Communication Training:
Worth The Investment?

When Harvard Medical School recently surveyed over 2,000 patients about their office visits, poor communication with their doctors emerged as THE most likely cause of dissatisfaction and switching physicians.

The Harvard study highlights a need that America's medical schools are already acknowledging: the importance of stronger communication skills. Approximately 75% now offer courses on this topic. Physicians long out of medical school are discovering that attending professional communications workshops can lead to more accurate diagnosis, better patient compliance, higher retention rates, more referrals, lower staff turnover, reduced malpractice premiums, and fewer lawsuits.

Gains may be intangible, as well: asked to cite a benefit of his communications training, Fred Husserl, MD, instantly replies, "Sanity!"

In 1989, burnt out and considering quitting nephrology, "I used to walk in, see certain names in my [appointment] book, and get a knot in my stomach. The issue was being able to handle those parts of medical practice that have nothing to do with medicine, which can become more of a problem than the textbook part that I know well," he reflects.

Dr. Husserl credits a communications workshop with improving both his and his patients' behavior. Understanding his own attitudes helped him learn how to help a patient make a change, remain neutral when his advice is ignored, and discover "how I can be the best doctor for that particular patient." Estimating that 50% of his patients are addicted to tobacco, alcohol, or another unhealthful habit, Dr. Husserl says, "Unless you know how to work with the patient and help them through that, you can't practice good medicine." He's proud that he now has a good rate of smoking cessation, the strongest single statistical contributor to death from renal disease.

Convinced that becoming a better communicator enabled him to stay in nephrology, Dr. Husserl took an advanced workshop so he can train residents at the busy Ochsner Clinic Foundation in New Orleans, where he is Acting Head of the Nephrology section. "Now, when patients don't receive a requested answer or prescription, they don't leave angry, frustrated or feeling not listened to, but with a sense that we had an honest disagreement. There are very few, if any, difficult patient interactions that I can't handle. I leave my practice each day knowing I have no unfinished business (like a disagreement with a patient) -- I don't carry home any angst." Although he's limited his practice to nephrology, Dr. Husserl says, "My measure of success is that a few times a month, a patient or their family member asks me to be their GP."

The Need for Better Communication

In the Harvard study, 12% of subjects had considered changing doctors. "Physicians underestimate patients' desire for health information and overestimate the amount of time they spend providing it. Patients want to feel heard," observes lead investigator Nancy L. Keating, MD, MPH, a Health Care Policy researcher. "Providers' decisions to limit tests, procedures or referrals are often entirely appropriate. Communication strategies to increase discussion about such decisions may result in fewer patients leaving the office feeling they were not provided a needed service," the authors suggest. (Journal of General Internal Medicine, January, 2002).

Patient frustration or disappointment may even signal a potential legal problem. Examining the association between patient complaints and doctors' risk management experience, "Risk appears related to patients' dissatisfaction with their physician's ability to establish rapport and communicate effectively," report Gerald B. Hickson, MD, and his colleagues at Vanderbilt University School of Medicine. (JAMA, June 12, 2002)

Why is dialogue so difficult? "Most medical training involves learning about disease-but much of the time, we also deal with the person wrapped around the disease. Pathophysiology encompasses all the sciences related to disease. The 'science' of dealing with the rest of the person is communication," explains Frederic Platt, MD, a general internist in Denver who also teaches communication skills at University of Colorado School of Medicine.

The Value of Better Communication

Fortunately, the essentials of good communication (listening, understanding, exchanging information, empathy, etc.) can be learned--and a growing number of physicians are choosing to acquire them.

Bayer Institute For Health Care Communications, the leading firm in this specialty, has trained over 40,000 clinicians and health care staff in more than 3,500 workshops. Associate Director Vaughn Keller, Ed D, finds that, "A truly skilled physician will get different diagnostic information than an unskilled communicator, who frequently will not get significant health problems to surface. Communication also affects adherence to a therapeutic regimen, because the doctor never really it talked it through with the patient. Skilled communicators can have a tremendous impact on whether a patient makes lifestyle changes," says Dr. Keller, a Lecturer in Medicine at Yale School of Medicine.

Dr. Platt concurs. "Too often, doctors get the story wrong. Asking, was the pain more on the right side or the left side, helps lead to a correct diagnosis, critical to treatment. People want to be heard and understood. Patients feel better right away if you give feedback showing your understanding and confirmation. The key value of better communication is improving the quality of patient care and the likelihood of a good outcome."

Steven Zabrowski, MD, a general internist in Plainfield CT, has a private practice, in addition to working with ProHealth Providers, an 80-office group practice. He, too, is pleased to see higher compliance rates and better quality of care. "It takes less time to listen initially than to have patients come back in deteriorating condition, and not get better. If people are comfortable calling you, they'll come for treatment earlier than they might otherwise."

Last year, staff turnover was 33% at ProHealth, which has 200 providers throughout central Connecticut. . Since communications training began last November, turnover is down by 50%. "We were very pleased. It's so expensive to recruit and train new staff, we have to make staff retention a company priority," Dr. Zabrowski stresses. Communications training at ProHealth involves everyone who works at each facility. Dr. Zabrowski has found that office atmosphere, including more harmonious communication between physicians and support personnel, has a strong influence on patient satisfaction and retention.

