The biggest problem in communication is the illusion that it has taken place.
—George Bernard Shaw
I’ve learned that people will forget what you said, people will forget what you did, but they will never forget how you made them feel.
There I was in the clinic, toe-to-toe with a 75-year-old woman yelling at me, “I need steroid pills!” She had a patch of four small hives on her right arm. She also had diabetes and osteoporosis. I sat down and asked her if she would like to sit down, too. I listened, asked questions, and tried to be empathic and explain in reasonable and clear language why oral steroids were not medically indicated and, furthermore, carried risks for her. Her voice escalated, “I don’t have a car. They told me I would get steroids. I live on the third floor with no air conditioning. This rash is going to erupt and get in my system if you don’t give me steroids.” I kept thinking to myself, “I am a doctor and am currently writing a book about physician communications, and this interaction is not going so well.”
During the course of writing this book, I would like to say that all of my face-to-face communications, especially with patients, have been perfect. Unfortunately, they have not. Before starting this project, I thought I had little room for improvement in this area. I was wrong. Through my research, study, and interviewing of experts for this book, I have learned much, and thankfully watched my own interactions and communication skills improve.
Are people born natural communicators? While some individuals are particularly gifted at these skills, for the most part people learn their communication skills, and how to improve them, through observation, training, courses, books, practice, and feedback. The good news is that it is possible to learn new techniques and methods to help you improve in order to have more positive therapeutic interactions with your patients. Just by becoming aware of the many issues of communication and acknowledging your own style and skills, you may augment all of your interactions. Also, it is possible not only to learn and adapt new skills but also to teach trainees how to do this. If we can enhance and deepen discussions with our patients and make them authentic and spontaneous—not forced, artificial, or formulaic—and remember the reasons we became doctors in the first place, we can ensure better relationships with our patients and hope for the future of our profession.
The eminent physician Roman W. DeSanctis taught at Harvard Medical School and practiced cardiology for 60 years. We can learn much from this brilliant caring clinician and authentic communicator. For years, he has spoken and written about the importance of deepening our connection to patients and always treating them with respect, dignity, and patience. Any discussion of patient communications should start with Dr. DeSanctis’s five pillars of medicine, which he calls the basis of his decades-long professional and moral practice.1
1. The patient should always come first in the life of a doctor.
2. In any situation, and at any time, weigh all of the information in hand and always try to do that which is best for the patient.
3. As the Golden Rule applies to life, so it applies in the practice of medicine.
4. Be a friend to your patients, as well as a caregiver.
5. Always demonstrate your humanity with honesty, sincerity, and empathy.
Source: Dr. Roman DeSanctis, Harvard Medical School.
Remembering why we wanted to become doctors in the first place may be the most important step in improving our communication with patients. We know that our inherent values and ultimate life motives are the foundation of our missions as doctors. Unfortunately, in our current medical climate of extremely high-speed, computer-dependent, robotic, and seemingly drive-through doctor visits, the intimacy and satisfaction of caring for our patients is often diminished. We may not even be asking how we can best communicate and connect with our patients or even why we should.
On another day while writing this book, a 90-year-old man with a draining and purulent wound on his leg is shouting at me, “Why do I need IV antibiotics?” I calmly respond, “Because we don’t want the infection in your leg to spread to your bloodstream.” “Oh, you mean sepsis?” he snarls and then snaps at the nurses that he needs to go to the bathroom. A nurse cheerfully helps him down the hall to the bathroom in his wheelchair. A few minutes later, he is smiling and says, “This place is just terrific.” Thank God for the nurses and of course for bathroom breaks. We start his intravenous antibiotic medication, and thankfully, he clinically improves.
Patients can be happy with you one minute and unhappy the next—and sometimes it depends on something as simple as a bathroom break (for you or for the patient) or plumping the patient’s pillow. But sometimes it is much more complicated. As physicians we have to step back, be patient, assess what is going on with each particular situation, and continue to treat each patient thoughtfully and respectfully. At times working with patients is an emotional volatile rollercoaster. We as physicians have to ride it out. Whether we are working in the intensive care unit (ICU) or the emergency department (ED) or in an outpatient or urgent care setting, the need for optimal communication is paramount. After all, we are here to help make the patients as comfortable, informed, and cared for as possible.
An hour later, a 30-year-old patient with miliaria (heat rash) on his inner thighs loudly complains to me that our 30 minutes together (when I listened to his history, examined him, answered his questions, and explained my diagnosis and proposed treatment) was a waste of his time. I thought it had all gone so well. I was left to wonder what I could have done differently. Later I learned the patient had waited for more than two hours to see me. He was mad long before I saw him. If I had noticed his mood from his body language and activity (pacing the room, using his cell phone, and not wanting to sit down or be examined on the exam table), I could have softened my own approach, apologized for the wait, and listened to and acknowledged his anger long before he stormed out.
As a physician, you no doubt have your own stories of unhappy, frustrated, or angry patients, including the patients who disagree with you about not prescribing antibiotics or narcotics or the ones who want a magnetic resonance imaging (MRI) study after two days of knee pain. Most patients just need to hear a thoughtful explanation of their diagnosis, thorough answers to their questions, and your medical reasoning and therapeutic recommendations. But it is true that on any given day, seeing many different patients with a myriad of different problems can bring up various challenging discussions and situations. Your ability to make a human connection to each patient will always improve your communication and ultimately your care—knowing that each conversation may be as diverse and varied as the patients themselves.
Can we learn how to take care of patients and at the same time always have a respectful, positive, and therapeutic interaction together? Can we provide excellent care despite the time limitations we are under and the computer screen between us, and make sure the patients are happy with their care and their doctors? Are there natural physician communicators among us? Why are some excellent clinicians so good at this and others so inept when it comes to interacting with patients? How can we deepen our connection to patients and enhance their experience and ours by improving our skills?
First, our success at face-to-face communications with patients is highly dependent on understanding our patients, ourselves, and the intricacies and nuances of clinical communication. We no doubt must acknowledge, establish, and strengthen our human interconnection to each individual patient. Despite the ever-increased mechanization and computer-driven clinical sphere, we still work in a very personal intimate setting with humans often going through life-changing moments. Ultimately, we need to have humility, patience, and compassion both with our patients and with ourselves. After all, we practice our profession in an environment where pain, stress, and suffering are common and where so many factors are beyond our control. These factors range from the patients’ experience before they see us to their expectations for the visit; from their health literacy to their individual social and cultural contexts; from the physical space we see them in to the physical spaces they live in; and from their opinions and past interactions with our profession to our own understanding and ability to connect emotionally. Underlying any attempt at improving our connection to our patients is the mission inside the exam room to make sure our profession remains a public service helping patients and not a business with a bottom line. Unfortunately, we as physicians come together daily with our patients in a virtual landmine of strained and tense interactions, in a profession in turmoil, and with changing patient expectations along with our own high levels of frustration and emotional burnout.
Think about your own interactions with patients at the most basic level. Have you knocked on a patient’s door expecting to have a wonderfully therapeutic session and offer your services, only to be shut down with a negative reception? Or have you asked a patient what you thought was a clinically important and straightforward question and received an uninformative response or, worse, one filled with a few disrespectful comments? Have you thought you were giving a full explanation of a diagnosis only to be derailed by the patient’s disagreement and oral history of their distrust of physicians? On the other hand, how often have you listened to friends complain about rude and dismissive physicians? Or have you heard a relative or an acquaintance tell a story about receiving bad news from an abrasive and condescending doctor? The litany of complaints about physicians’ communication skills, behavior, and professional etiquette is long and sometimes seems to be getting longer.
We may all have stories of clinical situations in which the emotional tenor of the room escalates as our communication plummets; when the supportive caring environment we hoped for crumbles before our eyes, our effectiveness is weakened, and hope for a therapeutic interaction is somewhat, if not completely, curtailed. The disconnection between physicians and patients is often more than evident; and while the patience and emotional stamina of all parties are tested, both soon realize the communication is not going well. We wish we could rewind the scenario and start again. Of course, as physicians and as patients, we want to avoid these miscommunications and be able to relate, listen, and connect so that we can successfully demonstrate and achieve what we went into medicine to do in the first place—care for the patient. But how do we do this?
