CHAPTER 1

Building the Case for Communication and Relationships

I (Calvin Chou) paused and shook my head as I previewed the chart of my new patient, Mr. Johnson. He was an Army vet and former line cook in his early 60s and had been on disability for many years for chronic lower back pain. He was treated with high-dose opiates until his urine tests turned positive for cocaine a year ago. His primary care physician at the time referred him to a pain management clinic, and opiates were quickly tapered. Mr. Johnson wasn’t happy about this. He had transferred to two different clinicians in the past year. I know and trust both of them, and I could see they’d had a rough time. Both had refused to give Mr. Johnson more opiates. Both had documented similar endings to their visits (and to the relationships): “patient got up, interrupted me, yelling epithets, and walked out, slamming the door behind him.”

Patients like Mr. Johnson once made me extraordinarily anxious. Clinical training generally does not teach us how to treat Mr. Johnson. My usual approach would have been to firmly state, with full justification, that opiates are not an option. The patient would leave the visit angry, and even though I would know I’d done the right thing, I would still feel terrible. Now, having developed a reputation for being a “communication expert” (a castle in the air, if ever there was one), I am often asked to see “difficult” patients. I don’t jump for joy about these visits, but I do feel more confident than I used to. I no longer expect that I will just get my way because I’m the one with clinical training. But when I rely on a toolbox of communication skills, including listening, empathy, and compassion, patients can leave the encounter with some hope, and I can derive some satisfaction from the visit.

Where did I get this toolbox? As a pre-med student in college in the early 1980s, I had only the vaguest notion of what becoming a doctor really meant. My parents were immigrants and didn’t work in healthcare, so what little I knew came from television: reruns of “Marcus Welby, MD,” or summers guiltily spent indulging in episodes of “General Hospital.” The contrasts couldn’t be sharper. Dr. Welby seemed like a kind, wholly trustworthy, humanistic physician who listened to his patients and tried to do right by them, whereas the doctors on “GH” found themselves repeatedly embroiled in scandal, intrigue, and bizarre plot lines. Still, I actually learned a lot by observing how the doctors and nurses seemed to really care about their patients and each other (when they weren’t being kidnapped or framed for murder). What a disappointment it was that the mad preparation for medical school consisted wholly of studying biology, chemistry, and physics rather than perfecting the finer points of humanism. The application to medical school seemed to depend wholly on test grades and scores, with no mention of the storied and elusive skills of “bedside manner.” I saw some classmates who were admitted to prestigious medical schools, but I wondered, given my observation of their interpersonal interactions, how they would enact the full range of physician skills as seen on TV—let alone in real life!

There was a bright spot in my training: in residency, when I was on outpatient-based months, we attended a weekly 90-minute seminar called “Medical Interviewing and Psychosocial Aspects of Medicine.” This was something I hadn’t explicitly learned about in medical school. That seminar focused less on the content and knowledge learning in medicine; instead, it emphasized how clinicians can communicate with patients to convert all that knowledge into effective treatment plans.

Clinicians have more than 200,000 patient interactions (e.g., outpatient appointments, emergency department visits, interactions on inpatient rounds) during their careers—and that doesn’t include telephone calls or secure messaging.¹ Clinicians also have innumerable meetings and conversations with colleagues and interdisciplinary teams. Yet, like me, most clinicians received little or no formal training in what might be seen as the most common procedure that all clinicians perform. Would you trust a surgeon who told you, “I haven’t had any formal training for this procedure, haven’t observed any experts, nor have I been observed and received feedback, BUT over the course of time, through trial and error, I think I’ve found what works for me”? That is essentially how physicians were “trained” in communication skills for decades.

In the 1970s the concept of “patient-centered care” emerged. This model shifted control of medical decisions toward the patient. It’s your body: you should be involved in the decisions about your care. Research has confirmed the value of a patient-centered orientation: we must know what is important to patients and what they understand. This does not mean, however, that the patient is always right, according to the customer service mantra. Effective communication, in the context of a patient-clinician relationship, is not the same as customer service in a retail business. Patient-centeredness research examines how the clinician cares for and shares power with the patient in an encounter, not whether the clinician completely cedes control to patients. Testing, diagnoses, and treatments should not be solely up to the patient to decide because clinicians bring expertise that patients need—and want—for the best care. It’s not safe to give Mr. Johnson any opiates, as much as he might want them.