Conversely, with a dissatisfied patient, "you're not just losing the patient, but all the potential referrals he or she could have made," says Susan Keane Baker, author of "Managing Patient Expectations" (Jossey-Bass, 1998). A specialist in service quality and patient satisfaction, Baker believes the biggest stumbling block in most medical practices is that patients are sometimes reluctant to voice complaints because they don't want to be perceived as difficult. "Without being asked, they may not share important information," she cautions.

The Legal View

Physicians' Reciprocal Insurers (PRI) of Manhasset, the second largest medical malpractice writer in New York State, is actively involved in training physicians they insure. For over two years, they've offered a Bayer workshop, Clinician/Patient Communication, and they're adding The Difficult Clinician/Patient Relationship, after working with Bayer to tailor the programs to the needs of PRI clients.

What's PRI's incentive? "Our principal reason is to support our doctors in their practices. Diagnosis and treatment rests in large part on communicating with a patient. We believe ­ and the data support ­ that a physician who is better able to communicate will find more adherence to treatment. The literature points to minimized instances of malpractice," says Marjorie Thomas, PRI spokesperson, "and we believe it will help to decrease the number of malpractice cases."

The training, part of PRI's Risk Management Education program, allows a physician to earn a 5% premium credit for completing both the workshop and the follow-up home study project. Similarly, Colorado Physicians Insurance Company also considers good communication essential, and encourages their doctors to attend communications workshops, reducing their premiums by a small amount upon completion.

Training Options

Communications training programs range from a few hours to the week-long workshops offered by Bayer, a not-for-profit organization established in 1989. "For changing communication behavior, there really is a dose response," notes Dr. Keller. "It's not unlike language training." All trainers stress the necessity for role-playing, practice and feedback to actually improve skills. Listening exercises are crucial.

In Bayer's highly-regarded one-week course on Clinician/Patient Communication, the small-group format provides one trainer to every three or four health care providers. (In addition to MDs, courses may be attended by ODs, MPHs, nurse-practitioners or other health professionals.) Standardized patients simulate a particular situation, helping participants learn specific communications techniques as well as strategies for dealing with patients they experience as difficult. Follow-up includes meeting with a "coach" for one hour per month over the next year, to review audio or videotapes of patient visits.

Programs can be offered through hospitals, national and state medical associations, insurance companies, or at a training firm's facility. Large group practices sometimes hire an experienced trainer to present an on-site program to their participating doctors. Some individual trainers, like Susan Keane Baker, will work with a small group practice staff (of six or more employees), in sessions of several hours.

CME credits may be available; Bayer Institute courses are fully recognized by the Accreditation Council of Continuing Medical Education, for example. The American Academy of Family Physicians gives credit to members who take a recognized communications course. Some training programs provide credit that meets state risk management requirements, or counts as points in a particular insurer's system.

Fees vary widely. Bayer's one-week program, at its West Haven CT headquarters, costs $2,500, which includes all materials and most meals. However, when presented by a sponsoring organization (such as the American Academy of Orthopedic Surgeons, Veterans' Health Administration, or PRI), the same communications workshops are usually free to participants. In addition to providing instruction, the sponsoring group typically covers the cost of materials and CME credits. (In PRI's case, doctors not insured by the company are welcome to attend their workshops, for a fee.)

Improvement in communication skills can actually be measured. The usual tracking instrument is the Patient Satisfaction Survey. "Our data show that 75% of people in the one-week program jump at least one quartile on surveys; 40% jump two quartiles," reports Dr. Keller.

Patient Satisfaction Surveys are also an excellent diagnostic tool. "When health care organizations start doing them, they gradually begin to see what the difficulties are in their own practice," Baker's learned.

Personal Rewards

Dr. Keating, also a primary care general internist at Brigham & Women's Hospital in Boston, has been affected by the results of her own study. She now tries to "be more aware of how I'm interacting with my patients, and to identify what their expectations are during a particular visit or conversation. At the start of each interaction, I say, 'tell me what's on your mind today,' which gives the patient the chance to shape the agenda." Before her research, she was less conscious of trying to elicit a patient's real concerns, and feels she's far better at it now. "My belief is that it will make my patients trust and respect me more, have more faith in my recommendations, and come to see me more freely," she says.

"How many times do I leave a patient with the sense that our relationship is sour or strained?" asks Dr. Husserl, the formerly discontented nephrologist. "Almost never. I may have time pressure, but no feeling of a situation I really can't handle. Commmunication skills have given me the satisfaction of making medical practice pleasant, and the control and confidence to handle difficult issues that come up with patients."

RESOURCES FOR READERS:

To get more information about communications training programs, check with your malpractice insurer, medical associations, or hospitals where you have admitting privileges to see if they offer (or recommend) courses. Any of these providers can be contacted directly:

Bayer Institute For Health Care Communications www.bayerinstitute.org For a complete catalog of courses, call 800-800-5907

Society For Teachers of Family Medicine www.stfm.org 800-274-2237 Established in 1967, the society has over 5,000 teachers of family medicine

American Academy On Physicians & Patients 703-556-9222 A consortium of physicians who teach communication skills to medical school faculty

Susan Keane Baker www.susanbaker.com 203-966-4880 Request a copy of their special report, "100 Ways To Make Your Organization More Patient-Friendly."