June 2006 | Back to Table of Contents

Quality Rounds

Caring Words

By Scott D. Smith

The quality movement has focused on clinical measures. Should the next step be rewarding doctors who can prove they care?

James Li, M.D., believes that if patients judge doctors based on their bedside manner, so should those who want to improve the quality and safety of health care. Li, who specializes in allergic diseases and internal medicine at Mayo Clinic in Rochester, has been involved with Mayo’s effort to find and implement the best methods for improving the way physicians and patients interact for about five years. “My own conclusion is that a great deal of attention to relationship-centered care should be part of a health care system’s quality agenda,” Li says.

Li is not alone. Health care facilities, medical schools, health plans, and quality organizations are placing more and more emphasis on how well patients and doctors talk to each other.

Why the newfound interest in physician-patient communication? A growing body of empirical evidence shows that bedside manner—how a physician handles a patient—directly affects medical outcomes.

Moira Stewart, Ph.D., an epidemiology professor at the University of Western Ontario, reviewed literature published between 1983 and 1998 on whether communication affects medical outcomes. Of the 22 articles reviewed, 16 showed that positive patient-physician interactions resulted in improved emotional health, symptom resolution, improved function, and better physiologic measures such as blood pressure and blood sugar levels and pain control. Other studies have found a link between an absence of supportive, empathetic communication and malpractice suits.

“In the past, one point of view was that this was icing on the cake. Nice to have but not really necessary, but as [researchers] looked at it more carefully they realized this is the cake,” says Li, who also addressed the topic in the March issue of the Mayo Clinic Proceedings.

Talking the Talk
Research has shown that medical visits are more productive if physicians use an interviewing technique that employs open-ended questions to encourage patients to explain why they came to the doctor. However, that doesn’t always happen in day-to-day practice.

Researchers Richard Frankel, Ph.D., of the Indiana University School of Medicine, and Howard Beckman, M.D., of the University of Rochester, found in 1999 that on average physicians interrupt patients 23 seconds after they start explaining their problem, thus often missing important information about their health and the reason for their visit. When physicians stop patients from explaining all of their concerns, they may miss critical issues because patients don’t typically list their concerns in order of importance. “We have to have adequate communication with the patients to know which test we should do,” says Norman Jensen, M.D., an expert in physician-patient communication at the University of Wisconsin, who worked as a consultant to Mayo Clinic as it developed its curriculum for training doctors.

Jensen advises using a method called agenda setting, in which the physician starts the interview by asking the patient her concern and continuing to ask “what else?” until she runs out of topics. Once the physician hears all the concerns, he or she can then set an agenda for managing them during the visit.

Doctors are often afraid that letting patients talk freely will open a can of worms and eat up more time than they can afford, Li says. But research shows the technique only takes about one minute longer and saves time in the long run because doctors can avoid hearing the words “one more thing” before they walk out the door.

Listening to patients and showing that you care can also improve compliance with treatment, physicians say. Li tells of one patient who needed surgery for degenerative arthritis of the hip. Other doctors had recommended the procedure. But the man didn’t agree to the surgery until a doctor at Mayo took the time to listen to him and alleviate his fears about complications and potentially losing the ability to walk. “We know that patients that say my doctor cares about me and understands me are more likely to take the pills you prescribe, even if they don’t understand why they need to take them,” Jensen says.

Poor communication can also result in safety errors. Jensen gave the example of a patient who had suffered a serious injury from a fall after taking a double dose of a painkiller. The woman had switched doctors, and her new doctor failed to check her medication list and tell her that he was switching her from a name-brand drug to a generic drug. The woman accidentally got the double dose because she took both the name-brand and the generic drugs thinking they did different things.

Can Caring be Measured?
The patient-satisfaction survey is one tool often used to measure bedside manner. These surveys are used extensively by Minnesota provider organizations and health plans.

In the past, HealthPartners measured satisfaction by how quickly patients were seen by providers. Starting in 2006, medical groups were also judged on how well their patients answer the question How satisfied are you with how well the doctors and staff listened to you? Gail Amundson, M.D., HealthPartners’ associate medical director for quality, says the question does a good job of revealing the quality of communication between patients and doctors.

