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It pays to listen: The importance of doctor-patient communication

Across the country, physicians are meeting in groups to figure out how to communicate better with patients -- or risk having them walking out of their practice forever.

By Cheryl Jackson, amednews staff. May 21, 2001.

Farmington, Minn. -- By her own account, she was a frustrated physician. Overwhelmed. Angry even. He, on the other hand, was generally happy. And he believed his patients were, as well.

But both were told they needed work in improving their rapport and communication with patients -- or risk losing them and the money they bring in.

How much does a loss cost?
Schools for communication

Internist Judy Easley, MD, was told when the chief physician at her Bloomington, Minn., HealthPartners clinic suggested she attend a five-day physician-patient communication retreat to improve her efficiency.

"I didn't like what I was doing, and if there was something else I could do and could earn the same amount of money, I would have done it in a flash," said Dr. Easley, who works mostly with senior women.

Still, she didn't have a lot of faith that discussions about communication would make much of a difference. "I thought it was a bunch of hooey. I did not want to go," she said.

Lenny Snellman, MD, a HealthPartners pediatrician in the White Bear Lake, Minn., clinic, got the call after the communications program coordinator complained about a lack of pediatricians represented in an upcoming workshop.

20% to 25% of patients switch physicians solely
because of communication issues.

"I told him I'd do it. But I told him I already communicate well. I don't really need it," Dr. Snellman said. "I was wrong."

Drs. Easley and Snellman sang different tunes. But now they're part of the same choir, one that has physicians across the country singing the praises of various workshops and short courses designed to help improve their abilities to communicate with patients.

The two were among about 18 doctors gathered around a conference table at a lodge meeting room at the Mount Olivet Retreat Center in Farmington, Minn., south of Minneapolis. They'd taken asphalt, then gravel, then dirt roads to get to the facility for the April gathering that was part reunion, part day-long refresher course.

The group of alumni from various HealthPartners communications classes listened to a brief presentation about ways to influence change in patients and watched videotaped scenarios of doctor-patient interaction, including those addressing how to get a law student to deal with his drinking problem and a teenage girl weaned from her six-cigarette-a-day habit.

They watched Dr. Easley comfortably portray a patient whose main agenda in seeing a doctor was to be diagnosed as disabled so that she wouldn't have to return to her job of heavy lifting -- and to get a prescription for pain pills.

As a large group, they talked about how to deal with particular patients. They broke into small groups and discussed what to do about the patient who had thoughts of gunning down fellow classmates or the patient who just wanted drugs prescribed or even the fellow physician who had a horrible rapport with patients and staffers.

They interacted with professional actors brought in to play difficult patients. They exchanged suggestions about how to approach problems. Then they broke away to try techniques on real patients in their practices.

Better business

Proponents say such programs help increase physicians' efficiency and boost doctor satisfaction in their practices. "Just give the patient the time and they'll tell you the diagnosis," goes the refrain.

That can lead to economic benefits, they say. Satisfied patients don't need to be replaced. And patient satisfaction is vital these days to both physicians and insurers as health plans look for ways to differentiate themselves in markets.

"In any business, you want to keep your customers," said Randy Hutchison, director of customer service and performance enhancement for Geisinger Health System in Pennsylvania. "It's a lot more expensive to go out and get a new patient than it is to keep the one you've got. So ideally, the more we can create patient loyalty, the better off it's going to be for all of us."

Also, he said, better communication leads to patients having more trust and confidence in physicians, which will make them more likely to follow doctors' orders and be healthier. And healthy patients are particularly important under capitated arrangements.

Geisinger, which has its main medical center in Danville, Pa., began an active service improvement initiative in 1997.

Over the past 16 months, the health system has pushed for the improvement in physicians' communications, requiring that all of its 600 or so physicians take classes.

Without being able to rely on medical outcomes to distance themselves from competitors, the plans find that getting a contract with an employer boils down to the increasing weight employers put on employee feedback and satisfaction, Hutchison said.

A study published in the February Journal of Family Practice found that dissatisfaction with personal interactions, communication of information and trust for their primary care physicians was the major reason about 20% of Massachusetts state employees switched their health plans between 1996 and 1999.

"The doctors were losing part of their patient base without really knowing what's going on," said Gregory Carroll, director of the West Haven, Conn.-based Bayer Institute, which has trained more than 60,000 clinicians, mostly physicians, since 1989. Bayer's own survey around that time showed that 25% of surveyed adults said they switched physicians solely because of communication issues and that most of them never told their doctors why they left.