So the pendulum is starting to settle in between patient and clinician. This approach is known as relationship-centered care (RCC).² RCC acknowledges the clinician’s expertise as well as the patient’s perspectives and preferences; it focuses on the space between patient and clinician, not exclusively on one person or the other. In fact, RCC brings all the relationships in healthcare together—patients, clinicians, team members, and families—to improve the quality and safety of healthcare and well-being. As a result, RCC requires that clinicians bring not only their knowledge base but also their genuine personhood into each patient encounter. It turns out that, contrary to the supposed ideals of my medical training, clinicians are not Spock-like creatures driven only by knowledge and rational thought. We have emotions, which affect patient and clinician alike and must be a prominent—and essential—part of the relationship.³ Recent research in basic neurological science has shown a physiological basis for empathy, and the healing power of recognizing emotion and providing compassionate support.⁴ Emotions are also inherently involved in the decision-making process, especially when there is scientific uncertainty. So there is a balance to strike: we can’t allow emotions to hijack our work, nor can we ignore them completely. We must cultivate awareness of our emotions and determine how they affect our own behavior, our relationships with our patients, and the decisions we make. Unfortunately, in the fast-paced and pressured practice of clinical medicine, it often seems easier for clinicians to remain more task-oriented and to minimize these emotions during the course of our typically hectic days. That stance runs risks, not only of sealing us off from the fulfillment of our relationships and the power of RCC, but also of misdiagnosis, poorer outcomes, and burnout.⁵

A hallmark of RCC is the interpersonal interactions and strong communication skills that allow clinicians and team members to connect with patients and the emotions they invariably bring. Though our training may have favored hypercerebral types who could name dozens of items on a differential diagnosis for blood in the urine, our system has evolved. Medical knowledge is just one of at least six areas required by medical school and residency training accreditation agencies for clinical trainees to demonstrate full competence in healthcare practice. The areas of interpersonal communication and professionalism both figure prominently in those mandated competencies. The medical marketplace has also changed. Patient satisfaction measures have existed for many years, but only recently have patient experiences of care become an important metric for healthcare systems and a basis for reimbursement.

RCC has contributed to moving medicine out of the paternalistic model of the past century. It is the right way to practice. In addition, over the past three decades, patient-clinician communication has become a prominent field of scientific research. Despite the details of legislation and political uncertainty that always exist, data about the positive effects of relationship-centered communication skills in healthcare continue to burgeon. What’s more, relationship-centered communication skills are completely transferable to relationships in one’s professional and personal lives: they are people skills, not just healthcare skills. This book focuses on practical strategies that are based on the extensive underlying research.

Effective Communication Leads to Better Outcomes

Overall, effective communication leads to increased satisfaction, increased trust with the clinician,⁶ improved overall health status, and functional and psychological well-being.⁷

Effective communication leads to improved outcomes in specific diseases. There is a reduced risk of coronary heart disease.⁸ Mortality from myocardial infarction decreases, because of effective communication with patients⁹ as well as improved systems communication.¹⁰ Hospital readmissions due to congestive heart failure also decrease.¹¹

Effective communication leads to better outcomes in chronic illness. Patients of physicians with high empathy scores, measured by a validated scale, were significantly more likely to have good control of diabetes and cholesterol.¹² Effective communication also improves patients’ ability to more effectively manage chronic diseases such as high blood pressure, diabetes, and HIV.¹³ Symptoms improve for patients with irritable bowel syndrome and chronic constipation.¹⁴ Patients with medically unexplained physical symptoms (the kind that lack easily biomedically solvable diagnoses) whose clinicians use effective communication skills have significant increases in satisfaction with their clinicians and their relationships with their clinicians.¹⁵

Effective communication improves outcomes after surgery. The incidence of serious postoperative outcomes, such as cardiac arrhythmia¹⁶ and delirium,¹⁷ decreases. Also, patients who perceived their trauma surgeons as being more empathic had better medical outcomes after hospitalization.¹⁸

Effective communication improves cancer outcomes through increased adherence to cancer screening,¹⁹ improved cancer survival,²⁰ reduced suffering from cancer,²¹ and better care at the end of life.²²

Effective communication results in improved pain outcomes. Patients report better pain control²³ and improved response to pain management modalities such as acupuncture.²⁴

Finally, effective communication reduces healthcare costs. Increased patient-centeredness is associated with reduced costs for diagnostic testing.²⁵ Clear communication with family members about decisions at the end of life decreases ICU admissions and unnecessary ventilation and resuscitation efforts.²⁶

A recent review found that the patient-clinician relationship has a beneficial effect on overall healthcare outcomes with an effect size approximately equal to that of taking a daily aspirin for five years to prevent heart attacks.²⁷ What’s more, unlike aspirin, good patient-clinician relationships do not cause GI bleeding!

Faulty Assumptions: “I Already Communicate Well”

There is more work to do, however. The literature also shows that clinicians do not communicate as effectively as they think. There are systemic factors that interfere with the way that most clinicians would like to practice optimally. Even so, there is still a gap between what we think we’re doing and what we’re actually doing.

