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Good Communication Is Not Magic

The role of communication between physicians and patients is sometimes regarded as merely the soft side of medicine. Perhaps more damaging is that even when communication skills are valued, many view them as innate and unquantifiable, thus precluding efforts at improvement. I am grateful to this issue's commentary author Mr. Al Perry for raising awareness of the importance of physician-patient communication to achieve clinical practice success, and for suggesting that this communication is amenable to quality improvement efforts.

Good communication increases patient recall of information, adherence to therapy, satisfaction and, ultimately, clinical outcomes such as diabetic glucose control and functional status.¹ Communication success and failure appear to generate more gratitude and complaints than any other aspect of the work performed by health care professionals and, among non-VA primary care providers, poor communication has been associated with malpractice claims.²Most importantly, substantial evidence confirms that the individual components of good communication can be identified and that physicians can be taught to improve those skills.³

These data all suggest there is no conflict between achieving the "desired clinical outcome and a positive patient experience."In fact, they are one and the same. To truly achieve the desired clinical outcome one must strive to include a positive patient experience. Good communication is not about just being nice. It is about finding ways to interact with patients that enhance their interests.

What does good communication look like? It starts with patients that feel empowered to ask questions and make their needs known. It continues with physicians that use reflective listening skills to elicit and clarify patients' concerns, and that respond to empathic opportunities (i.e., emotional cues) with unambiguous empathic language. It includes the ability to negotiate and arrive at a shared agenda that reflects both patient and physician priorities. Finally, it requires the giving of information in a way that is understood and retained by patients and their loved ones.

Changing the Communication Culture

Transforming the VA into an institution where patients can expect such an encounter on every visit is not something that will be accomplished through a single CME course or innovative clinical practice. Rather, this is a culture change that will depend upon multiple, empirically-based efforts directed toward patients, physicians, and the system.

First, physicians must learn better skills. Many doctors have received little formal communication training or none at all. The key to successful training is practicing communication skills with observation and feedback. Intensive courses are the gold standard and, although these may seem time consuming and expensive, they can be cost-effective given the potential improvements in quality and cost savings from unneeded tests, referrals, and treatments. On the horizon are computer-based communication skills training programs that use physicians' own recorded conversations for feedback, as well as avatars, and thus achieve the same results without the requirement for a multi-day course.

However, efforts to improve physician-patient communication that concentrate only on physician skills will never fully address the problem; interventions must focus on patients as well. Patients' barriers to disclosure of concerns do not relate solely to physician behavior. A number of proven interventions exist that promote patients' abilities to seek information, ask questions, make their needs known and, in general, achieve a greater sense of control. These include prompt sheets to complete prior to visits, the ability to review their recorded encounters with their doctor, and coaching to help patients formulate questions and overcome barriers to asking. Computerized approaches to such tools are also in development and, with added sophistication, have the potential to be effective and relatively simple to introduce into the clinical setting.

A third cutting-edge tool that can be explored is the introduction of direct observation of clinical encounters for the purposes of quality improvement. The VA is currently very good at providing feedback to physicians about their patients' physiological parameters, such as blood pressure control or hemoglobin A1c. Technology exists to audio-record clinical encounters and code them for the use of ideal communication skills. Although more complicated than simply extracting an A1c from Computerized Patient Record System (CPRS), the value of the feedback could be significant.

Finally, true culture change toward enhanced physician-patient communication will require the alignment of incentives to reward good communication. For example, physicians are currently rewarded for completing multiple clinical reminders during each patient visit. Although worthy individual components, addressing the sum of them in a given visit, particularly if it involves detailed on-screen instructions, may not result in an overall patient-centered experience. We should look at how many of these reminders can be moved out of the physician-patient encounter itself (e.g., patient self-report using tablet PCs), so that the time spent together can focus on patients' concerns. The recognition by VA leaders' such as Mr. Perry that good communication is central to excellent health care is a critical first step toward changing the culture. Communication research has advanced to the point where proven interventions are available that could enhance patients' overall experiences. Both physicians and patients will benefit if we can find ways to integrate these innovations into the health care system.

References

1. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the Effects of Physician-Patient Interactions on the Outcomes of Chronic Disease. Medical Care 1989; 27:S110-27.
2. Levinson W, et al. Physician-Patient Communication. The Relationship with Malpractice Claims among Primary Care Physicians and Surgeons. Journal of the American Medical Association 1997; 277:553-9.
3. Fallowfield L, et al. Efficacy of a Cancer Research UK Communication Skills Training Model for Oncologists: a Randomised Controlled Trial. Lancet 2002; 359:650-6.