Getting to the Heart of the Patient Interview
Steps to Healthy Physician-Patient Communication

By Susanna Donato
Susanna Donato is a writer for Physicians Practice

Every physician has had one. A patient who nods and smiles through the appointment but later forgets important instructions; calls after a visit to confess the real problem, or rambles in the exam room.

A classic study of physician-patient interviews conducted in 1984 by Howard Beckman and Richard Frankel found that the first step in great patient communication begins with the physician first listening to hear what the patient has to say. Physicians typically interrupt a patient just 18 seconds after the patient begins to speak, according to the study. Hopefully, things have improved over the past 20 years, but hearing the patient remains just the first step in great patient communication.

“Often, patients come in for one [stated] reason. They might have a second reason for the office visit but aren’t comfortable saying so upfront,” said James Woods, M.D., chairman of the Department of Obstetrics and Gynecology at the University of Rochester, New York, Medical Center. “If you interrupt them and they never get to say the real reason, that’s a big mistake.”

Learning to listen
Historically, medical school students were not given pointers on how to speak with patients, according to Steven L. Blum, M.D., an attending physician at Rush North Shore Medical Center in Skokie, Ill., and an assistant professor at Rush Medical College in Chicago, Ill.

“I’ve learned over the years that things like the patient history can be so much more important than the physical exam,” said Blum, who today gives his students the following patient communication pointers:

• Sit down. “That conveys to the patient that you’re taking time to see him. If you stand the whole time, the patient will assume you’re in a hurry,” Blum said.
• Make eye contact.
• Ask the patient to tell his story. “Let the patient talk at least for a minute or two about whatever he needs to talk about. He’s going to need some direction because you need to focus, but the problem may not be what’s immediately apparent.”
• Shake hands. “Treat patients like, ‘I’m a person, and you’re a person.’ A younger doctor might even be nervous; so, you need to put the patients at ease and see them as human beings, not as diseases or entities to be diagnosed.”

Teaching communication
Times are changing. Most medical schools now offer some communication training, according to Elizabeth Morrison, M.D., M.S.Ed., director of research in the Department of Family Medicine at the University of California at Irvine.

“Sometimes, it’s just a matter of not having experience,” said the Irvine, Calif.-based physician. “The student knows what should be said but hasn’t ever said it before, so he or she may not be comfortable saying it.”

Even experienced physicians’ communication skills are improving, in part because of industry initiatives. Although Woods said some would disagree, he believes better and more open patient communication could eliminate part of the nation’s medical malpractice crisis.

“In any survey, about a quarter of lawsuits are submitted by patients because they’re angry that no one will talk to them about what happened and why it happened,” Woods said.

Woods, who also is an author and a speaker on the topic of conveying difficult information to patients, believes physicians have trouble telling patients all the facts for several reasons.

“Young [physicians] seldom have incurred significant events in their lives, such as dealing with serious illness, and that’s a disconnect,” Woods said. “The best thing they can do is mentally take off their white coat and their M.D. and think about what they have in common with patients to make them a little better at communicating difficult issues.”

How does your office communicate?
Communication is part of an overall atmosphere that makes a patient feel comfortable — or not.

Bob Kieserman, M.B.A., a professor of health administration at Arcadia University in Glenside, Pa., last year led teams of students to review physician practices on their communication policies, particularly on practice management aspects.

“When a patient walks in your door, the doctor has to remember that this person is a customer,” Kieserman said. “I truly believe that many doctors don’t see patients as customers. None of us would wait three hours to do much of anything else besides see a doctor.”

Kieserman’s student teams looked at areas such as the magazines available in the waiting area, how long patients had to wait in exam rooms, the degree of concern for comfort and entertainment and whether patients were updated when a physician had been delayed because of an emergency.

Efficient listening
All this concern for patient comfort might sound like it could take forever, but experts swear that is not the case.

“If you become more efficient at communicating, you don’t have to spend more time,” said Sara Miller, Ed.D., a physician coach based in Howell, Mich. “On the whole, patients aren’t going to speak for 15 minutes [if you let them talk]. They’re going to express themselves in two or three minutes.”

Morrison agreed. “It takes a lot less time than we think to let the patient and family, if they’re there, speak before we jump in. I try to ask more open-ended questions at first and give them a chance to tell me what’s going on in their own words.”

Listening can improve outcomes, according to Morrison, who believes involving the patient and family in the decision-making process lets patients take ownership of their care — thereby increasing compliance.

“The more they can buy in and personalize [care plans] for how they’re going to manage them, the better, because it’s the patient and family who are going to achieve those goals, not the practitioner,” she said. “We’re a trusted advisor, but we’re not going to live with those goals.”

To help patients retain what physicians communicate, Woods encourages physicians to write down information.

“We’re finding that if information is written, patients can remember 75 percent [of it]. If patients are told information, they remember just one-third of the time,” said Woods. “More physicians also are being encouraged to ask patients, after they’ve received a discussion, to speak back what they heard.”

Finally, Morrison advises physicians to look within. “We have to find ways to renew our enthusiasm and to focus on our own well-being as practitioners,” she said. “We’re busy and practice issues are challenging. From time to time, we need to remember why we decided to become physicians in the first place. That can be positive for the physician and for the patient.”

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