We know that learning and improving our face-to-face communication skills should help us support our patients and ourselves and diminish uncomfortable, unproductive, or, at worst, adversarial interactions. Inherently we know that if we hone our skills of listening, respect, expressing concern, sharing, and collaborating, then our care of our patients and their clinical outcomes will be optimized. Our backgrounds, personal experiences, societal stereotypes, and cultural contexts all have an impact on our decisions and actions. We also need to know that our implicit or unconscious biases affect our judgments and assessments of patients and situations. We need to learn how to limit the negative influences that limit our abilities to connect and care for patients.
Underlying all of it is the patients’ need to retain their agency. In social science, agency is the capacity of individuals to be respected and to make their own decisions. Patients need information, support, and guidance and as long as they are competent and not in an emergency situation, they need to make (or help make) their own decisions. Patients are ultimately in charge of their bodies and their lives. They should always be treated with dignity, reverence, humanity, humility, and sincerity. We who work in healthcare organizations must ensure that our patients’ agency is protected, encouraged, and assured no matter who they are or the structure or circumstances of the environment.
Why We Should Care
Once, while presenting a physician communications lecture at a medical conference, I was taken aback when a surgeon raised his hand and asked me, “My clinical outcomes are great, why should I care about my communication skills?” His question seemed to represent a past sentiment from a previously paternalistic time of medicine. But today, fortunately, we live and work in a patient-centered world of medicine, and the attitudes of many physicians and healthcare institutions have changed. Our interpersonal skills and relationships with patients are a priority, or at least they should be. My answer to the surgeon on that day was, “Along with our established clinical outcomes, which are still imperative, our communication is now an additional outcome to measure.” I know this to be true because how we act, think, and talk as physicians are central to a patient’s experience. After all, our communication affects not only the patient’s clinical course, satisfaction, and behaviors but also our own rankings, ratings, reimbursement, burnout, liability, and healthcare costs according to several decades of research on physician–patient communications and institutions such as the Cleveland Clinic Center for Excellence in Healthcare Communications.2
Beginning more than a decade ago, The Joint Commission that accredits more than 21,000 healthcare organizations and programs in the United States, concluded that communication problems in medicine are one of the most common causes of sentinel events.3 A “sentinel event” is defined as any unanticipated event resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient’s illness.4 The Joint Commission now recommends an approach to communicating health information that “encompasses language needs, individual understanding, and cultural and other communication issues” and provides information and resources on The Joint Commission’s Health Equity Portal.5 For more than a decade, other academic institutions and accrediting boards of medicine have defined, endorsed, or required training and demonstrated competency in physician communication and interpersonal skills. Those organizations include the American Association of Medical Colleges, American Medical Association, American Board of Medical Specialties, Liaison Committee on Medical Education, and Institutes of Medicine.
For several years, the Centers for Medicare and Medicaid Services (CMS) have queried hospitalized adult patients about their care with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys.6 The 32-item survey is conducted by mail or phone two to forty-two days after the patient is discharged. It captures the patients’ unique perspectives on hospital care for the purpose of providing the public, and the government, with comparable information on hospital quality, including how well doctors and nurses communicate. Patients who have been recently hospitalized, with any type of payer plan, are randomly surveyed about the communication skills of their caregivers, along with questions about pain management, cleanliness, quietness, and overall ratings of the hospital. The HCAHPS survey includes questions such as, “Did your doctor explain things in a way you could understand?”; “Did your doctor listen to you?”; “Did your doctor treat you with courtesy and respect?” Hospitals who receive low scores on the HCAHPS survey can lose money through the Inpatient Prospective Payment System (IPPS) annual payment provisions. The incentive for IPPS hospitals to improve patient experience of care was further endorsed and strengthened by the Patient Protection and Affordable Care Act of 2010, which specifically included HCAHPS performance in the calculation of the value-based incentive payment in the Hospital Value-Based Purchasing program. About four thousand hospitals participate in HCAHPS, and more than three million patients complete the survey each year.6 Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally, regionally, and nationally.
The results from these surveys have prompted hospitals to try to improve the patients’ experiences by improving caregivers’ demonstration of courtesy, respect, listening, and clinical explanations. Hospitals have also tried to respect patients by reducing unnecessary ambient noise, streamlining staff communications, reducing patients’ wait times, and keeping patients informed about their caregivers as well as their diagnosis, treatment, and discharge information. We need to continually ask ourselves, “What can we as individual physicians do to improve the experience of our patients?” including focusing on improving our ability to provide empathy and support, to answer questions and summarize, and, at times, to simply stop talking so we can listen more.
Communication Training Courses
Today, physicians, at every level of training and practice, can learn and improve communication skills. After several years of planning and researching pilot programs and previous studies, and under the direction of Dr. Adrienne Boissy, the Cleveland Clinic developed the Center for Excellence in Healthcare Communication. The center has various communications training programs designed specifically for all of their doctors, staff, residents, fellows, and students. Thousands of clinicians have received the training. The vast majority of attendees (95%) at their campus courses are Cleveland Clinic caregivers, according to Jennifer Muehle, PMP, Program Coordinator. In an article published in 2016 in the Journal of General Internal Medicine, Boissy and her colleagues concluded that their system-wide relationship-centered communication training program improved patient satisfaction scores, physician empathy, and self-efficacy; the training also reduced physician burnout.2 In other words, better physician communication skills translate into happier patients, more fulfilled physicians, and better organizational environments. Most important, improved communication means a better chance for improved clinical outcomes. Communication skills can and should be part of physicians’ continuing education.
Source: Cleveland Clinical Center for Excellence in Healthcare Communication.
I have attended, taught, or facilitated several different communication skills training courses throughout my life. In 2018, I had the opportunity to take the communications training course offered by the Cleveland Clinic. The Cleveland Clinic conducts six to eight similar day-long sessions each month, with an average of twelve physician participants in each session taught by two trained physician facilitators. The take-home lesson from this extraordinary program for me was a reinforcement of the foundations of good communications with patients. Specifically, their R.E.D.E. (Relationship, Establishment, Development, and Engagement) program identifies three important stages of the physician–patient relationship during a patient’s visit:
Phase one: establishment—this is when we as physicians convey value and respect by welcoming the patient appropriately, collaboratively set an agenda with the patient, and begin to demonstrate empathy
Phase two: development—this is when we need to engage in reflective listening, elicit the patient’s narrative, and explore the patient’s perspective
Phase three: engagement—this is when we share our diagnosis and information, collaboratively develop a treatment plan, provide closure, and remember to encourage a dialogue with the patient throughout the visit.7
The full-day program allowed time for practice, feedback, and group collaboration between different types of physicians and trainees. On my day, there was a mix of trainees in internal medicine and orthopedic surgery. The group comradery, sharing, and safe space to practice were all invaluable, as were the lessons on how to encourage patients to express themselves and their concerns early in the patient visit and on how to provide adequate closure.
I asked the medical director Dr. Katie Neuendorf if the Cleveland Clinic would ever make the program available online. She said they had been looking into ways to try to present the program online for the past few years but had not found one that worked. According to Dr. Neuendorf, there seems to be no way to encapsulate the effectiveness of the face-to-face presentation, participation, feedback, and practice sessions of the in-person workshop in an online forum. Perhaps this is really the heart of our learning and practicing human-to-human communication skills. In order to assess ourselves, as well as learn and practice new skills, we need to do it in person and face to face. We cannot use electronic screens, online video, hardware, or software to help us. This may be an area where we need to omit the computer completely—especially when we are trying to improve our human connections with patients and each other.
Today, there are a growing list of medical educational organizations, healthcare plans, and training institutions offering a variety of workshops, single classes, and multiday courses on communication for clinicians. I was in China in 2018 and listened to physicians and hospital employees discuss the need for physician communications programs. It seems the need for discussion and training on this topic is now worldwide. According to the Agency for Healthcare Research and Quality (AHRQ) at the US Department of Health and Human Services, “the purpose of these programs is to improve providers’ effectiveness as both managers of care and educators of patients. It is believed that trained physicians may allocate a greater percent of clinic-visit time to patient education, leading to increased patient knowledge, better compliance with treatment, and improved health outcomes.”8
Many hospitals and healthcare plans in the United States now offer their own communication training; a few hire outside health communication organizations to run their programs. Some mandate training for all clinicians, and others offer optional courses or provide the instructions as an intervention for physicians with low patient-satisfaction scores or other problems. Communication training programs promise to cover various strategies for improved communication in a relatively short period of time for busy clinicians, often charging $1000 a day or more per practitioner and offering continuing medical education (CME) credits and other incentives. Some of the organizations are listed on the AHRQ website (https://www.ahrq.gov).
