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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At the Doctor’s: Coaching for Communication and Patient Satisfaction

By ERIC NAGOURNEY
Patients often have a lot of questions when they are visiting the doctor, then realize later that somehow many were either not asked or not really answered.
But with coaching by the doctor’s office, a new study reports, some of the communication problems can be eased.
Writing in The Cochrane Library, researchers said that to be effective, the preparation should be done the day of the appointment, not in the days or weeks ahead. The coaching is often done either in person or by giving guides like checklists to the patients to help them figure out what to ask and to remember to ask it.
The researchers, led by Paul Kinnersley of Cardiff University in Wales, reviewed more than 30 studies from 6 countries and found that patients who were given the coaching expressed more satisfaction with their care. Perhaps not coincidentally, their visits tended to be longer.
There are many reasons patients don’t get enough information. They can be nervous, unsure how to phrase a question or simply forget to ask it.
But often, the study said, the fault may lie with the doctor. “Clinicians may underestimate or undervalue the information needs of patients,” the researchers wrote. “They may also lack the skills to give information effectively.”
While one solution may be to better train doctors, the study said, doing so might take a lot of resources and, in the end, not make a big difference. The researchers said it might simply be more effective to train patients.
The researchers looked at studies involving more than 8,000 patients. While coaching patients and giving them written materials were found to have the same benefit, patients responded more favorably to coaching.

Most Patients Prefer Their Physicians to Greet Them With a Handshake and Introduction

June 19, 2007 — Most patients prefer their physicians to greet them with a handshake and to introduce themselves using their first and last name, according to the results of a survey reported in the June 11 issue of the Archives of Internal Medicine.
"Widely used models for teaching and assessing communication skills highlight the importance of greeting patients appropriately, but there is little evidence regarding what constitutes an appropriate greeting," write Gregory Makoul, PhD, from Northwestern University Feinberg School of Medicine in Chicago, Illinois, and colleagues. "The purpose of this study was to provide some guidance for medical students, residents, and practicing physicians by defining patient expectations for physician behaviors during the greeting stage of medical visits."
In a computer-assisted telephone survey of adults in the 48 contiguous United States, the investigators asked closed-ended questions about preferences for shaking hands, use of patient names, and use of physician names. To characterize patterns of greeting behavior in everyday clinical practice, they also analyzed an existing sample of 123 videotaped new patient visits.
Although patient expectations varied somewhat with patient sex, age, and race, most (78.1%) of the 415 survey respondents reported that they wanted the physician to shake their hand, 50.4% wanted their first name to be used when physicians greeted them, and 56.4% wanted physicians to introduce themselves using their first and last names.
Videotapes showed that physicians and patients shook hands in 82.9% of visits but, in 50.4% of the initial encounters, physicians did not mention the patient's name at all. However, physicians tended to use their first and last names when introducing themselves.
"Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior," the authors write. "Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.... Greetings create a first impression that may extend far beyond what is conventionally seen as 'bedside manner.'"
The authors have disclosed no relevant financial relationships.
Arch Intern Med. 2007;167:1172-1176.

Learning from both ends of the stethoscope

INDIANAPOLIS – A systematic review of studies published over the past four decades has confirmed that good doctor-patient communication makes a difference not only in patient satisfaction but in patient outcomes including resolution of chronic headaches, changes in emotional states, lower blood sugar values in diabetics, improved blood pressure readings in hypertensives, and other important health indicators. The review, published by researchers from the Indiana University School of Medicine and the Regenstrief Institute, Inc. and colleagues from the Centers for Disease Control and Emory University, appears in the April 2007 issue of Medical Care, a journal of the American Public Health Association.
“In looking at these 36 studies we learned many things. For example, research on non-adherence to doctor’s instructions has focused on bad or poor behavior by patients rather than on the clarity of the physician’s instructions or whether the physician actually checked to see if his or her instructions were understood by the patient. The physician assumed that the patient understands and thus will comply. But is this a logical assumption? We don’t assume that when a pilot and an air traffic controller converse that they have understood each until there is an affirmation of understanding. That acknowledgement is lacking in most patient-physician encounters,” said Richard Frankel, Ph.D., IU School of Medicine professor of medicine and Regenstrief Institute research scientist, senior author of the study. Dr. Frankel is a sociologist who studies ways to improve the doctor-patient relationship. He is currently investigating how behavioral changes by both doctors and patients impact medical care.

http://www.eurekalert.org/pub_releases/2007-04/iu-lfb040907.php