Rx for time-crunched physicians

15 july 2008-With their waiting rooms crowded and exam rooms full, many physicians say they are too busy to be good communicators. Those who study physician time-management think otherwise. Certain communication skills can foster efficiency and effectiveness during an office visit without sacrificing rapport with patients, according to researchers at the University of Washington (UW) and the University of Rochester.
Their guide to a smoother flow of communication between doctors and patients appears in the July 14 issue of the Archives of Internal Medicine. Their model is based on the authors' observation: "Effective communication in primary care must include skills that enhance the quality of care while helping patients and physicians use time wisely… Making the best use of available time is important for visits of any duration."
The researchers are Larry Mauksch, a UW behavioral scientist in family medicine who studies and teaches doctor/patient communications; David C. Dugdale, an internal medicine physician and director of the UW Hall Health Primary Care Center; Sherry Dodson, UW clinical medical librarian; and Ronald Epstein, professor of family medicine, psychiatry, and oncology at the University of Rochester School of Medicine and Dentistry and its Center to Improve Communication and Health Care.
A few of the lessons the researchers presented in the resulting article, "Relationship, Communication, and Efficiency in the Medical Encounter: Creating a Clinical Model from a Literature Review" are:
First, focus the purpose of the visit with the patient: Instead of addressing each issue as it surfaces, creating a list at the start enables the doctor to confirm which problem is most medically urgent or most important to the patient. This approach also reduces the "Oh, by the way" issues brought up at the end of the visit.
Then, understand the patient's perspective: Exploring the patient's viewpoint is useful for promoting self-management, suggesting healthy changes, assessing motivation, learning the patient's family and cultural beliefs, understanding the social and psychological problems that are diminishing the patient's ability to function, or getting to the root of medically unexplained symptoms.
Near the end, reach a mutual agreement on a plan: The physician and patient decide on approaches the patient is willing to follow to manage or prevent the health concerns explored during the visit.
Throughout the office visit, it's helpful for physicians to:
Establish rapport and maintain the relationship: Some ways doctors do this are by eye contact, recognizing others in the room, or a brief warm greeting, such as, "Nice to see you." On the other hand, too much small talk steals away time from considering the patient's problems.
Practice mindfully: This occurs when physicians pay close attention to their own beliefs and reduce distractions in order to observe their patients' response to what is being said and done, and adjust accordingly. For example, a doctor lecturing on excess weight might notice the patient withdrawing. The doctor stops and asks about the patient's views. A physician who doesn't continuously monitor the interaction or doesn't check in with the patient may cover areas of little interest to the patient, and miss significant issues.
Track topics: Sometimes an interview veers off course, particularly when there are multiple topics and no clear agenda. Unless the conversation is redirected, it's likely that no clear decisions will be made on some problems before the end of the visit. Sharing an impression of what has and hasn't been covered and realigning by agreeing on what to talk about next can keep the discussion organized.
Acknowledge cues: When a physician responds with empathy to a patient's cues, a patient may reveal beliefs and preferences that can shape a successful treatment plan. Also, once their concerns are taken into account, most patients don't keep restating them. This saves time.
"Visits with the doctor that contain these fundamental elements," Mauksch said, "lead to greater patient satisfaction, better adherence to medical regimes, increased self-management, better health outcomes, lower costs, and fewer malpractice claims. These skills enable physicians to do it right the first time, so they don't have to do it over."
"We've tried to propose a model of doctor/patient communications," Dugdale added, "that is at the intersection between what patients need and the reality of a doctor's world. These are skills that make a difference and that doctors can use throughout their entire careers."
Some Facts on Doctors' Office Visits
During their careers, physicians conduct upwards of 100,000 patient interviews, making it the most common "medical procedure" in an office setting.
The mean length of time spent with a doctor during an office visit: 18 minutes.
Primary-care patients bring up 3 to 6 concerns per visit.
A physician's communication style tends to remain the same regardless of the length of the visit.
Teaching Doctors-in-Training How to Do Office Interviews
Patient communications are addressed in medical schools and residency training programs, but after starting practice, many new doctors abandon what they learned.
Larry Mauksch, who is on the faculty of the UW Department of Family Medicine, said it's difficult for medical students to learn doctor/patient communications only through classroom lectures or reading. Medical student training at the University of Washington (UW) includes observations of actual, enacted and Web-taped doctor visits.
Trainees use checklists to monitor specific parts of a medical encounter and they learn to put a name to specific skills. Students rate video demonstrations that are missing core communication elements and identify strategies for improvement. They also observe one another to help each other learn. Communication skill building is a key component of the UW medical school's introduction to clinical medicine course for second-year medical students and the family medicine clerkship for third-year medical students.
Some senior medical students take a clinical clerkship that concentrates on patient-centered communication. Mauksch likens the method he uses to the training of an athlete or a musician, where students have many opportunities to try out their skills, get comments, and try again, with refinements.
"Students experience for themselves how specific communications skills help them avoid pitfalls in patient interactions and make better use of time," Mauksch said. "They see themselves becoming more effective and enjoy their work more."
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