Effective communications skills training, whether it is presented as part of a national conference or as an in-house CME course, can offer a supportive environment for clinicians where they can learn specific tools to help communicate with patients, including providing specific interviewing techniques, learning to express compassion, working with time constraints, understanding the patient’s perspective, and setting boundaries. Unfortunately, today the obstacles that reduce the quality of our relationship with patients are innumerous: shorter visits, computer screens, electronic health records, unconscious biases, cultural and language differences, misaligned expectations, uncoordinated specialists’ consultations, lack of a relationship with the patient, our diminished stature in the patient’s eyes, and physicians’ own feelings of frustration. According to the AHRQ, “Most practicing physicians have not been taught to appreciate the patient’s experience of illness; nor do they learn how to partner with patients and serve as a coach or a guide. As a result, they typically do not know how to communicate with patients in a way that maximizes understanding and involvement in decision-making, lets the patient know that his or her concerns have been heard, and ensures that the care plan meets the needs of the patient.”8
One of the most obvious obstacles to the patient–physician alliance may be the computer. Dr. Margot Hartunian, a primary care doctor with Beth Israel Deaconess Health Care in Lexington, Massachusetts, uses an ingenious way to integrate the computer into her patient visits. She wheels in her WiFi-connected laptop placed on a small high-topped wooden table into the exam room. With its beautiful wood rounded corners and quiet wheels, Dr. Hartunian maneuvers the small table so it is never between her and her patient. She can stand or sit near it, push it to the side or wheel it in close to the exam table. It never seems obtrusive. Other doctors have hired scribes to take notes so that they can keep their attention and hands free for patient care. Others have tried to come up with alternative solutions using technology including audio recording devices or iPads. But unfortunately, many solutions still interrupt the personal intimacy of the patient–physician human connection in the exam room.
Technology and the electronic universe of the Internet increasingly affect our clinical relationships and interactions in many different ways. Much has been written about the shortcomings of the electronic medical record (EMR), from taking our eyes off the patient in order to type, to cutting and pasting inaccurate information into the patient’s chart. But there are many advantages of the EMR. At first, many older physicians rejected EMRs, but some like Dr. Pablo Rodriguez, an obstetrician-gynecologist affiliated with Women and Infants Hospital of Rhode Island, welcomed the EMR and thinks it is a blessing. He practiced for several decades before using the EMR. Today, he says the EMR allows him many “firsts” in his practice, including making his notes more legible and accessible to everyone, always having access to the patient’s chart (no more “missing charts”), and having immediate access to seemingly unlimited information and data analysis about each patient. (See Chapter 2 for more discussion about EMR and other technology impacting our healthcare communications.)
While the computer can both intrude and augment our face-to face relationships with patients, it certainly has influenced patients’ understanding of their ailments. Patients often search the Internet and consult “Dr. Google” before they arrive in our offices. Sometimes this is advantageous; the patients are more educated and prepared about their symptoms and condition. Sometimes the opposite is true. They may look up symptoms and give themselves an inaccurate diagnose (or more than one) and alarm themselves long before we ever see them. Many patients have a set idea about what they are suffering from and what treatments they want. Some do not want to talk about their symptoms or to be examined. Instead, they just want to request a prescription or a specific test. Some request a referral based on what they have learned from the Internet. In such cases, it may take some additional time and discussion to establish a connection with the patient so that you can make your own assessment and properly take care of them. You might be able to explain how Dr. Google is not always an accurate diagnostician or able to provide a complete therapeutic evaluation of their symptoms and concerns; but often your approach to your clinical interaction may need to be adjusted when the Internet’s Dr. Google has already seen the patient. On more than one occasion, after I finish taking a history, examining the patient, and explaining what I think is causing their symptoms, the patient exclaims, “Oh, good that is exactly what I read on the Internet.”
Patients may also have read your online patient reviews and expect you to live up (or down) to what other patients have written about you. You may have no established relationship with the patient, whether you are a primary care doctor or a specialist. In this new world of increased expectations, changing roles, lack of physician–patient relationships, and abundance of online medical information, how can we best communicate with patients? Has our job changed in the exam room in the doctoring environment of today? Has our own communication evolved or devolved with the advances (or intrusion) of technology? How can we re-establish and maintain our relationships with our patients in the ever-changing environment of healthcare expectations?
Physician Communication Concerns: What Do Physicians Fear?
There are as many different communication styles as there are physicians. However, many physicians share the same fears and worries when trying to improve their own communication skills with patients. What are physicians most fearful of when it comes to trying to communicate with patients? Here are some common fears physicians express.
1. “I worry that if I ask my patients too many open-ended questions, they will never stop talking.”
Once patients start talking, physicians interrupt within several seconds (on average between 18 and 23 seconds).9 Interestingly, if you let patients talk, without interrupting, they will talk for just about 90 seconds before stopping.10,11 Patients need to be heard and to tell you everything they are experiencing. They will feel better for having told you everything they came into tell you and for the opportunity to express themselves without being interrupted. As most doctors know, often the diagnosis comes from the history. I often find that patients will give an almost complete history if I just allow them to talk.
2. “I don’t always know how to handle their strong emotions.”
As physicians, our job is to find solutions to problems and to fix what is broken, injured, or hurting. But according to the Cleveland Clinic and other healthcare communications programs, as physicians, we cannot always “fix” emotions or “mend” all concerns or feelings. What we can do is listen and be present, respectful, and grateful for our patients’ ability to share their emotions. We can make sure our patients have been heard, comforted, and supported. We need to identify their emotions accurately and respond to them appropriately. We need to be there for them, encourage them to share with us, witness their predicaments, and offer solace when and where we can.
3. “I don’t have enough time to communicate effectively.”
It takes less time to communicate effectively with patients than it does to communicate ineffectively. More important, the clinical, professional, and personal benefits of effective and collaborative communications between physicians and patients are numerous.
4. “Sometimes, there are no tests or treatments needed, there is nothing more I can do for a patient. Then what should I do?”
The art of listening can be very therapeutic. Just letting your patients talk and express their emotions can be the most important part of the therapy you offer. Affirming and supporting their feelings and emotions and listening to their fears and opinions is all part of our job as clinicians. Asking them directly about their feelings and expectations and encouraging them to share their concerns should always be part of the discussion.
5. “Patients don’t seem to think I care about them.”
Being genuine, respectful, and appreciative can be very helpful. Often in medicine, we assume that just by working as a doctor and wearing our white coats, patients should know how much we care for and respect them. They should know we want to understand them and make them feel better. But this is not always communicated by us or understood by our patients. Sometimes we need to use specific words, phrases, questions, and body language to communicate these important messages. We need to ask or say things such as, “Thank you for coming in today,” “Thank you for sharing that with me,” “What I think I hear you saying is . . . ,” and “What were you hoping for during today’s visit with me?”
A healthy relationship between physician and patient does not mean agreeing with everything the patients says or requests. A healthy relationship with a patient does not mean “agreement on everything, unlimited time, tolerance of boundary violations or practicing outside your usual scope of practice,” according to the Cleveland Clinic’s Center for Excellence in Healthcare Communication. It does mean, according to the center, “making an emotional connection, showing mutual respect and genuine interest in the patient perspective and psychosocial context and a shared commitment to a positive outcome.” In all relationships, we need to learn how to agree to disagree. We need to value ourselves and our opinions just as we do our patients and their opinions, while acknowledging that the stressful environment of healthcare and the uncertainty and emotions of illness can strain any interaction.
What Do Patients Want? What Do Physicians Want?
