Patient-Physican Communication: Title and subTitle BreakIt's About Time

The last few decades have witnessed incredible progress in the scientific underpinnings of medicine. New discoveries and innovations have created sophisticated tools and technologies that have changed the way diseases are diagnosed and managed. Ironically, some of these technologies have taken precedence over one of the most important skills of the compassionate physician—the art of listening to the patient. Patients often experience physicians as being too busy to listen and too distant to care. Consumer Web sites abound with criticisms about physicians' deficiencies in communication skills. This appears equally true in Canada and in the United States, despite the major differences in their health care systems.

Concerns about physicians' communication skills are not really new. For decades, there have been calls for physicians to pay greater attention to the person with the disease rather than to the disease itself.¹ In 1925, Peabody² told Harvard medical students, “The secret of the care of the patient is in caring for the patient.” In the 1960s, Engel³ coined the phrase “biopsychosocial model” to describe the need for a new and broader medical model incorporating the psychological and social context of the patient. The Institute of Medicine popularized the use of the term “patient-centered care” to describe a model focusing on understanding the needs of the individual patient and tailoring specific treatment to them.⁴ Although the words may differ, each writer or organization has highlighted the same essential message—excellent medical care combines sophistication in scientific knowledge with equally sophisticated communication skills to understand the needs of the individual patient, to address his/her feelings and concerns with sensitivity and compassion, and to educate patients about their choices in care. The benefit of good communication on patient care and outcomes is unequivocal, whereas deficiencies in communication are associated with medical errors and a negative patient experience.⁵ So why has there been so little progress over the years?

First, effective communication with patients takes time. “Active listening,” a core skill in effective communication, requires that physicians listen deeply to patients telling the stories of their illness and how it has affected them. Even though some specific communication skills can improve efficiency, ultimately listening to patients requires time. Most physicians in clinical practice, as well as faculty members in academic medical centers, express a desire to spend more time with patients, but acknowledge that they are under intense pressure to be productive, measured in numbers of patients observed in units of time. Perverse incentives have contributed to physicians developing “efficient styles” that squeeze out time to listen because it is perceived to take too much time. Frequent handoffs in transitions of care, increasingly common today, make time to connect with patients even more challenging.

Second, medical schools and residency programs provide relatively little education about effective communication skills compared with the educational time devoted to teaching science and technology.⁵ Medical schools, particularly in the preclerkship years, have incorporated teaching communication into their curricula and often use observed structured clinical examinations to test students' communication and physical examination skills. However, in the clerkship years when students observe and participate more directly in the actual practice of medicine, communication skills are rarely addressed. The transition between medical student and resident is all too frequently accompanied by a deterioration rather than enhancement of communication skills. Although there are exceptions in family medicine, palliative care, and some primary care internal medicine programs, most residency programs have no structured curricula in communication. Furthermore, medical students and residents are rarely observed during their interactions with patients or given specific feedback to improve their communication. Busy faculty members, seeking to meet their own productivity targets, simply do not have time or otherwise prioritize the time necessary to provide the one-on-one supervision required to teach these skills.

Although time to listen to patients and teach communication skills may be scarce, technology is plentiful. Academic medical centers almost worship technology.⁶ Students are rarely criticized for ordering too many tests but could be for not having the results of a computed tomography or magnetic resonance imaging on hand. Some faculty members may insist that all laboratory tests and imaging are performed before they even observe the patient because having information from those evaluations at the first encounter increases their efficiency. Both faculty and hospitals have made more money by the use (and sometimes overuse) of sophisticated technology. Financial incentives, concerns about litigation, and perceived standards of practice that are not always evidence based have favored ordering tests over spending time with patients.

Academic medical centers, accrediting bodies, and policy makers could make changes to improve this situation. First and foremost, leaders in academic medical centers are responsible for signaling what is valued. They can deliver a clear message that faculty members are valued for their discoveries and innovations in science and their delivery of high-quality, patient-centered care. Metrics to measure and incentives to reward faculty can be aligned with both discovery as well as compassionate care. For example, quality of care programs should give physicians feedback on their performance based on peer and patient reports of their communication skills. Well-validated measures of patient satisfaction are available⁷ and 360-degree evaluations are increasingly used to provide feedback from peers and other health care team members.⁸ Physicians with low scores should be required to participate in intensive educational programs that have been demonstrated to improve communication skills.⁹ Patient satisfaction scores should be transparent to colleagues and to the public. Leaders should celebrate the accomplishments of individual faculty and the entire medical enterprise in achieving benchmarks in patient satisfaction with their care experience.

Medical education at the student and residency levels requires major efforts to increase the teaching of communication skills. This will require faculty development to enhance the skills of supervisors, many of whose own skills need retraining. Faculty development programs at the national level can support this training. Credentialing bodies, including the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education, require trainees to demonstrate competence in communication but also should increase the required standards for teaching and assessing these skills. The American Board of Medical Specialties should incorporate assessment of communication into certification and maintenance of certification. In fact, by 2012, the American Board of Medical Specialties will require some form of peer and patient assessment in maintenance of certification programs. Better assessment tools are needed to allow trainees and practicing physicians to measure their skills on basic and more advanced communication skills, such as disclosing medical errors and discussing patients' end of life care wishes.

Academic medical centers could also apply the science of quality improvement to analyze “communication errors” and develop quality improvement plans. Root cause analyses can be used to study breakdowns in communication between clinicians or with patients and families. It is likely that systematic analysis will reveal the need for improved communication among team members and the need for communication training within teams. Patient complaints about their care can be analyzed using similar methods. Patients can be active participants in quality improvement efforts by providing their views of potential strategies for improvement.

At a policy level, it is critical that physician leaders articulate the effect of proposed reimbursement systems on the patient-physician relationship. Incentive systems that focus rewards on the number of patients observed will have the consequence of decreasing the time a physician can spend listening to patient concerns. Leaders can advocate for reimbursement that incorporates patient feedback as a component in payment—just as clinical quality metrics are being used and will soon be tied to physician payment.

Science and technology have advanced enormously over the last decades but ultimately the best medical care requires deep knowledge of science as well as the skills to communicate effectively with patients. If the medical profession wishes to maintain or perhaps regain trust and respect from the public, it must meet patients' needs with a renewed commitment to excellence in the communication skills of physicians. It is time to make this commitment.