Ronald M. Epstein

How does communication heal? Pathways linking clinician–patient communication to health outcomes

OBJECTIVE Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patients anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. CONCLUSION Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway. PRACTICE IMPLICATIONS Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.

The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry

The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex—subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term “new paradigm” would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient.

The Values and Value of Patient-Centered Care

Patient-centered care has now made it to center stage in discussions of quality. Enshrined by the Institute of Medicine’s “quality chasm” report as 1 of 6 key elements of high-quality care,[1][1] health care institutions, health planners, congressional representatives, and hospital public

Developing Physician Communication Skills For Patient-Centered Care

Growing enthusiasm about patient-centered medical homes, fueled by the Patient Protection and Affordable Care Acts emphasis on improved primary care, has intensified interest in how to deliver patient-centered care. Essential to the delivery of such care are patient-centered communication skills. These skills have a positive impact on patient satisfaction, treatment adherence, and self-management. They can be effectively taught at all levels of medical education and to practicing physicians. Yet most physicians receive limited training in communication skills. Policy makers and stakeholders can leverage training grants, payment incentives, certification requirements, and other mechanisms to develop and reward effective patient-centered communication.

Patient trust: Is it related to patient-centered behavior of primary care physicians?

Background:Patients’ trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients. Methods:We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physicians practice and to SPs. We used multilevel modeling to examine the associations between physicians’ Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs. Results:Component 1 of the MPCC, which explored the patients experience of the disease and illness, was independently associated with patients rating of trust in their physician. A 1 SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02–0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001–0.02). Component 1 and visit length were also positively associated with SP trust ratings. Conclusions:Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians’ exploration patients’ experiences of disease and illness improves trust.

Patient-Centered Communication and Diagnostic Testing

PURPOSE Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODS We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTS Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%–17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%–6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures. CONCLUSIONS Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians’ and health systems’ willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.

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.

Beyond Information: Exploring Patients' Preferences

quired not only to produce the same level of health as the current ones but also to be substantially less expensive. Showingtheprivatesectorthatcomparativeeffectivenessfunds will be used in this way could change the entire research and development process in the US health care industry. It could also help the current administration achieve its goal of making health care more affordable for all US citizens. To adopt these 2 criteria for funding comparative effectiveness research, the agencies that release funds must make tough decisions. The agencies will be accused of sponsoring rationing. A strong case can be made that this does not represent rationing but rather uses research dollars to produce therapies that are better and substantially less expensive. After all, when a computer is purchased today at a small percentage of the cost of computers produced years ago, it is not believed that the private sector has rationed computer chips. Instead, the research and development model in the computer industry has been to make better machines and to make them at increasingly lower costs, thereby making computers affordable to many more individuals. It is time to use public funding and comparative effectiveness research toaccomplish the same thing inmedicine. If this opportunity is missed, another one is unlikely to come along. Thenrationingmayactuallybecometheonlywaybywhichreductions in health care expenditures can be achieved.

Could this Be Something Serious? Reassurance, Uncertainty, and Empathy in Response to Patients' Expressions of Worry

BACKGROUNDPrevious work suggests that exploration and validation of patients’ concerns is associated with greater patient trust, lower health care costs, improved counseling, and more guideline-concordant care.OBJECTIVETo describe physicians’ responses to patients’ worries, how their responses varied according to clinical context (straightforward versus medically unexplained symptoms [MUS]) and associations between their responses and patients’ ratings of interpersonal aspects of care.DESIGNMultimethod study. For each physician, we surveyed 50 current patients and covertly audiorecorded 2 unannounced standardized patient (SP) visits. SPs expressed worry about “something serious” in 2 scenarios: straightforward gastroesophageal reflux or poorly characterized chest pain with MUS.PARTICIPANTSOne hundred primary care physicians and 4,746 patients.MEASUREMENTSPatient surveys measuring interpersonal aspects of care (trust, physician knowledge of the patient, satisfaction, and patient activation). Qualitative coding of 189 transcripts followed by descriptive, multivariate, and lag-sequential analyses.RESULTSPhysicians offered a mean of 3.1 responses to each of 613 SP prompts. Biomedical inquiry and explanations, action, nonspecific acknowledgment, and reassurance were common, whereas empathy, expressions of uncertainty, and exploration of psychosocial factors and emotions were uncommon. Empathy expressed during SP visits was associated with higher patient ratings of interpersonal aspects of care. After adjusting for demographics and comorbidities, the association was only statistically significant for the MUS role. Empathy was most likely to occur if expressed at the beginning of the conversational sequence.CONCLUSIONSEmpathy is associated with higher patient ratings of interpersonal care, especially when expressed in situations involving ambiguity. Empathy should be expressed early after patient expressions of worry.

Peer assessment of professional competence.

Background  Current assessment formats for medical students reliably test core knowledge and basic skills. Methods for assessing other important domains of competence, such as interpersonal skills, humanism and teamwork skills, are less well developed. This study describes the development, implementation and results of peer assessment as a measure of professional competence of medical students to be used for formative purposes.