Patients and physicians want the same thing: to be respected, to be heard, to have a therapeutic interaction, and to have an improved outcome for the patient. When it comes down to it, our job is to listen, and their job is to talk. But we need to provide patients with the right questions, information, environment, support, and time so that they will be encouraged to talk. We need to answer the patients’ questions and give them honest explanations that will help them. Patients do not want to be rushed and treated like multiple-choice questions, “Aha, I know what you have, the answer is B!” Patients also do not want to hear a medical lecture or public health speech from us. They want a dialogue with us, not a monologue from us. Having a therapeutic interaction takes time to listen and time to be present. It also takes patience and compassion. Knowing that we have the same goals as the patient of an accurate diagnosis and an improved outcome is central to connecting and communicating. Unfortunately, without an established relationship, patients do not know who we are or how much we care. We often don’t understand their background, their lives, or their experiences. They don’t think we have the time or interest in hearing all of their concerns or questions. And it seems that both patients and physicians are strapped for time.
A Harris poll conducted in 2015 indicated that three out of five adults would choose telehealth visits to replace in-person visits for things such as follow-up visits, eye infections, skin checks, and minor ailments if this option were offered by doctors, according to an article published in Business Wire.12 What does this say about the patients’ comfort and satisfaction with face-to-face communications with their doctors? What does this say about the way some would prefer to have their healthcare delivered? If patients prefer efficiency over an in-person visit, or if they prefer to search their symptoms online instead of seeking advice from us, then the nature of our relationship is surely changing. It seems that computer screens, in some instances, may have replaced our listening ears and our healing hands. However, while patients can search the Internet, “Dr. Google” cannot make a diagnosis, provide empathy, or care for them like we can. But access to online health information and a lack of a personal relationships with patients have possibly increased the miscommunication and misaligned expectations between us. As physicians, we have to remember that our job is to be reflective and empathic listeners, accurate diagnosticians, and excellent caregivers. We also need to remember to let the patients tell their story, including what information they believe to be true about their symptoms. Here is an essay I wrote a few years ago about how I learned this lesson.
* H. B. Beckman and R. M. Frankel, “The Effect of Physician Behavior on the Collection of Data,” Ann Intern Med.,1984;101;692–696.
† L. Silbert, C. Honey, E. Simony, D. Poeppel, and U. Hasson, “Coupled Neural Systems Underlie the Production and Comprehension of Naturalistic Narrative Speech,” Proc Natl Acad Sci USA, 2014;111(43):E4687–E4696.
To sit in silence with other people is one of the most intimate experiences imaginable.
In a clinical setting, silence or a pause can represent many different emotions from our patients, such as fear, exasperation, exhaustion, shock, awe, anger, concern, sadness, or confusion, to name just a few. But sitting in silence with our patients for a few seconds or a few minutes can be very therapeutic, for them and for us.
Why do we feel like we need to fill every minute with chatter, questions, or explanations? It is okay to embrace the pause, exhale, and give the patient and yourself a break. Our verbal exchanges can be like a dance with an escalating pace and volume at times. What if we just took a moment and sat with some of our patients as we would a friend near a stream? What if we allowed ourselves to share a moment of silence with our patients? What if we were not afraid to just be quiet with our patients?
Silences occur naturally in all conversations, if we allow them. They can help recalibrate the rhythm between you and your patient. You may have been rushing for the last several hours in your busy day while your patient may have been sitting in silence waiting for you. Having the same emotional rhythm or pace between you and the patient is very important. Silence can allow you to observe the mood of your patient and feel the tenor of the room. Silence may occur spontaneously or may emerge in response to a strong emotional moment. Sometimes after a patient says something very powerful, perhaps about the recent loss of their spouse or the fear of a diagnosis, I say, “I am so very sorry” or, “I hear what you are saying and it sounds like you are sad, concerned, or fearful.” I then try to stop and just embrace the pause—allow the simple act of sitting in silence and observing the two of us together to comfort and soothe the patient.
I often regret that I have spoken; never that I have been silent.
Sometimes we avoid silence because it feels awkward. Our lives our generally filled with noise, and our days are busy with sound and activity. The time we are with patients, we need to gather information, ask them questions, and encourage them to explain in detail what is wrong. But a few appropriate pauses or natural moments of silence can actually improve our time with patients in three ways. First, silence can slow down the pace of the room. Often, you will hear people exhale during a pause. Second, allowing some silence can show how comfortable you are in the room and with the patient. Third, it gives the patient an opportunity to say something spontaneous and not just give another answer in response to your questions.
We are embraced by silence and silence cares for us deeply. In the embrace of silence we sense the essence of living things radiating loudly.
A few moments of shared silence with your patient may be worth an hour of noisy verbal exchange. Do not deprive yourself or your patients the comfort and intimacy of silence when it naturally occurs. You will save energy and time; you will gain a calm connection with your patient. You may observe, hear, or intuit important clinical information from the quiet time you spend in their presence.
Of course, our ultimate goal is to help the patient achieve optimal health status. We know that the better we are at communicating, the better chance we have of achieving that goal. If Aristotle (384–322 bc), the Greek philosopher and scientist, could accompany us while we are taking care of patients today, he might remind us of what he thought of as the critical components of good communication: ethos, pathos, and logos (Figure 1.1). Ethos is our credibility or character, pathos is our emotional or personal connection with the patient, and logos is the logic we are using and the actual words we are saying. Our rhetoric, he wrote, is “worthy of systematic and scientific study.”14
The patient’s perception of us and our communication skills rests on what Aristotle described as this “rhetorical triangle.” The image illustrates how the three components are dependent on each other, ultimately define how our patients perceive us, and perhaps ultimately determine our ability to achieve our clinical goals. If we use an abrupt or off-putting tone or style, the patient may think we are not credible or trustworthy (ethos), and the communication triangle collapses. If we are rushed, brief, or dismissive, we may not make an emotional connection with the patient (pathos). If we use reasoning, with data and words that are not understandable or logical (logos) for the patient, then our connection with the patient is interrupted. The patient will be confused by the information we are providing and not appreciate our intentions.
Establishing an emotional connection with a patient always requires respect, time, and patience. I enter with a warm hello and open-ended questions and then try to assess the situation before we begin, dipping a toe in before we enter the pool of true interaction. I cannot assume anything about the patients’ history, mood, or expectations until I spend time with them. I must be aware and cautious of first impressions and my own biases.
Of course, preparation is key. I need to learn as much as I can from the medical record, my own notes, the nurse, or any other source to help me determine the best approach to take with the patient before walking into the room. After many years, I have learned to trust what my nurses say about the patients’ mood and interactions that occurred before I see them. But I also try to imagine a “clean slate” when I walk in the room. I don’t make any assumptions. I try to stay open and enter calmly, with a smile and a welcome gesture. I do not assume I am going to get a warm reception or that I can predict how the patient will interact with me. I need to get to know my patients, their expectations, and their fears by asking them the right questions and letting them talk. I need to listen and observe as much as I can. I want to make an emotional or human connection. They need to know that I care.
Small gestures can be important. I try to watch my volume and pacing so that I am not shouting or speaking too quickly. I want to make sure my verbal and nonverbal language is open, welcoming, and caring and appropriate for the patient. I need to match the tenor of my approach and interaction to each individual patient and circumstance. I want to try to have a therapeutic interaction with each patient.
• Greet patients with a smile and a handshake or other respectful gesture.
• Sit down and make eye contact.
• Have a dialogue with the patient—not a monologue.
• Do not interrupt.
• Listen, reflect back what they are saying (reflective listening).
• Allow for pauses and silence.
• Provide a plan and closure at the end of the visit.
• Make sure the patient understands.
• Make sure the patient has no more questions.
Source: The Cleveland Clinic.7
Aristotle and modern-day communication experts encourage us to articulate our specific goals before any encounter with a patient. If we can define our specific goals beforehand, then our mission will be clear as to why we want to be good communicators with each patient in the first place. Remember each day why you are seeing patients. What are your goals and what is your mission with each patient?
Goals of Communicating with Patients
1. To gather information
2. To listen to the patient’s needs and concerns
3. To offer empathy and support
4. To assess their expectations
5. To encourage questions
6. To explain your clinical thinking, diagnosis, and treatment
7. To make a connection
8. To foster a therapeutic relationship
Physician attitudes that can lead to poor communication include emotional burnout, insecurity, intolerance of diagnostic uncertainty, and negative bias toward specific health conditions.15 Inadequate training in psychosocial medicine and a limited knowledge of the patient’s health condition can lead to difficult encounters.15 If we are anxious, depressed, exhausted, overworked, dealing with personal health issues or situational stressors or sleep deprivation, our patients will suffer; and if we have difficulty feeling and expressing empathy or are easily frustrated, we will not be good doctors.15
Learning from Other Communication Training
Can we learn from other types of communication training? During advanced cardiovascular life support (ACLS) training, communication is emphasized as the most important component needed in an emergency situation. The six essentials for communicating during an emergency are respect, constructive criticism, constructive intervention, closed-loop communications, algorithms, and a team leader.16,17
While many physicians do not work in emergency situations requiring the level of communication to run a code, all of us work in unpredictable, stressful, emotional, and sometimes chaotic environments with individuals who we do not always fully know. We can learn from the underlying principles of the ACLS training in our communication with patients and peers in any type of situation if we respect others, make sure our communications are clear and understood, make sure we fully understand what the other person is saying, and are willing to question, converse, and relate with reverence.
