If “lack of time” is the chief barrier to better (aka patient-centered) physician-patient communications, it logically follows that longer patient appointments are the solution.
Ok…lets’ say that I could wave a magic wand and add 5 or even 10 more minutes to the average primary care office visit. Would more time really make a difference?
No. A quick examination of just some of the key drivers of physician-patient communications reveals why:
- More Time Will Not Change How Physicians Were Taught To Relate To Patients
A physician’s communication style is a “window” into how they view the physician-patient relationship, e.g., disease-oriented and physician-directed versus patient-centered. Physicians with a disease-oriented or physician-directed style tend to focus on the disease a person has with the goal of arriving at a diagnosis and treatment plan. The “patient’s voice” factors very little into how physician-directed clinicians relate to patients.
Physicians with a patient-centered style of communicating focus on the person with a disease. While the goal of diagnosing and treating the patient is the same, patient-centered clinicians recognize the value of actively including the “patient’s voice” throughout the medical interview.
One landmark study of physician communication styles found that almost two-thirds of physicians (IM and FP) in the study had a physician-directed view of how physicians and patients should relate to one-another.
- The Disease Focused/Physician-Directed Communication Skills Taught To Most Practicing Clinician Are Different Than The Patient-Centered Communications Skills Now Being Taught To New Physicians
The communication style and skills employed by physicians during the medical exam are learned in medical school. Upon until the last few years, medical schools taught physicians how to communicate with patients using in the disease-focused/physician-directed style.. As such, physicians were taught how to do two things: 1) diagnose patients and 2) treat their complaints.
The sole purpose in talking to the patient was to elicit just enough information to arrive at a diagnosis….nothing more. There was no reason to be concerned about the patient’s perspective, e..g., their health beliefs, fears, motivations and such. Nor were they concerned about the about the patient’s health context – whether they were old and frail and lived alone, couldn’t afford their medications, etc.
The communication style and skills reflected this disease orientation. Closed ended questions enabled clinicians to arrive at a differential diagnosis and begin working up the patient from there. Because the physician was in charge there was no need to engage the patient in conversations about shared decision-making or developing consensus around a care plan. The patient was expected to do what the doctor told them. The visit was finished when the doctor had what they needed.
A patient-centered communication style require an entirely different set of communication skills. Because the patient’s perspective is central to the diagnosis and treatment, physicians need to be trained in techniques fro getting the heretofore passive patient to open up to share their story. They also have to be mindful and good listeners….to avoid making a diagnosis based upon the first and often least important complaint offered by the patient.
The patient-centered physician is trained to look for and respond to verbal and non-verbal cues given by patients indicative of a question, concern or disagreement, . They are taught to recognize the importance of being empathetic and supportive of patients’ fears and concerns. Thet are taught how to engage patients in shared decision-making, consensus building and more.
The Take Aways?
Patient-centered communications is the new gold standard for high quality physician -patient communications. More time alone will not magically transform a physician oriented in, trained in and practiced in a disease-focused/physician-directed communication into an accomplished patient-centered communicator. Such a transition, according to the evidence, is only possible with the right training and skills and motivations.
So let’s not be so willing to accept lack of time (or lack of reimbursement) as excuses for why physicians don’t communicate better with patients. Let’s also not look for someone to blame. Rather, let’s acknowledge that we all need to help our physicians make the transition form being physician-directed to patient-centered communications and get on with the business of training.
Sources:
Roter, D. et al. Communication Patterns of Primary Care Physicians. JAMA. 1997:277:350-356.
Mauksch, L. et al. Relationship, Communication, and Efficiency in the Medical Encounter. Archives of Internal Medicine. 2008;168(13):1387-1395.
Aita, V. et al. Patient-centered care and communication in primary care practice: what is involved? Patient Education and Counseling. 58 (2005) 296–304.
Braddock, C. et al. The Doctor Will See You Shortly – The Ethical Significance of Time for the Patient-Physician Relationship. Journal General Internal Medicine. 2005 November; 20(11): 1057–1062.
Excellent post. Patients are more compliant with treatment when there is good rapport with the provider. I believe there is also a real placebo-type effect with good rapport, where patients feel cared about which clearly contributes to healing. Thanks.
Robert,
Thanks for the kind words. You are right about the beneficial aspects of a positive relationship between patient and physician. Patients that rate their relationship with their doctor as excellent or very good, have better outcomes, are more likely to comply with the doctor’s recommendations and so on compared to patients with the same medical problems but reporting a less than optimal physician relationship.
How true. Another aspect of physician-centered communication is that many don’t even realize how little knowledge some their patients might have about treatment plans/options or disease processes. When I worked for a medical communications company producing newsletters for client hospitals, I called physicians to interview them for a story about their practice specialty. You’d be amazed by how many of them would say, “Why are you writing about that? Everyone already knows all about that topic.” Then, after the article was published, some of them wanted to know why I “dumbed down” their esoteric medical terminology and buzz words. If that attitude characterizes their private patient communications, all I can say is YIKES!
Beverly,
Thanks for your thoughts. A often quoted study found that physicians do indeed tend to underestimate the patient’s interest in receiving health information and over estimate how much information they actually do give to patients.
I have found this to be true, mostly because we initiate the Office Visit with our agenda, which does not allow for the patient to feel like his concerns were addressed. Especially if the visit is focused on a consequence of the patients behavior which remains hidden dure to the lack of interest by the physician to uncover the root cause. How many times do we increase medication, when adherance is the issue, or initiate tests based on preconsieved diagnosis.
Several 15 minute OV are more effective in understanding medical conditions than the yearly physical. One must consider the motivation or lack of for each patient before care can be effective..
I found this thoughtful post to be extremely valuable, as the lack-of-time argument is so pervasive that I accepted it as a given. Upon applying a few minutes of critical thinking to the issue, it is easy to see the flaws in the accepted version of the story. I have taught over 1,500 doctors how to market and grow their practice or hospital, and I can see how a certain percentage of them would fare no better if they had all the time in the world.