement. Another, related, factor that influences patients’ satisfaction with healthcare is the communication skills of support staff members. IHC also offers communication skills workshops and coaching training for support staff. Visit us at http://healthcarecomm.org/.
November 14, 2017 at 10:54 am
nancy english
This is an impressive study, yet, to some of us in the nursing profession you have achieved what any two year nursing student must achieve in order to pass her nursing studies. You also failed to mention the midwives through out the world who were providers of care to women during their most vulneralbe time, childbirth, were required to do what your 'skill' list indicated for physicians in the 21st Century. Although it is to your credit to admit such a failure of your profession during the past century.
Nancy English Ph.D. APRN
November 15, 2017 at 12:49 pm
Bob
The checklist is a pretty good outline. It brings the patient into the discussion rather than the recipient of directives. I would add to the outline of next steps, inclusion of how much each costs and asking the patient if they are ok with this plan or do they have any suggestions.
November 15, 2017 at 2:12 pm
NWWell.com
It’s utterly false to state that doctors with ‘better communication skills’, whatever that means, have lower rate of burnout. In fact the more sensitive you are, the more attuned to what’s going on, the more caring, the greater the chance for burnout. The uncaring, who don’t mind giving nothing of themselves to patients, who could care less about patient feelings, they have a wall of immunity. Less likely to be a target of admin bullying, less likely to be affected by anything, less likely to burn out.
November 16, 2017 at 2:43 pm