In any communications training, including “organizational or institutional communications” or even “self-help and communication for couples” or other similar courses, attendees learn about themselves as well as interpersonal skills to develop understanding and empathy for each other, specific methods for effective communication, nurturing, influencing, and resolving and repairing relationship conflict. Of course, “self-help for couples” communication skills may not seem appropriate for the physician–patient relationship, but there are many aspects of the training we might consider with our patients and our peers, including the type of respect and caring needed in any human relationship. While “love may mean never saying you are sorry,” in medicine we certainly can say “I’m sorry” with our patients and our peers. “I am sorry I am running late,” “I am sorry I forgot to call you,” “I am sorry to tell you that you have pneumonia,” or “I am sorry you have been waiting so long to see me.” Gratitude is also very important. “Thank you for telling me that,” and “Thank you for coming in today.” Respect + gratitude + empathy = care.
Relationship Skills Building
1. Show caring and warmth. There are so many nonphysical ways of showing warmth, from a smile to shared silence. Physical affection is not appropriate, of course, for a physician–patient relationship, and individuals react differently to different physical gestures from hugs to touching a shoulder or a hand. But we can certainly show kindness and caring by small and large gestures, from shaking hands to helping patients on and off the table. One person described how touched she was when a doctor who was caring for her dying husband helped carry his shoes from one room to the next. Showing warmth toward a patient can come in a variety of nonphysical and professionally appropriate physical ways.
2. Be patient with each patient. If we are rushed or abrupt with patients, they are not going to feel cared for. If we cannot patiently listen, they will not feel we care. Just like with other relationships, we need to sit down and give them the time they need. Learning to make the most of the time you have and giving the patient your undivided attention for that time is key. Learning to listen and to accept your patients’ unique qualities and never losing your curiosity about your patients or their lives are important. Learn how you can show respect to your patients, and you will learn more about them and how you can help them.
3. Listen carefully and thoughtfully. Be a good listener by leaning in, nodding, responding with “yes” or “uh-huh,” and looking directly into your patients’ eyes. Note not only the emotions of their words but also the cues of their body language.
4. Be thoughtful with small and large acts. Small acts can show you care. You can certainly show thoughtfulness by remembering important personal information about a patient’s family. You can also pick up something they have dropped or ask them if they need a glass of water. Comment on the book they are reading or ask them what they are knitting. These interactions also give you a minute to put down your stethoscope and just relate human to human. Large acts of thoughtfulness mean going the extra mile in every aspect of their care. Take care of them as if they were a family member.
5. Show gratitude. Showing appreciation shows respect for the patients and their time. Thank patients for their questions. Thank them for sharing information with you. Thank them for coming into to see you and being on time.
6. Be calm, gentle, and understanding. A calm, gentle, and understanding approach with most patients is much more beneficial than the opposite approach. Each patient is different. Each set of circumstances is different. We should remain gentle, open, humble, and understanding.
7. Be open to their questions and ideas. Patients have their own concerns and ideas about their symptoms. They have their own ideas about the diagnosis and appropriate treatment. We need to elicit their thoughts, reasoning, and fears. We may know more about medicine, but they know more about their bodies, emotions, and lives than we do. Never assume you know everything about the patient or their symptoms, concerns, feelings, and lives.
8. Learn to agree to disagree. We are not going to agree on everything. We need to set personal and professional boundaries. We can always listen and respond with respect. Losing control and becoming emotional rarely help solve any problems. Recognize when you are stressed and need to take a time-out. On more than one occasion, I have asked a patient to excuse me for a minute. I then just step outside the room for a few minutes. The patient may think I am answering a page or answering a question from my nurse, but in all honesty, I am just taking a few minutes to breathe and calm myself. Once I step back into the room, I am always amazed at how an emotionally charged situation will diffuse by just taking a break for a few minutes. Generally, I re-enter the room, the heightened emotions have resolved, and the conversation proceeds smoothly.
Learning from Other Professions
How do other professions connect and communicate with people? Professionals, including journalists, clergy, teachers, and actors, must relate and develop relationships with their readers, their congregation, their students, and their audiences. They have many of the same concerns and face many of the same barriers and difficulties as physicians when trying to connect and communicate with others. We may be able to learn something from each of them.
Journalists interview a variety of people in a variety of difficult situations. Award winning news producer and video documentarian Wonbo Woo has worked for network television shows, including ABC 20/20 and NBC Nightly News. In the course of his career, he has interviewed thousands of people, from soldiers in war-torn areas and survivors of national tragedies to the parents of a transgender child and clergy who have lost their faith. He not only asks people to share their personal information but also asks them to do it in front of a camera. I asked him to share his secrets on how he is able to make deep and sometimes quick connections with people in difficult situations and encourage them to share information with him—information he needs in order to tell an important news story. Here are his keys to good communication and a successful interview. As one of my medical students said, “he could be talking to physicians with this advice.”
Person-to-Person Communication Advice from a Journalist
• Know what information you need to get before the interview.
• Prepare beforehand.
• Read as much as you can.
• Understand their story before going in.
• Go in prepared to listen.
• Listen to the emotional cues in their voices.
• Watch the physical cues in their body language.
• Listen between the lines.
• Respect them at all times.
• Make sure you have eye-to-eye contact.
• Treat them as humans.
• Manage the stress (yours and theirs).
• Ask them about their concerns.
• Try to connect in that moment.
• Be there in that moment (cut everything else out).
Like many successful journalists, Wonbo loves meeting new people, and he loves hearing people’s stories. We should feel the same about our patients. We should never lose our curiosity about our patients and our interest in their lives.
Several years ago, ministers, priests, rabbis, and other clergy made regular visits to see many patients in the hospital. At most hospitals, they would check in at the front desk and would be given a list of the patients who identified as Catholic, Christian, Jewish, Muslim, or other religion. Members of the clergy would then take the list and walk the halls of the hospitals finding these patients and visiting with them. The patients may or may not have been members of their congregations or synagogues, but clergy were allowed open access to these patients to provide them with spiritual care while they were hospitalized. Today, while individual patients or their family members may request their priest or rabbi visit them in the hospital, many of the routine spiritual rounds and other regular types of clergy visits have greatly diminished or gone away completely at some hospitals. There are a variety of reasons for this, including that patients spend less time in the hospitals than they used to so that by the time the rabbi or the minister hears about the patients in the hospital, they may be discharged. Also, there are more rules and regulations concerning patients’ private information, including their religious preferences, and some clergy feel intimidated or unwelcome by some hospital settings today. I sat down with Rebecca Spencer, Senior Minister at Central Congregational Church in Providence, Rhode Island, who used to spend many hours a week doing these visits and, like many, misses them. While there are certainly still clergy present in hospitals, the declining number of regular hospital visits seems to be a reflection of many changes in our healthcare environment.
I asked Reverend Spencer about the art of listening and talking to members of her congregation in and out of the hospital. She stressed that people overwhelmingly just need to be listened to. But listening takes time and presence. Spencer calls it the “ministry of presence.” I think the problem for physicians is that although are we worried that we don’t have the time to listen, we are not always emotionally present for the time we are with patients. Worse yet, if we are on “auto-pilot,” for example, thinking that it is a straightforward case of another upper respiratory infection or urinary tract infection and we don’t need to be fully emotionally present, then we and our patients will miss out on the therapeutic human connection of presence. Another problem for physicians is that we are often much more interested in the objective data than the subjective data. Patients want to share both with us. They want to tell us what their high fever felt like or how the itch kept them awake all night, along with their other worries, fears, and expectations.