"You'd think that with medical school and residency training that this topic would be covered," Carroll said. "But it remains a bit of a hidden issue."

More emphasis

Communication, generally an after thought in initial training, needs more emphasis, Carroll said, particularly in the drastically changed climate in which physicians find themselves practicing.

Many physicians are used to a time when medicine was more paternalistic. Now patients armed with printouts from the Internet and drug ads and articles ripped from magazines are heading to offices with demands. Meanwhile, managed care has forced doctors to become more rushed.

"In a way, it's kind of a no-brainer," said John Ulwelling, executive vice president of the Foundation for Medical Excellence, based in Portland, Ore., which seven years ago founded the Northwest Center for Physician-Patient Communication.

"The greatest challenge seems to be getting physicians to pull the days needed out of their schedules," he said.

The Northwest Center offers about 15 different communications courses. Classes can be as short as one hour, targeting a specific issue, or as long as a week, where the sessions are more general.

"Listening is a good start," Ulwelling said. "So often, a doctor will come in with his or her clipboard and say 'what's your blood pressure' and go down this list. Patients need some time to tell their story," he said. "The fear doctors have is that if they tell their story, it can go on too long. But many people can tell their stories pretty succinctly."

When asked how long they spend in the average visit educating patients, physicians are likely to respond nine to 10 minutes, Hutchison said. Actually, it's more like about one minute.

A typical physician visit is interrupted within the first 27 seconds, Carroll said, often by a nurse or telephone call.

"The patient doesn't always get to tell their story," Carroll said. "Sometimes you can't help that. But just making doctors aware of these things that can happen helps."

Listening more closely also can help doctors avoid some tests, which saves money, he said.

Doctors who get high ratings for communications skills are less likely to be sued, experts say. "More than 70% of lawsuits are based on communication problems," Hutchison said.

Medical liability insurers cut prices for physicians who attend such workshops, which often count as continuing medical education.

"The concept is simple. But finding the words is more challenging," said Barry Egener, MD, medical director of the Northwest Center for Physician-Patient Communication. "They get marginalized as people skills. Or the attitude occurs that either you're good at communication or you're not good at communication."

Those attitudes might leave openings for entrepreneurs such as speech pathologist Jacque Ater to capitalize on. Since November, she has coached patients in their communication with their doctors, charging about $225 for three 30-minute sessions. Six clients have signed on with her.

"I think some people come to their professions with better organizational skills and better time-management skills. But not a lot of personal emphasis is placed on the aspect of communicating with the patients," she said. "A lot of people are very unhappy with the breakdown of communication in health care. Patients are anxious. They're overwhelmed."

Changing attitudes

Success comes, experts say, when doctors change their attitudes about dealing with patients.

"You see patients on your schedule and you know you don't want to deal with them," said Dr. Snellman, in practice for about 19 years. "There are a lot of people who are unhappy and a lot of people who aren't as much fun to have on your schedule. And they're probably the people you need to see the most.

"I think I'm happier. My patients are happier. I learned I talk more than I should. I don't listen as much as I should." Dr. Snellman said. "Before I would come out and say, 'Whoa! I'm glad that's over.' I think now I come out and say, 'Wow! I feel better about the way I did that!' "

But even though keeping patients is believed to help physicians' pocketbooks, there's little evidence to quantify the economic success of such programs.

"I don't think there's any question that doing this increases efficiency. It's just incredibly difficult to measure," said John Butler, MD, who in 1994 initiated the HealthPartners communications training program. HealthPartners has more than 500 physicians.

Also, there are plenty of unanswered questions about how much a doctor 20 to 30 years into his or her practice can be turned around in a half-day to a week.

"We can teach skills in a workshop. The question is, will physicians take those skills and implement them in their practices? Will the impact on the patient save money? Will it make the patient more healthy?" Dr. Egener said.

Experts and representatives from various physician communication entities, including the Bayer Institute and the Northwest Center, are planning a meeting for 2002 to try to answer those questions and others related to how to evaluate the programs' effectiveness.

"We are trying to meet the same standards that we expect of other medical interventions -- to prove that they do work," Dr. Egener said.

ADDITIONAL INFORMATION:

How much does a loss cost?

At HealthPartners, a Minnepolis-based nonprofit physician group and HMO with 650,000 members, revenue is about $400 per patient per year. Patients average about two visits a year to a primary care doctor, plus visits to specialists and related activities. With fixed costs at about 50%, losing a single patient means losing $200.