Larry B. Mauksch

Relationship, Communication, and Efficiency in the Medical Encounter Creating a Clinical Model From a Literature Review

BACKGROUND While there is consensus about the value of communication skills, many physicians complain that there is not enough time to use these skills. Little is known about how to combine effective relationship development and communication skills with time management to maximize efficiency. Our objective was to examine what physician-patient relationship and communication skills enhance efficiency. DATA SOURCES We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications. STUDY SELECTION From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis. DATA EXTRACTION The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus. RESULTS Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues. CONCLUSIONS Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.

Integrating communication training into a required family medicine clerkship.

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity—students’ clinical years—to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

Teaching inpatient communication skills to medical students: an innovative strategy.

At the University of Washington, a group of medical educators defined a set of communication skills, or “benchmarks,” that are expected of second-year medical students conducting history and physical examinations on hospitalized patients. In order to teach the skills listed in the communication benchmarks, an educational strategy was devised that included training sessions for 30 medical teachers and the development of an innovative videotape tool used to train the teachers and their students. The benchmarks were designed in 2003 for the developmental level of the students and were based on key communication concepts and essential elements of medical communication. A set of five short videotaped scenarios was developed that illustrated various segments of a student history and physical examination. Each scenario consisted of an “OK” version of communication and a “better” version of the same scenario. The video scenarios were used in teaching sessions to help students identify effective communication techniques and to stimulate discussion about the communication benchmarks. After the training sessions, teachers and students were surveyed to assess the effectiveness of the educational methods. The majority of students felt that the educational design stimulated discussion and improved their understanding of communication skills. Faculty found the educational design useful and 95% felt that the curriculum and videotape contributed to their own education. The development of communication benchmarks illustrated with short videotaped scenarios contrasting “OK” with “better” communication skills is a useful technique that is transferable to other institutions.

A patient centered care plan in the EHR: improving collaboration and engagement.

Patients attempting to manage their chronic conditions require ongoing support in changing and adopting self-management behaviors. However, patient values, health goals, and action plans are not well represented in the electronic health record (EHR) impeding the ability of the team (MA and providers) to provide respectful, ongoing self-management support. We evaluated whether a team approach to using an EHR based patient centered care plan (PCCP) improved collaborative self-management planning. An experimental, prospective cohort study was conducted in a family medicine residency clinic. The experimental group included 7 physicians and a medical assistant who received 2 hr of PCCP training. The control group consisted of 7 physicians and a medical assistant. EHR charts were analyzed for evidence of 8 behavior change elements. Follow-up interviews with experimental group patients and physicians and the medical assistant assessed their experiences. We found that PCCP charts had more documented behavior change elements than control charts in all 8 domains (p < .001). Experimental group physicians valued the PCCP model and suggested ways to improve its use. Patient feedback demonstrated support for the model. A PCCP can help team members to engage patients with chronic illnesses in goal setting and action planning to support self-management. An EHR design that stores patient values, health goals, and action plans may strengthen continuity and quality of care between patients and primary care team members. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Effectiveness of Intensive Physician Training in Upfront Agenda Setting

BackgroundPatients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised.ObjectiveWe hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status.Design and ParticipantsPost-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004—March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed.InterventionExperimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks.Main MeasuresOutcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status.Key ResultsExperimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional statusConclusionCollaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of “oh by the way” concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.

Design, dissemination, and evaluation of an advanced communication elective at seven U.S. medical schools.

Purpose To test educational methods that continue communication training into the fourth year of medical school. Method The authors disseminated and evaluated an advanced communication elective in seven U.S. medical schools between 2007 and 2009; a total of 9 faculty and 22 fourth-year students participated. The elective emphasized peer learning, practice with real patients, direct observation, and applications of video technology. The authors used qualitative and quantitative survey methods and video review to evaluate the experience of students and faculty. Results Students reported that the elective was better than most medical school clerkships they had experienced. Their self-confidence in time management and in the use of nine communication skills improved significantly. The most valued course components were video review, repeated practice with real patients, and peer observation. Analysis of student videos with real patients and in role-plays showed that some skills (e.g., agenda setting, understanding the patient perspective) were more frequently demonstrated than others (e.g., exploring family and cultural values, communication while using the electronic health record). Faculty highly valued this learner-centered model and reported that their self-awareness and communication skills grew as teachers and as clinicians. Conclusions Learner-centered methods such as peer observation and video review and editing may strengthen communication training and reinforce skills introduced earlier in medical education. The course design may counteract a “hidden curriculum” that devalues respectful interactions with trainees and patients. Future research should assess the impact of course elements on skill retention, attitudes for lifelong learning, and patients’ health outcomes.

Comparing narrative and multiple‐choice formats in online communication skill assessment

Objectives  We compared multiple‐choice and open‐ended responses collected from a web‐based tool designated ‘Case for Change’, which had been developed for assessing and teaching medical students in the skills involved in integrating sexual risk assessment and behaviour change discussions into patient‐centred primary care visits.