Time is a commodity we all seem to have less and less of. Other professions, including members of the clergy and journalists, seem to have less time, too. But some individuals seem to help manage this obstacle by being more present. Journalist Wonbo Woo says he relies on “being present in the moment.” He says that no matter how little time he has with the people he is interviewing, he tries not to be distracted and keeps his total focus on the other person and what they are saying. Rebecca Spencer’s “ministry of presence” means she is fully there for her congregates when she is sitting with them. Perhaps we as physicians need to think about this as well. We must be fully emotionally, physically, and intellectually present for our patients every minute we have with them. We cannot be thinking about the next patient, or the last patient, or a lab or x-ray result we are waiting for. For a few minutes, we need to just sit and listen. Reverend Spencer also believes it is important for clergy (and physicians) to ask people what they need and what we can do to help. When was the last time you walked into a patient’s room and simply asked, “How can I help?” and then with laser-like focus really listened and observed?
[I]t cannot be overstated that listening in an openhearted, attentive manner may be more helpful than we might imagine. Absorbing someone’s anguish by the unspoken reassurance of our presence can mean a lot. Therefore, the best wisdom is often: Don’t do something, just stand there!
—Rabbi Leslie Y. Gutterman
Rabbi Gutterman’s personal experience with doctors has led him to believe it is important for doctors to learn about their patients no matter how much or how little time they have together. Years ago, when his first wife was diagnosed with leukemia and just a year before she died, they had an experience with a physician who was abrupt and abrasive. Rabbi Gutterman felt that the physician had prepared a speech for him and his wife and never took the time to get to know them or to listen to their concerns or questions. He learned in that painful moment that physicians who cannot stop to listen and learn about their patients do not seem like physicians who care.
Person-to-Person Communications Advice from Clergy
• Listen to the patient.
• Be fully present when you are with the patient.
• Answer the patient’s questions.
• Ask the patient, “Is there anything we did not talk about today?”
• Let the patient know you will stay in touch and you won’t abandon him or her.
• Ask the patient, “What did you hear me say?”
• Always ask, “Is there anything else?”
Educator Cotty Saltonstall taught school for forty-six years at Dexter (Dexter Southfield) School in Brookline, Massachusetts. Now retired, his advice about relating to his students can certainly be helpful to physicians trying to relate and interact with their patients. Finding a common ground, for example, asking patients about their children at college or how their garden is this year, is as important as the first handshake of greeting or the exchange of smiles after the closure of the visit and, similar to communicating with students, may make the difference in how well you connect with them.
The art of relating to children—and others—derives, I believe, from listening to them as opposed to talking at them. When students realize that one is truly interested in hearing what they have to say, be it about weekend activities, favorite foods, games, sports, books, or anything they might like to talk about, the foundation of a relationship is formed. As time passes, trust is usually built, resulting in a strengthening of the connection between teacher and pupil, and as that evolves, it becomes easier to inspire those whom one is trying to teach. Throughout the process, the teacher is able to recognize areas of strength and weakness, and address them, helping the child to gain in confidence and start to dare to tackle new challenges.
In summary, although I retired some years ago, I believe that much of what I learned about relating to and inspiring children still holds true today and also applies to others in other professions. For those adults who are willing to listen to those whom they are mentoring, teaching, guiding, or treating, the rewards are many.”
I asked a professional theater actor, Fred Sullivan Jr., how actors “show” empathy. He quickly educated me on the fact that actors don’t “show” anything—they embody a character who is feeling an emotion such as empathy. In learning a character, they ask themselves, “What if what was happening on stage to my character was happening to me?” and then they feel the emotions of their character. Of course, as physicians we can learn the verbal language and nonverbal techniques of showing empathy, but unless we really feel it for our patients and their stories, no one will believe us. We must always ask ourselves, “What if that was me or my mother or my grandfather or my son on the table?”
The take-home lesson for me in talking to a professional theater actor was to remember that as physicians we need to think more about how we feel and embody the virtues of medicine, including kindness, patience, humility, and respect, and then practice them—not try to emulate some technique that we think our patients will perceive as empathic or respectful. We must be empathic and respectful. We must listen and relate. We must care both about and for our patients.
The Words We Use
Like many professions, medicine has its own language. Many of the words sound scientific, obtuse, or archaic. Most have Latin origins. Some have English or Germanic or just odd pronunciations. During our training, these words seems to invite us into the secret society of medicine. The jargon is part of our “in-doctor-ination” or induction. Why do we say “palpate” when we could say “touch?” Why do we say “hydrate” when we mean “drink?” “Inhale” instead of breathe? “Expire” instead of “die?” Why do we use so many military metaphors such as “doctor’s orders” or “war on cancer” or “armamentarium against cancer?” Interestingly enough, the first definition of armamentarium in the Oxford English Living Dictionary is not about war but about medicine. It reads, “the medicines, equipment, and techniques available to a medical practitioner,” with the example “leeches of the medieval armamentarium are making a comeback in modern medicine.”
Using jargon puts us at a distance from patients. It separates the landscape of human connection, understanding, and emotion. Do the words of our profession keep us from feeling our emotions and separate us from our patients? Do they place an artificial and imposing barrier between us? Are they harming our ability to communicate and connect with patients?
When University of Rhode Island Professor of English and creative nonfiction author Mary Cappello spoke to my medical students at Alpert Medical School at Brown University, she challenged them to think of synonyms we use in our everyday language and in medicine that appear very close in meaning but in fact may have nuanced or not so nuanced distinctions. Words like “listen and hear”; “cut and incise”; “care and concern”; and “learn and know.” Professor Cappello then gave us a list of five medical terms she wanted us to think about: documenting; observing; witnessing; attending; and studying.
Each of these words carries a different meaning for physicians in relation to patients and for writers in relation to their subjects. What this lesson exposed and illustrated was the distance from the subject (the patient) we feel (or don’t feel) by using certain clinical words. It also raised the question, is the patient the subject or the object in our sentences? We quickly realized that we rarely ask ourselves what our words and our sentence structure really mean to us and to our patients. Most words in medicine may place us further from the patient, not closer. Perhaps we need to think more about the specific words we use with patients and among ourselves and how they make us act and feel.
Patients know we have these unique and specialized words in our profession. Sometimes they use medical jargon in front of us to try to get closer or to show us that they may, too, be in the secret society of medicine. When a patient says something to me in medical-ese such as “Is my PO2 coming up?” or “Did my x-ray show a one-centimeter calcified lung nodule in the left upper lobe?” I often ask if they work in medicine. Sometimes they do, and sometimes they do not. If they work in medicine as a clinician, our conversation is often then filled with medical terms and often becomes less emotionally connected. This is not for the better. We need to be aware of the words we use with all of our patients and try to avoid technical jargon to keep the caring human connection established. The words we use not only set us apart as a profession but also may make the patient feel like an object in a scientific experiment. Capello asks us specifically of how we thought of the patient—and how our language reveals the answer. Is the patient doing something or having something done to them? Are their stories and experiences and emotions being validated? Are ours? Are we performing the action or are we removed from the action of palpating or cutting or repairing? Are we partners or parents or paternalistic caregivers? Listen to and note the words you use. How do these words confuse, alienate, and objectify—or reassure, calm, and help us care for our patients and ourselves as physicians?
The words we use in front of patients carry great power and influence. We need to be thoughtful and judicious in the selection of the specific words we speak when caring for patients. Lest you think our words do not matter, think of the three words that begin some of the most important and pivotal sentences, “The doctor said. . . .” Whether we are talking with patients about important recommendations to stop smoking, lose weight, or use condoms or we are explaining a serious diagnosis or describing a therapy, our exact word selection matters.
Our words can comfort, educate, and heal. But unfortunately, they can also hurt, insult, or judge. We need to be careful not to retraumatize those who have experienced trauma, we need to be respectful about the use of pronouns for the transgender community, and for all patients of all ages, ethnicities, and socioeconomic and educational levels. We need to use words that are clear, unbiased, helpful, and healing regardless of whether our patients look like we do or not.