We do not elicit the full spectrum of patient concerns at the outset of the encounter, so we wrestle with “doorknob” questions that make us less efficient.²⁸ We redirect patients after 18–23 seconds of listening to them speak, and rarely allow them to return to their thoughts.²⁹ We unreliably seek patients’ perspectives on their illnesses and inadequately address their emotions.³⁰ We incompletely attend to cultural differences.³¹ We use incomprehensible jargon and don’t confirm that our patients understand their diagnoses and treatment plans.³² We do not effectively involve patients in decision-making or when we obtain informed consent.³³

We can measure the negative process outcomes of our ineffective communication. Outpatients do not return to clinicians with poor communication skills.³⁴ Readmission rates for inpatients are higher in cases of inadequate communication.³⁵ Worst of all, from the clinician’s perspective, perceived failures in communication, or patient experiences of humiliation from poor communication from clinicians, even nonverbal ones, are associated with more malpractice claims.³⁶

Communication Skills Can Be Taught … and Learned

There is good news. Clinicians with more effective communication achieve benefits beyond individual patient “satisfaction.” (See Chapter 2 for further discussion.) We all have challenges in our daily practices (difficult conversations, dissatisfied patients) that leave us feeling unsettled and dissatisfied with how we have performed. Learning to communicate more effectively with patients helps us not only make more accurate diagnoses and enhance adherence to treatment but also helps us increase our own well-being and resilience.

Clinicians who use communication skills such as agenda-setting for a clinical encounter,³⁷ motivational interviewing,³⁸ or specific communication skills for managing patients with dementia³⁹ report increased satisfaction with their encounters and decreased frustration and burnout. Clinicians who participated in a mindful communication program had higher well-being and attitudes toward patient care.⁴⁰ Clinicians who underwent a daylong communication skills course showed higher patient experience scores, increased empathy scores, and lower burnout scores when compared with those who did not.⁴¹

Finally, contrary to widely held assumptions, clinicians practicing in diverse settings (primary care, inpatient, surgical, subspecialty) can improve fundamental as well as advanced communication skills,⁴² using motivational interviewing,⁴³ shared decision-making,⁴⁴ cross-cultural communication,⁴⁵ and end-of-life communication.⁴⁶ It’s tempting to offer a “quick fix” to help clinicians with low patient experience scores. But as chief medical officers and patient experience staff have begun to discover, it is not enough to attend a 30- to 60-minute lecture to acquire proficiency in these skills. Learning skills is not the same as learning a concept. Whether you were on the football team or in the marching band, you know that skill improvement and achieving mastery require deliberate practice and feedback.⁴⁷ No one would ever expect a proceduralist to attend an hour-long lecture, or even a half-day seminar, and then be able to do a new procedure with complete proficiency. With communication skills, clinicians must also take into account the complex needs, desires, histories, approaches, stories, assumptions, and psychology that every individual patient brings to a relationship. This work is challenging, to be sure; we all view the way we communicate as strongly personal, and feedback about communication may feel more like an attack than a gift.

Therefore, in order to effectively teach skills for lasting benefit, trainers must not only explain concepts but also facilitate skills practice and become experts at giving feedback. Studies also show that effective training processes result in persistence of learned skills over time. Data on effective communication skills programs show that they typically last for one entire day, focusing on applying learnings to clinical practice and on learners’ goals and needs. Skills-based exercises, including role-play, in small groups or in individualized coaching work better than isolated didactic presentations; specific feedback on communication skills is the most important element that contributes to heightened patient experiences of care.⁴⁸ ACH faculty have found that when we teach these skills in these ways, the vast majority of clinicians find not only that these skills are helpful to their everyday practices but also that the programs inspire renewed energy and dedication to their careers.

Conclusion

Returning to Mr. Johnson, the veteran with back pain and an unhealthy relationship with opiates, suffice it to say that it was not a perfect interaction, nor does it have a storybook ending. By carefully using the skills outlined in this book, particularly the fundamental skill sets in Chapters 3–5, we had some successes. Even though I did not prescribe opiates, Mr. Johnson did not fly off the handle, and in fact, at the end of the visit, he stuck out his hand and calmly said, “Thank you.”

I performed no magic on him during our encounter. In retrospect, the main magic I did was on myself, by resisting the urge several times to emphasize my superior knowledge, which I think would have been a relationship-breaking move. Instead, I used every single clinical skill I know and remained aware of my emotions. I was noticing the patient’s frustration and disappointment as well as my own, knowing that because I was systematically approaching the visit, I could validate his experience. I could offer emotional support … but not opiates.

While communication skills training is not a panacea, it can reliably improve quality of care, outcomes, and patient experience. As recent technological advances drive people toward interacting with devices rather than directly with others, interpersonal communication skills have never been more important in healthcare. In the high-stakes setting of health, well-being, and wellness, a trustful, caring relationship between patient and clinician leads to better outcomes for both. We invite you, your colleagues, and your institution to join with us in our efforts to transform healthcare through effective communication.