Identifying transparency in physician communication

OBJECTIVE To categorize physician communication demonstrating understanding of what patients want to know and skill in conveying that information. Physicians underestimate how much information patients want and patients rarely seek information during clinic visits. Transparent communication is advocated to facilitate patient understanding and support autonomy, informed decision-making and relationship development. METHODS Analysis and coding of 263 audiotaped interactions between 33 primary care physicians and their patients in eight community-based, primary care clinics in Washington State, USA. RESULTS Physicians proactively used five types of process transparency to preview speech and actions. Four types of content transparency were used to explicate diagnosis and treatment, demystify medical language and concepts, and interpret biomedical information. Physicians spent the greatest proportion of clinic time explicating medical content. CONCLUSION The primacy of information exchange over process-oriented, relational communication was demonstrated. Proactive transparency appears promising to increase understanding and collaboration. PRACTICE IMPLICATIONS In patient-centered care where collaboration is the ideal, transparency in its various forms is a critical ingredient. Without much communicative effort, physicians who proactively communicated that an examination was over, that they were leaving the exam room briefly so patients could dress provided information that appeared to address patient uncertainty and demonstrated empathy and respect.

Questioning a Taboo: Physicians’ Interruptions During Interactions With Patients

A seminal event occurred in 1984. Howard Beckman, MD, and Richard Frankel, PhD, published a study1 reporting that physicians interrupt patients, on average, after 18 seconds during an encounter. According to Google Scholar,2 this study has been referenced 1115 times in academic journals and books, 50 times alone in 2016. The mainstream press picked up on this study with titles such as “Study Finds Doctors Aren’t Good Listeners” or “Prescription for Doctors: Listen More.” In light of the 1984 finding, how many students, residents, and practicing physicians in the last 30 years have been told not to interrupt patients? This admonishment is well intentioned. Most people associate interruption with rudeness, often leading to patient complaints. Skillful listening is essential to accomplish critical health care functions such as identifying the reasons patients request care, making accurate diagnoses, conveying empathy and support, exploring self-management challenges, and more. Yet there is a nagging question: Should physicians never interrupt their patients? Over the years I have asked scores of physicians and many psychotherapists, “Do you ever interrupt your patients?” I have received two answers: “Yes” and “Of course.” Frequently the respondent laughs sheepishly as if to say, “I know I’m breaking a rule.” What does the literature tell us about interruption in the medical encounter? Early research examining interruption of patients stressed physicians’ tendency to assert and retain power in the relationship. Subsequent studies provide a broader, more nuanced view. Physicians and patients interrupt one another often, and patients interrupt at least as frequently as physicians.3 Not all interruptions are intrusive, competitive, or power-claiming.3 While some interruptions are classified as neutral, others build rapport, offer support, and express cooperation.4 The frequency of interruption varies among visit phases.5 The first phase combines rapport building and agenda setting. A middle phase focuses on diagnostic inquiry and hypothesis testing. The final phase is treatment planning. Physicians tend to interrupt in the earlier phases of the visit using questions to clarify symptoms or concerns. Later in the interview, patients may interrupt more often using statements more than questions.3 Despite this research, writings and teachings claim that interrupting patients is taboo. Can some interruptions improve the quality of care and help the patient and physician make better use of time? I believe the answer is yes. Allow me to share a few examples from different situations when interruptions might improve health care efforts and decrease physician stress. Let’s start with the critical, agenda-setting phase, when patient and physician should identify and prioritize issues to address during the visit. A physician who understands the 18-second interruption study1 may be more effective at agenda setting. Beckman and Frankel classified four physician behaviors as interruptions when used during the opening moments because these behaviors distracted the patient from sharing additional concerns. The first form of interruption is an “interrogative” or closed-ended question, such as “How long have you had this pain?” This interruption inaugurates a string of diagnostic questions that are virtually automated behaviors rooted in medical training. Second, an “elaborator” encourages a patient to continue speaking on a topic. For example, “Tell me more about your pain.” A third form is a “recompleter,” a way of reflecting or confirming the patient’s statement. For example, “So, your pain is waking you at night.” Both the elaborator and the recompleter encourage patients to go into greater depth on a single issue. Fourth, a statement such as “Let’s figure out what is going on” interrupts the patient from naming new concerns. While all of these physician comments may be helpful later in the visit, when used early they interrupt the process of agenda setting. Beckman and Frankel did not code asking “anything else” as an interruption because it prompted the patient to name other concerns, even though it may have “interrupted” some patients from sharing more details about their first concern. Beckman and Frankel’s rationale made sense then as it does now. The first reason for the visit may not be the only or most important concern. Knowing about all the concerns at the outset of the visit helps the physician develop hypotheses, plan time use, and significantly decrease the chance that the patient or the physician will raise “Oh, by the way” concerns late in the encounter.6 To help physicians with agenda setting, I teach a more elaborate form of asking “Anything else?”

Seeking a wider lens for scientific rigor in emerging fields: The case of the primary care behavioral health model.

In response to widespread recognition of the need to blend biomedical and psychosocial health care efforts, the primary care behavioral health (PCBH) model has achieved rapid uptake across the United States. Reports of its application come from military sectors, community health centers, and a variety of health care systems, large and small. Examining the PCBH models appeal, evidence, and design forces us to confront important questions. These questions and much more are addressed in this issue of Families, Systems, & Health. (PsycINFO Database Record