Once I was seeing a young man about a rash on his legs. After describing the history of the rash, I examined him. He was a pleasant young professional man who had been bothered by the rash for several weeks. In the middle of the visit, he looked up at me squarely and politely and said, “Doctor, you know that I was born as a woman right?” His transgender status had nothing to do with his rash. And because I had recently written an article about transgender care and moderated a panel for medical students about caring for transgender patients, I knew to say, “Yes, but you identify as a man, right?” He smiled and nodded. I continued to refer to him as a man for the rest of the visit. I was so thankful I knew the right words to say to support him and care for him. We need to be aware of the specific words, including pronouns, nouns, verbs, adjectives, and adverbs, that we use with every patient.
Nonverbal Communication: Our Body Language
Just as careful listening is critical to understanding our verbal pronouncements, so careful observation is vital to comprehending our body language.
—Joe Navarro, FBI agent and author of What Every Body is Saying
The body never lies.
Most physicians receive little or no training about reading body language—that of their patients or their own. This is unfortunate because an estimated 60 to 65% of interpersonal communication is conveyed through nonverbal behaviors.18 And while most nonverbal behaviors are unconscious, they may represent a more accurate depiction of what the patient is thinking or feeling.19
For the most part, we observe body language subconsciously. Learning how to consciously observe, note, and assess the meaning of various physical gestures, postures, and movements can help you better understand your patients. There is a reason that law enforcement and other professions use body language to help in assessment and communication. Think about some of the body language you observe (or express) on a daily basis with patients. Think about the body language you should be observing in the exam room and elsewhere in your environment.
Positive Body Language in the Exam Room
• How did you greet the patient (handshake or other gesture)?
• Are you sitting at eye level with the patient?
• Have you removed any physical obstacles (computer or desk) between you and the patient?
• Are your facial expressions warm and comforting?
• Are you leaning forward?
• Are your arms and legs uncrossed?
• Are you mirroring the patient’s body language and expressions (isopraxism)?
• Are you physically respectful and appropriately comforting during history taking and physical exam?
Negative Body Language in the Exam Room
• Are you standing?
• Are your toes pointing toward the door?
• Are your arms or legs crossed?
• Are you leaning away?
• Are you looking uninterested or angry?
• Is your hand on the door knob?
• Are you glancing at the clock or the door?
• Are you checking your smart phone?
• Are your hands or eyes on a computer?
• Are you looking harried, hurried, or inpatient?
Your Patient’s Body Language
• What is the patient doing when you walk in?
• How is the patient’s posture?
• Is the patient standing, sitting, or lying down when talking to you?
• Is the patient straining to look up at you?
• What is the patient’s facial expressions saying to you?
• Is the patient avoiding making eye contact with you?
• What are the patient’s hands and feet doing while the patient is talking to you?
• Are the patient’s arms or legs crossed or feet twitching?
• Are the patient’s physical gestures or posture inconsistent with the patient’s verbal message?
Here are a few specific tips:
1. Eyes. Making eye contact is very important in communication. If someone doesn’t make eye contact, it can mean that person is angry, hurt, bored, disinterested, or even lying. It can also indicate nervousness or a submissive nature. Blinking rate can speed up when people are stressed but also when they are lying, especially if they touch their mouth or eyes at the same time. Looking up and to the right can indicate a lie. Looking up and to the left can occur when a person is trying to recall an actual memory.
2. Feet. Although many people think hands or eyes are the most emotionally revealing aspects of our bodies, experts say it is actually our feet. Next time you are with a patient, take a look at the patient’s feet (and at your own). Are they fidgeting? Tapping? Crossed at the ankles? Pointing toward the door? They may be telling you something different than the words being spoken.
3. Hands. One common gesture we may see in patients is clasping or squeezing hands together. This indicates fear or discomfort. Clasped hands with interwoven fingers can mean anxiety and frustration. Hiding one’s hands or putting them in one’s pockets can indicate mistrust or reluctance. If you notice patients’ hands in their pockets, they may not trust you or be interested in what you have to say. (They may also just be cold.)
4. Crossed arms or legs. If your patient is exhibiting a defensive posture, something is wrong. You may want to take a break, move on, or ask some open-ended questions about how the patient is feeling because he or she is clearly self-protecting or indicating a closed posture. If the patient’s legs or arms are crossed, try to find out what is going on.
The skills you have developed throughout your life when it comes to reading another person’s nonverbal cues will likely be what you use in the clinic and your career. But like all aspects of our communication, increasing your awareness about the nonverbal communication between you and your patient and improving your skills in this area can improve your understanding of each other—and may help you provide better care.
Teaching Communication Skills to Trainees
I think we learn most about the types of doctors we'll become from watching our preceptors and residents and learning from them if they do something particularly well or not so well from our vantage point.
During clinical training, students witness both positive and negative examples of communication styles in their attendings and senior residents. In other words, they are learning by watching us. They certainly can learn from different types of examples and can decide which behaviors to emulate and which to reject. Although we hope they have many more good examples to emulate, unfortunately many attendings who have been in practice longer than fifteen years may have never had formal communication skills training. It is only over the past decade or so that medical schools and residency training programs have instituted regular standardized communication skills into the curriculum. Practicing physicians may have few opportunities for communications training once they are busy in practice, and unless the training is mandated, few may actually sign up. While many attendings may be excellent communicators with their patients and staff, others are not. The truth is, most practicing physicians need to improve their communication skills, and there is a great necessity for formal institutional training in this area.
I am still learning how to balance wanting to get to know a person, versus needing the necessary info to help manage their condition.
I want to hear their whole life story [but] then I remember it's only a 15-minute appointment.
The Accreditation Council for Graduate Medical Education (ACGME) identifies communication and interpersonal skills (CIS) as one of the six core competencies for residents to learn along with patient care, medical knowledge, practice-based learning and improvement, professionalism, and system-based practice. And through various courses throughout medical school and examinations such as the Objective Structured Clinical Exam (OSCE) and the US Medical Licensing Examination (USMLE) Step 2 Clinical Skills Exam, we try to teach trainees to effectively exchange information, to be active listeners and articulate speakers, and to develop meaningful relationships. But once trainees begin seeing patients, why do they learn so much by simply observing?
Observational learning most often occurs when a person lacks confidence in his or her own knowledge or abilities; when the situation is confusing, ambiguous, or unfamiliar; or when there is an authoritative person present, according to renowned social psychologist Albert Bandura at Stanford University. I cannot think of a better description than that of young trainees beginning their clinical training. We need to remember that when residents and students are following us, our communication skills are even more important because they are observing and learning from us. Ultimately, the hidden curriculum for our trainees is the way we conduct ourselves and demonstrate human connection with our patients, family members, colleagues, and staff—and, of course, how we communicate directly with our trainees. Trainees are watching us closely, both our verbal and nonverbal communications. They are not only asking, “How do I learn and apply your medical knowledge?” but also, “How do you look at the patient and others?” “Where do you sit?” “What are your expressions and word choices?” “What is your tone of voice?” “How do you give bad news?” “How do you handle emotions?” and “How do you talk about the patient when the patient is not present?” Trainees listen to our tone and read between the lines. They watch our body language. They are listening and watching when we don’t think they are. It is clear that while we mentor them, they learn from us through observational learning.
Certainly, I have seen both good and bad communication skills in our superiors. In terms of bad communication, most of this has been speaking past a patient, or broaching a difficult topic without much tact or warning.
Do medical students come into the medical education system as better communicators than when they finish their training? Often, patients seem more satisfied after interacting with a first-year medical student than with a resident or even a mid-career physician. Furthermore, a medical student will gather more information from the patient while giving the patient more of a sense of caring than anyone else on the medical team. Students generally have more time with each patient than other team members, but often they also appear to have more curiosity and empathy as well as the ability to communicate those traits. We know that empathy and perhaps our communication skills wain during our training. This may be due in part to our physical and emotional exhaustion. But it may also be due to our lack of role models and specific discussions about displaying empathy and excellent communication between physicians and patients. And, unfortunately, after our medical training, we may never fully regain the ability to sit and to be present and curious about another person in a clinical setting as we did when we were first-year medical students. Once in practice, we may not have the time or the interest in assessing or improving our communication styles. Once we become “doctors” and they become “patients,” we enter an arena rife with miscommunication and unsatisfying interactions. Perhaps the first-year medical students realize that the patient on the table could be their mother or sibling, or could even be them, and that is what helps them talk to the patients sincerely and with empathy.
• Are you reading the patient’s chart and becoming fully knowledgeable about the patient beforehand?