Patient Choice, a Medica health plan that puts provider groups in different cost tiers and charges higher premiums to members who choose the more expensive provider groups, uses patient satisfaction information to place provider groups in different quality and cost tiers. Providers can receive a “quality credit,” which may qualify them for a lower cost tier based on their performance, even if their prices are high.

“Patients can relate to this. I don’t think there are many patients who will make a provider choice based on their Chlamydia screening rates, but there are lots of patients interested in learning about the compassion, caring, and thoroughness of their physicians,” says Ann Robinow, vice president and general manager of Patient Choice. Patient Choice and other health plans don’t rate individual doctors primarily because it would be costly, about $240 per doctor, Robinow says, and there’s currently no survey that is universally used by physician groups that could compare individual doctors across groups.

That may change. The Centers for Medicare and Medicaid Services has adapted a Consumer Assessment of Health Plans Survey (CAHPS) for use in assessing individual physician practices. Many expect this survey to become the standard yardstick for measuring patient satisfaction.

MN Community Measurement, a nonprofit that currently issues public reports about how clinics perform on various quality measures, plans to start using the CAHPS surveys to measure patient satisfaction with medical groups in 2007, says Jim Chase, executive director. Although Chase’s organization isn’t planning on grading individual physicians at this time, physician groups may decide to use the CAHPS survey to rate their own doctors.

Can Caring be Taught?
Good bedside manner may have once been considered a personality trait. However, experts now say doctors and medical students can learn to be effective communicators.

All new physicians at Mayo Clinic in Rochester as well as the approximately 700 physicians in the Mayo Health System in Minnesota and Wisconsin are required to take a day-long seminar on communication skills. Mayo has similar initiatives at its clinics in Arizona and Florida.

The course uses role-playing and small-group discussions to teach doctors how to display empathy, deal with angry patients, and deliver bad news. Participants also practice patient-centered interviewing techniques that are built around a three-functions approach developed by the American Academy on Communication in Healthcare. The three functions are information gathering, relationship building, and patient education.

With less time for patient visits and the distraction of computers in exam rooms, physicians will need to be more conscientious than ever about honing their communication skills and, thus, improving their bedside manner, says Dan Hurley, M.D., co-director of patient-physician communication and one of several faculty members who teach the course at Mayo.

Liz Osborne, M.D., a family physician at Mayo Health System’s St. Peter Clinic, took the seminar in April. Osborne was familiar with many of the pointers such as maintaining eye contact and not fidgeting or moving toward the door as time runs out. But the most important thing she learned wasn’t about what to say or how to say it. “My No. 1 lesson was to talk less and listen more. Listening with the intent of genuinely hearing what the patient has to say is the foundation of good communication,” she says.

Starting in October, Keith Stelter, M.D., who also practices family medicine at the St. Peter Clinic, will school medical students on the finer points of interviewing patients.

Stelter is a faculty member with the Rural Physician Associate Program, a nine-month rural medicine experience for third-year medical students at the University of Minnesota. He, along with the other faculty, will be training students in the Four Habits Approach to Effective Clinical Communication, a model that was created by Indiana University’s Frankel and medical communication experts Terry Stein, M.D., and Edward Krupat, Ph.D (see p. 25). The four habits have been used by doctors in the Kaiser Permanente system in California since 1996. The idea is to encourage physicians to ask patients at the start of the interview what concerns they would like to address and to continue to ask if there’s anything else until the patient runs out of concerns. Stelter has used the four habits in his own practice and has seen it work. “What it does, is it forces us to look a little more in depth at what the patient’s needs are and not necessarily what our agenda is,” he says.

“I’ve always felt that if you manage it right, it will save you time because you can take a more active role in managing expectations,” he says. For example, he can immediately take some issues off the table during a visit by saying he’d need to refer the patient to a specialist or by saying the patient would need an additional appointment to address the concern.

Stelter says the approach is simple enough for a medical student with little knowledge of the theory of patient-physician communication to use immediately. “What we know now is that if we can standardize our approach and get the patient’s agenda out on the table, we are going to provide better care.” MM

Scott Smith is a staff writer for Minnesota Medicine.