• Are you knocking on the patient’s door first and waiting until the patient says “come in” before entering?
• Do you remain calm, focused, caring, and ready to listen to and learn from the patient?
• Do you shake hands, sit down, and make eye contact with the patient?
• Do you allow the patient to finish talking and not interrupt?
• Are you asking about the patient’s fears and expectations?
• Do you check in with your patients to make sure they understand what you are saying?
• Do you answer their questions and then make sure they understand your answer?
• Do you allow the trainees to come with you during difficult encounters and when you need to break bad news?
• Are you displaying empathy?
• Are you actively listening? (“What I hear you saying is. . . .”)
• While talking about the patient with staff or the trainee, are you respectful and nonjudgmental?
• How effectively do you work on the patient’s behalf?
• Do you acknowledge and address the patient’s emotions?
• Do you create a collaborative and caring environment for the patient?
• Are you always respectful of patients, family members, staff, and trainees?
• Are you successful in making sure the patient has no more questions?
• Are you summarizing and offering closure with each patient?
You may have witnessed the same scenario I have on teaching rounds at the hospital when the junior member of the team imitates the senior member. If medical students or interns perceive someone on their team (often the senior resident, chief resident, or attending) as being the most knowledgeable, then no matter how poorly the senior clinician communicates, the trainees begin to imitate that person’s communication style. If the third-year resident speaks in a quiet low monotone manner (and much too quickly) while presenting information to the group, then the medical students will start to do the same. If the chief resident is abrupt, avoids shaking hands with the patient, and is only slightly engaged with patients, then others will follow suit. I have seen this time and time again. Whether it is with presentations or interactions with patients, everyone on the team starts to imitate the senior person—and not always the best communicator.
In teaching students and residents to ask specific questions, do we end up forcing them to ask leading questions as part of the history assessment? In trying to obtain certain clinical information, are we unknowingly encouraging the trainee to ask leading closed-ending questions instead of open-ended questions? Are we discouraging letting the patients tell their own story in their own words to the trainee? In asking physicians to see patients more quickly while they type into a computer, are we forcing them to become interrogators instead of caregivers practicing active listening and shared dialogue?
How can we better mentor our trainees about their communication styles and skills? To improve our trainees’ communication skills, we must first acknowledge our “hidden curriculum”—how we are modeling behavior, communication, and interpersonal skills for our trainees. Second, we should assess and improve our own communication skills. And finally, we should create comprehensive, integrated, and ongoing communication programs for trainees and faculty together.
I have often thought about what the differences in patient satisfaction scores would be between the patient interviewed by a first-year medical student on their very first day of medical school, someone who is ten or fifteen years out of training, and a senior clinician who is thirty or forty years out of training. My guess is that the medical student might receive the highest scores for authenticity, empathy, listening, and overall attentive human dialogue. The senior clinician might score positive reviews as well, but I worry about all the years in between. What happens to our communication skills during training and practice? Medical school, residency, and the first few years of practice do not train us to communicate well with people. In fact, our training years may do just the opposite by putting a greater distance between us and our patients through shrinking our time and our relationship with patients, putting computer screens between us, and not having systems in place that support us, our patients, and patient–physician relationships, dialogue, and collaboration.
Furthermore, studies have shown that it is not easy to measure how our trainees are retaining communication skills. While we might congratulate ourselves on communication sessions we teach in medical school or residency, there are still no studies showing a relationship between the scores students or even residents may achieve on various communications skills assessments and their skills or their patients’ satisfaction scores once they are in practice.
Advice for Teaching Communication Skills to Trainees
1. Listen and observe them: they will show and tell you what they need.
2. Realize they are learning more from observing what you do than from what you say.
4. Watch their verbal and nonverbal communication skills.
5. Observe their emotional cues with you and with patients.
6. Remind them to think of themselves or their family members on the table someday.
7. Encourage them to discuss their own thoughts and feelings about communicating with patients and peers.
8. Encourage them to continue their communications training throughout their careers.
Adrienne Boissy and Timothy Gilligan, Communication the Cleveland Clinic Way: How to Drive a Relationship-Centered Strategy for Superior Patient Experience (New York: McGraw-Hill, 2016).Find this resource:
Roman W. DeSanctis, On Being a Physician (Middletown, DE: @Roman W. DeSanctis, 2018).Find this resource:
Jennifer Fong Ha et al., “Doctor-Patient Communication: A Review,” Ochsner Journal, 2010;10:38–43.Find this resource:
Wendy Leebov and Carla Rotering, The Language of Caring Guide for Physicians: Communication Essentials for Patient-Centered Care, 2nd edition (Language of Caring, LLC, 2014).Find this resource:
David Matsumoto, Mark G. Frank, and Hyi Sung Hwang, Nonverbal Communication: Science and Application (Thousand Oaks, CA: Sage Publications, 2013).Find this resource:
Joe Navarro, What Every Body Is Saying: An Ex-FBI Agent’s Guide to Speed Reading People (New York: Harper Collins, 2014).Find this resource:
1. Roman W. DeSanctis, On Being a Physician (Middletown, DE: @Roman W. DeSanctis, 2018).Find this resource:
2. A. Boissy, A. K. Windover, D. Bokar et al., “Communication Skills Training for Physicians Improves Patient Satisfaction,” Journal of General Internal Medicine, 2016;31(7):755–761.Find this resource:
3. The Joint Commission. Retrieved from: https://jointcommission.org https://www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf.
4. The Joint Commission, “Facts about Patient-Centered Communication,” January 6, 2019. Retrieved from https://www.jointcommission.org/facts_about_patient-centered_communications/.
5. The Joint Commission, “Health Equity Portal.” Retrieved from https://www.jointcommission.org/topics/health_equity.aspx.
6. L. Kettleson, K. Cook, and B. Kennedy, The HCAHPS Handbook 2: Tactics to Improve Quality and the Patient Experience, 2nd edition (Pensacola, FL: Fire Starter Publishing, 2014).Find this resource:
7. A. Boissy and T. Gilligan, Communication the Cleveland Clinic Way: How to Drive a Relationship-Centered Strategy for Superior Patient Experience (New York: McGraw-Hill, 2016).Find this resource:
8. Agency for Healthcare Research and Quality. Retrieved from https://www.ahrq.gov.
9. H. B. Beckman and R. M. Frankel, “The Effect of Physician Behavior on the Collection of Data,” Annals of Internal Medicine, 1984;101:692–696.Find this resource:
10. M. Marvel, R. Epstein, K. Flowers, and H. Beckman, “Soliciting the Patient’s Agenda: Have We Improved?” JAMA: The Journal of the American Medical Association, 1999;281(3):283–287.Find this resource:
11. W. Langewitz, M. Denz, M. A. Keller, A. Kiss, S. Ruttimann, and B. Wossmer, “Spontaneous Talking Time at Start of Consultation in Outpatient Clinic: Cohort Study,” BMJ, 2002;325(7366):682–683.Find this resource:
12. “Harris Poll Survey Finds Patients Want a Deeper Digital Connection with Their Doctor,” Business Wire, April 6, 2015. Retrieved from: https://www.businesswire.com/news/home/20150406005190/en/Harris-Poll-Survey-Finds-Patients-Deeper-Digital.
13. D. Toft, February 10, 2018. Retrieved from: https://dougtoft.net/2018/02/10/the-intimacy-of-shared-silence/.
14. Aristotle and W. R. Roberts, Rhetoric (Dover Thrift Editions, 2012).Find this resource:
15. R. C. Lorenzetti, C. H. Mitch Jacques, and C. Donovan et al. “Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors,” American Family Physician, 2013;87(6):419–425.Find this resource:
16. ACLS Certification Institute. Retrieved from https://acls.com/free-resources/knowledge-base/bls-articles/resuscitation-team-dynamics.
17. A. Fitzgerald Chase, “Team Communication in Emergencies: Simple Strategies for Staff.” Retrieved from http://www.zoll.com/codecommunicationsnewsletter/ccnl04_10/ZollTeamCommunications04_10.pdf.
19. P. Philippot, R. Feldman, and E. Coats, “The Role of Nonverbal Behavior in Clinical Settings,” in P. Philippot, R. Feldman, and E. Coats E, editors, Nonverbal Behavior in Clinical Settings (New York: Oxford University Press, 2003), pp. 3–13.Find this resource: