The American Academy of Orthopaedic Surgeons has identified that patients rate the orthopaedic profes-sion as high in technical and low in communication skills.. Effective communication
Trang 1The abundant new technology that
has dramatically improved clinical
outcomes and quality of life for
orthopaedic patients has
paradoxi-cally caused patients to view the
medical profession less favorably.1,2
At the heart of this deterioration in
the physician-patient relationship is
a failure of communication Among
the reasons for this problem are
inadequate training of physicians
and other health professionals in
communication skills, wide
varia-tions in patients’ levels of
compre-hension, and cultural barriers
Advancing technology also
pro-vides increasing amounts of
in-formation that might be shared with
patients However, the time for
physician-patient interaction is
reduced because of the constraints
of managed care as well as the
trend to provide much medical treatment, including some surg-eries, in the outpatient setting
When hospitalization is required, lengths of stay are short To ensure the best possible communication with their patients, therefore, physi-cians must understand the charac-teristics and benefits of good com-munication, improve their commu-nication skills, and appreciate the consequences of failing to commu-nicate effectively
Is There A Communication Problem?
In 1998, the American Academy of Orthopaedic Surgeons commis-sioned a survey of consumers (patients) to “probe their
percep-tions and attitudes towards ortho-paedic surgeons.”3 Simultaneously, Academy fellows were interviewed
to explore their beliefs about the image held of their profession As a result of this research, the Academy could determine the gap between the image orthopaedic surgeons wished to project and the public’s perceptions A total of 400 inter-views from a random sample of the public were conducted, followed by
a second wave of 407 interviews, for
a total consumer base of 807 inter-views A random sample of 3,500 questionnaires to Academy fellows yielded 700 completed responses (With these sample sizes, the expected error range is ± 3.6 percentage points.) The results of the survey defined
a number of issues First, orthopae-dists self-rated themselves as good listeners and as caring and compas-sionate (so-called high-touch attrib-utes) However, they were far less charitable in assessing how patients would rate their fellow orthopaedists (Table 1) Second, the patient
sam-Dr Frymoyer is Professor Emeritus, Depart-ment of Orthopaedics and Rehabilitation, and former Dean, University of Vermont, College of Medicine, Burlington, VT Ms Frymoyer is Patient Educator and Founder, Community Health Resource Center, Fletcher Allen Healthcare, Burlington.
Reprint requests: Dr Frymoyer, 1450 Braeloch Road, Colchester, VT 05446.
Copyright 2002 by the American Academy of Orthopaedic Surgeons.
Abstract
In the face of rapid advances in technology, there has been a progressive
deterio-ration of effective physician-patient communication The American Academy of
Orthopaedic Surgeons has identified that patients rate the orthopaedic
profes-sion as high in technical and low in communication skills Poor
communica-tion, especially patient-interviewing skills, has been identified in medical
stu-dents as well as in practicing physicians Effective communication is associated
with improved patient and physician satisfaction, better patient compliance,
improved health outcomes, better-informed medical decisions, and reduced
mal-practice suits, and it likely contributes to reduced costs of care Recognition of
the importance of communication has influenced medical schools to revise
cur-ricula and to teach communication skills in residency training and continuing
medical education programs National certifying examinations also are being
designed to incorporate these skills Although written material is useful in
increasing awareness of the importance of good physician-patient
communica-tion, behavioral change is more likely to occur in a workshop environment The
American Academy of Orthopaedic Surgeons is taking leadership in designing
and implementing such an approach for its membership.
J Am Acad Orthop Surg 2002;10:95-105
John W Frymoyer, MD, and Nan P Frymoyer, MEd
Trang 2ple placed high value not only on
technical skills (so-called high-tech
attributes) but also on effective
lis-tening, care, and
compassion—high-touch attributes (Table 2) The
com-parison of the orthopaedists’
per-ception of themselves and how
patients perceive them reveals a
sig-nificant gulf (Table 2) The study
also indicates that orthopaedists,
compared with primary care
physi-cians, are rated as less caring and
compassionate and as more
techni-cally oriented (Table 3) One
appar-ent consequence of these negative
patient perceptions is that the
respondents rated orthopaedists as
giving less value for the cost of
ser-vices compared with primary care
providers and chiropractors
As a result of this survey, it was
recommended that a public
rela-tions campaign be initiated that
combined a high tech–high touch
image of the orthopaedic profes-sion More specifically, the mes-sage desired by fellows of the Academy is that orthopaedists not only achieve successful medical results and have a high level of training but also combine their technical expertise with a caring and compassionate attitude and lis-ten to their patients The AAOS also has initiated an education pro-gram in communication, starting
with a section of the Bulletin
devot-ed to this topic.4 The results of this survey, and the development of plans to pro-mote effective communication, mir-ror closely steps taken by other professional groups For example, the American Medical Association has promoted a number of initia-tives to improve physician-patient communication, including a col-umn on the topic in its journal
The Nature of Communication
Although definitions of communica-tion “vary in their emphasis on the verbal, nonverbal, content, process, informational, relational, and cultural aspects,” communication clearly is
“a transactional process in which messages are filtered through the perceptions, emotions, and experi-ences of those involved.”5 In the clinical setting, communication is
“the process of influencing patient behavior, producing changes in knowledge, attitudes, and skills required to maintain and improve health.”6 All aspects of the com-munication should be part of the physician-patient interchanges Communication in the physician-patient relationship usually begins with the initial medical interview Subsequent encounters in the office
Table 1
Fellows’ Perception of Self Versus Perception of Orthopaedists in General
How Do You Think Top Two Positive How Do You Think Patients Would Rate Responses Patients Would Orthopaedic Surgeons Excellent (5)‡ (4 and 5)‡
Describe You?* % in General?† (%) (%)
Answers patient’s questions 89.5 — — —
Listens to patients 86.1 Listens to patients 6.1 21.3
Spends time with patients 71.3 Spends time with patients 5.5 17.7
Caring and compassionate 71.1 Caring and compassionate 5.8 28.9
Level of medical training 70.4 Level of medical training 20.3 70.7
Successful medical results 64.4 Successful medical results 19.8 89.2
Cost on par with other physicians 64.7 — — —
Ease of scheduling an appointment 58.8 Ease of scheduling an appointment 2.7 15.3
Value provided for cost 2.9 33.4 Prestige of specialty 17.1 60.2
Research orientation of specialty 1.5 12.8
* N = 698 Source: survey question 5: Which characteristics do you perceive your patients would use to describe you?
† N = 694-698 Source: survey questions 17-26: How do you perceive patients would rate orthopaedists on…?
‡ On a 5-point scale on which 5 = excellent and 1 = poor.
Bold type indicates suggested characteristics for emphasis in public relations program.
Adapted with permission 3
Trang 3or hospital, however, will help to
determine the accuracy and
com-pleteness of the patient’s story,
iden-tify problems, establish the nature
and effectiveness of the
physician-patient relationship, and serve as a
source of patient education
According to Lipkin et al,7 the medical interview is a core clinical skill for the physician It and subse-quent interchanges serve three basic functions: gathering information, developing and maintaining a thera-peutic relationship, and counseling
the patient and negotiating plans for treatment
Gathering Information
The primary goal of the medical interview is to gather as much use-ful information as possible about all
Table 2
Attribute Ratings of “Very Important” and Performance Ratings of “Excellent” *
Consumer Ratings Important to Important to Attribute of Orthopaedists (%) Consumers (%) Orthopaedists (%) Listens to patients NA 84.7 56.2
Level of medical training 35.2 85.6 70.9
Prestige of specialty 28.3 33.0 NA
Research orientation 22.4 38.5 NA
Successful medical results 18.4 83.7 88.4
Caring and compassionate 17.7 76.7 63.8
Spending enough time to listen 13.3 73.5 47.8
Ease of scheduling an appointment 12.8 64.6 24.0
Value for cost of service 12.7 70.4 50.2
Physician of choice for musculoskeletal surgery NA NA 75.0
* Source: Consumer survey question 10: “How important is it that your health care professional…?” (N = 807) and fellows’ survey questions 59-67: “Please rate how important it is to have patients associate each of the following characteristics with orthopaedists….” (N = 700) Both based on a 5-point scale on which 5 = very important and 1 = not at all important.
Bold type indicates communications messages for public relations program.
Reproduced with permission 3
Table 3
Consumers’ Ratings of “Excellent” *
Attribute Orthopaedist (%) Primary Care Physician (%) Chiropractor (%) Podiatrist (%)
Level of medical training 35.2 36.8 20.7† 19.3†
Prestige of specialty 28.3 23.2 14.7† 13.2†
Most knowledgeable in field 27.2 27.2 19.5† 16.9†
Research orientation 22.4 17.6 16.0† 11.2†
Successful medical results 18.4 22.9 15.1 11.5†
Caring and compassionate 17.7 34.1† 24.6† 14.1 Spending enough time to listen 13.3 31.2† 25.5† 12.8 Ease of scheduling an appointment 12.8 27.3† 28.4† 13.8 Value for cost of service 12.7 26.1† 19.9† 11.4
* Source: Consumer survey questions 6-9: “How would you rate…?” Based on 5-point scale on which 5 = excellent and 1 = poor.
† Statistically significant differences from orthopaedist scores.
Bold type indicates communications messages for public relations program.
Reproduced with permission 3
Trang 4of the relevant factors (medical,
psychosocial, familial,
occupation-al) that will help the physician
obtain an accurate diagnosis and
develop a comprehensive
treat-ment plan Gathering information
requires the following skills: the
ability to ask effective questions;
accurate observation of data
com-municated through verbal and
nonverbal cues; addressing and
integrating relevant components of
the comprehensive medical history;
recognizing barriers to effective
communication and adapting
con-structively to these barriers; and
adapting to the diverse beliefs,
cul-tural values, and socioeconomic
variables of patients and their
fam-ily members.7 It is important in
gathering information to use
open-ended questions and recognize
nonverbal cues
Case Study
A 72-year-old woman was seen 2
days after sustaining a comminuted
fracture of the distal radius In
dis-cussing treatment options after the
interview and examination, the
resi-dent and attending physician
con-sidered open reduction and internal
fixation (ORIF) to be unwarranted
in a patient of this age, despite
ra-dial shortening Before outlining
the treatment options, however,
they asked the patient the
open-ended question, “What is the most
important thing that we can do for
you?” The patient replied with both
verbal cues (“Make sure I can keep
working on my sculpture”) and
nonverbal cues (waving her
frac-tured arm) Further questioning
revealed that she was an
accom-plished sculptor who worked in
granite and marble She made the
resident and attending physician
aware of the physical requirements
of sculpting and convinced them
that ORIF was essential to maintain
her required level of function
Following surgery, the patient made
a complete recovery
Developing and Maintaining a Therapeutic Relationship
In developing a therapeutic rela-tionship with the patient, and often with family members, the following skills are necessary to establish trust and mutual respect: treating the patient and the family in a humanis-tic fashion; active listening; recog-nizing emotions and responding empathically to those emotions; rec-ognizing and responding appropri-ately to conflict; and remaining aware of one’s own personal needs, values, and biases while maintain-ing professional integrity.7 An em-pathic approach can sometimes re-veal the cause of a patient’s concerns that, if otherwise unrecognized, could lead to treatment failure
Case Study
A 50-year-old male farmer com-plained of low back pain following heavy lifting 1 month earlier Dur-ing the interview, the patient
report-ed that his family doctor thought his symptoms to be those of a sprain but nevertheless had referred him for radiographs The radiologists suggested the possibility of a defect
in the pars interarticularis and rec-ommended oblique views, but these were negative A bone scan was unremarkable Because the patient was still symptomatic, a computed tomography scan was done, which suggested a bulging disk To con-firm that diagnosis, the family doc-tor ordered a myelogram, which was negative except for clinically insignificant bulging of the L4-5 disk Serologic tests were negative
The patient then was referred to the orthopaedist, who found no abnor-malities on physical examination, thought the patient to be emotionally depressed, and prescribed physical therapy Four days later, when the patient was seen because of in-creased back pain, there was no change in his affect or in the physi-cal examination
During the initial interview, the orthopaedist had been overbooked and it was not until the follow-up visit that he took time to learn how emotionally upset the patient and his wife had become They had put the farm up for auction because the patient did not think he was going
to recover The patient assumed that he must have cancer because
“they have done all of these tests and can’t find out what is wrong with me, so it must be cancer.” Un-derstanding these concerns allowed the orthopaedist to reassure the patient and his wife that his discom-fort was not caused by cancer and to give them a detailed explanation of the cause of the symptoms and likely course of recovery The orthopae-dist also recommended refraining from auctioning the farm Two weeks later, the patient and his wife reported that he was working full time and that his back pain had notably lessened Two months later, the patient’s only complaint was mild aching in the low back, a condi-tion he had experienced for years
Counseling and Negotiating With the Patient
The third function of physician-patient communication is to impart information to the patient and rele-vant family members that will help them understand the patient’s con-dition, options for treatment, and likely outcome The important com-ponents are providing effective edu-cation and counseling, motivating changes in behavior, and negotiat-ing treatment plans.7 Failure to un-derstand a patient’s needs can lead
to inadequate counseling, which can adversely affect outcome Con-versely, understanding a patient’s concerns can lead to effective educa-tion and counseling and positively affect the outcome
Case Study
A 48-year-old woman with se-vere osteoarthritis of the right hip
Trang 5secondary to congenital dysplasia
underwent an uneventful total hip
arthroplasty (THA) Six weeks
postoperatively, physical
examina-tion revealed 90° of flexion and 35°
of abduction She walked well with
a cane, and radiographs showed a
well-seated THA However, the
pa-tient was depressed and unhappy
with the results More intensive
physical therapy was advised; 6
weeks later, her flexion had
im-proved to 100° and abduction to 45°,
and the patient walked without a
limp Radiographs showed
excel-lent prosthetic positioning Again,
however, she indicated
dissatisfac-tion with the results and was
de-pressed The patient confirmed for
the orthopaedist that the outcomes
she had expected, reduced pain and
better walking, had been achieved
However, with further questioning
she revealed that, because of the
osteoarthritis, she had experienced
pain preoperatively during sexual
intercourse that had created strain
in her marriage In fact, that was
her major reason for seeking THA
Postoperatively, no one had told her
when she could resume sexual
activity, and she was embarrassed
to ask Her husband was
threaten-ing to leave her Sexual counselthreaten-ing
was given to the patient and her
husband with assurances that she
was not at risk to injure herself Six
weeks later, she described her
out-come as excellent
The Benefits of Good
Communication
Good physician-patient
communi-cation has been associated with
improvements in patient and
physi-cian satisfaction, greater compliance
with treatment plans, better and
more appropriate medical decisions,
and reduced malpractice claims
Good communication also likely
contributes to improved cost
effec-tiveness in providing care Patient
health is more apt to be improved with congruence between patients and physicians in identifying prob-lems and determining course of treatment.8,9 Stewart1 reviewed MEDLINE citations from 1983 to
1993 using physician-patient rela-tions as the primary medical subject heading She concluded that there were positive benefits for good com-munication on emotional health, symptom resolution, function, phy-siologic measures (blood pressure, blood sugar), and pain control
Others have reported similar results, such as more effective management
of headaches, hypertension, dia-betes, and peptic ulcer disease, as well as reduced numbers of office visits and reduced hospital lengths
of stay.8-11
Patient and Physician Satisfaction
The American Academy on Physician and Patient developed a collaborative study that involved expert analysis of 550 patient audio-tapes recorded during visits to pri-mary care physicians.12 Patients and physicians were given exit question-naires about the problems they had discussed, the priority of each prob-lem, satisfaction, and patient inten-tion to comply with the physician’s recommendations Patient satisfac-tion correlated with the patient’s perception of the physician,
where-as physician satisfaction correlated with the use of open-ended ques-tions
These findings are consistent with those of other studies For example, the satisfaction and com-pliance of parents with children treated in the emergency room were greater when the parents could express their concerns.13 Stiles et
al14 found that the satisfaction of adults in a medical clinic correlated with their ability to talk about ill-ness in their own words Similarly, eliciting and meeting patient re-quests in psychiatric and family
practice clinics are associated with greater satisfaction.15,16
Stringer et al17used 16,230 sur-veys of patient encounters to ana-lyze the office practice of orthopae-dic surgeons Notable correlations were found between overall patient satisfaction and the following vari-ables: patient understanding of diagnosis and treatment, worker’s compensation status, patient age (older patients were less satisfied), and a wait time >45 minutes
Wom-en approximately 40 years old were most likely to be dissatisfied with the encounter and with office com-munication: their most common complaint was that the orthopaedist talked down to them Deyo and Diehl18found that patient satisfac-tion was greater in patients with low back pain when an adequate, comprehensible explanation was given for the cause of their symp-toms
Compliance With Treatment Plans
Transmitting appropriate informa-tion to patients is highly associated with their adherence to a treatment plan.19 Effective communication is influenced by the amount, complex-ity, and content of the information given and how that information is transmitted Typically, the physi-cian discusses a recommended treatment with the patient and sometimes supplements the discus-sion with written material and/or videotapes The patient, however, may or may not be ready to receive information, depending on his or her physical and emotional status Sometimes the patient may be emo-tionally overwhelmed
Case Study
A 38-year-old single mother of two was seen for evaluation of chronic low back pain that intermit-tently had caused her short-term disability For 6 months she had noted some numbness and pain in
Trang 6the sciatic distribution The
physi-cal examination revealed some loss
of sensation in the L5 nerve root
dis-tribution bilaterally Spinal
radio-graphs established the presence of a
grade II L5-S1 isthmic
spondylolis-thesis Computed tomography
con-firmed entrapment of the L5 nerve
roots The surgeon presented the
nature of the problem in detail to
the patient and discussed both
sur-gical and nonsursur-gical treatment
options One week later, the
ortho-paedist was surprised when the
patient requested an appointment to
learn about her condition and to
discuss a treatment plan At this
visit, the woman explained that,
during their previous conversation,
when the surgeon had mentioned
the possibility of surgery, “I thought
I would lose my job, and wouldn’t
be able to take care of my children
I wasn’t able to listen to you, and
‘tuned out.’” The surgeon had missed
the nonverbal cues indicating the
woman’s distress
Problems with patient
compre-hension and noncompliance extend
to the use of reading material
De-spite the widespread availability of
patient-directed literature, few
or-thopaedists use it routinely Patients
have major variations in reading
comprehension, and much material
used in health education is beyond
the understanding of many
pa-tients.20-22 One analysis of medical
illiteracy revealed that 40% of
pa-tients were unable to understand
written instructions to take
medica-tions on an empty stomach.20
These variations in medical
liter-acy are influenced by a patient’s age,
primary language, education level,
occupation, and cognitive function
Gazmararian et al22evaluated 3,260
Medicare enrollees aged ≥65 years:
33.9% of English-speaking and
53.9% of Spanish-speaking
respon-dents had inadequate or marginal
health literacy Advancing age was
significantly (P < 0.001) correlated
with decreasing literacy Gazmar-arian et al22and others21have noted that medical illiteracy is associated with substantially worse health sta-tus and poorer outcomes from med-ical treatment
Difficulties in physician-patient interchanges are exacerbated when time for effective communication is inadequate, which is particularly an issue in the managed care setting
Early discharge from the hospital logically necessitates increased patient education regarding matters such as self-care and self-monitor-ing, but the opportunities for com-munication are fewer Effective strategies include postdischarge tele-phone calls to monitor a patient’s recovery and ascertain the need for more information.23
Problems in both verbal and writ-ten communication also can arise when a patient requires multidisci-plinary care Unless there is a well-coordinated team of caregivers, con-flicting information can be given
to a patient, or miscommunication among the team members can result
in a patient’s not being given the appropriate information.24 This breakdown in communication can easily occur in orthopaedic surgery, where conflicting information may
be given by the surgeon, the physi-cal therapist, and the nurses One way to avoid such a communication breakdown is for the team to develop
a shared plan for the diagnosis and treatment of common conditions, often termed critical pathways
A patient’s need for information and ability to comprehend that information also vary according to his or her recovery For example, patients who had undergone coro-nary artery bypass reported that they could not assimilate informa-tion in the first 4 or 5 days after surgery, which often was the time when information was given.25 The analysis also showed wide dis-crepancies between the information physicians and nurses thought the
patient needed as well as between the information patients thought they needed and actually received The results of this study indicate that patient education must be reit-erated and reinforced throughout recovery
Successful communication also includes the involvement of the patient’s family and, as appropriate, close friends, particularly when lan-guage and cultural barriers must be overcome In such situations, the physician should understand how his or her own psychosocial feelings and beliefs can influence the man-ner in which a patient responds.26
Case Study
A 34-year-old recently immigrated Vietnamese woman complained of knee pain and difficulty moving one leg (her companion served as trans-lator) The physical examination suggested, and magnetic resonance imaging later confirmed, the pres-ence of a torn medial meniscus An uneventful arthroscopic partial men-iscectomy was performed One month later, the patient still com-plained of pain and difficulty mov-ing the leg Aside from stiffness, the physical examination was unre-markable At the third follow-up visit, the surgeon asked the compan-ion why she thought the patient was taking so long to get better The companion noted that the patient had not previously had any expo-sure to Western medicine and had relied solely on traditional cures when she had been ill or injured in the past The patient had not volun-teered this information to the phy-sician, however, because doing so would have been disrespectful When asked what should be done, the companion suggested using tra-ditional cures simultaneously with the recommended postoperative regimen The surgeon agreed, and 2 weeks later, the patient’s pain had improved and range of motion was approaching normal
Trang 7An alternative aspect of patient
literacy is represented by
computer-literate patients The Internet
pro-vides these patients with sources for
information other than their
physi-cians Approximately 43% of the
40.6 million adults who accessed the
Internet in 1997 did so to obtain
medical information.27 However,
the information patients often
ob-tain from the Internet is “unfiltered”
for content and reliability Surveys
show that computer-literate patients
would like to communicate with
their physicians by e-mail, but only
1% to 2% of physicians currently
offer that service.27
Appropriate Medical Decisions
and Good Outcomes
Communication is a major factor
both in a patient’s decision to
un-dergo surgery and the process of
informed consent Considerable
evidence suggests that the consent
is not truly informed in many
situa-tions because of failures in
commu-nication An analysis of one
thou-sand audiotaped physician-patient
discussions involving more than
3,500 clinical decisions revealed that
fewer than 10% met the study’s
cri-terion for informed patient
decision-making.28
Data indicate that more explicit
information may reduce the rates of
surgery for some types of
condi-tions For example, videotapes have
been developed as a mechanism to
aid patients in making a
well-informed decision.29 The use of this
approach has been associated with
significant reductions in surgical
procedures A randomized
con-trolled trial29compared the use of
an informational booklet plus an
interactive videotape with use of the
booklet alone to inform patients
scheduled for lumbar spine
decom-pressions Patients entering the
study had either a clinically
estab-lished lumbar disk herniation or
spinal stenosis Of the patients with
herniated disks, the group that used
the videotape chose surgery less fre-quently than did the control (book-let alone) group (32% versus 47%,
respectively; P = 0.05 by
Kaplan-Meier test) However, of the pa-tients with spinal stenosis, the rate
of surgery was higher for the group that used the videotape than it was for the control (booklet alone) group
(39% versus 29%, respectively; P =
0.04) The symptoms and functional outcomes were similar at 1 year postoperatively for those who had surgery and those who had not
Although use of the videotapes had
no impact on patient satisfaction, those who did view the videotape stated that they were better in-formed.29
Reduced Risk of Malpractice Suits
There is a greater risk of medical malpractice suits with poor physi-cian-patient communication or a breakdown in communication, par-ticularly when complications of treatment have occurred.30-32 Beck-man et al30studied patients’ deposi-tions to determine the causes of mal-practice and found the following causes for lawsuits: deserting the patient (32%), devaluing the pa-tient’s and/or family’s views (29%), delivering information poorly (26%), and failing to understand the pa-tient’s and/or family’s perspectives (13%) Thus, 68% of suits originated
in failures of communication Or-thopaedic surgeons who had better rapport with their patients, who took time to explain the proposed treatment, and who were available
to answer questions had fewer mal-practice suits.31 Primary care physi-cians in Oregon who had received explicit training in physician-patient communication had a reduced rate
of malpractice exposure.33
Cost Effectiveness
Improved communication and patient access to information affect hospital utilization and outpatient
care Analysis of readmission rates has shown reductions of up to 50%
in cardiac patients when explicit education was given to these pa-tients and reinforced.34 Similarly, effective preoperative education has been associated with reduced length
of hospital stay and fewer complica-tions, as well as with decreased use
of narcotic pain medications.34 All of the advantages of improved communication suggest that cost benefits result from better outcomes, reduced lengths of hospital stay, reduced utilization of office re-sources, and reduced risk of mal-practice suits To date, however, no study has explicitly quantified any cost benefits attributable to mutually satisfying physician-patient commu-nication
Improving Communication The Status of Effective Communication Skills
Despite the importance of com-munication between patients and physicians, development of the skills needed to become an effective communicator is not a core compe-tency stressed in medical, resident, and postgraduate education Tradi-tionally, the physician-patient rela-tionship has been taught by role modeling: accomplished physicians are observed by students who are expected to emulate the teacher In
a cross-sectional analysis of medical students’ communication skills, Helfer and Ealy35 found that stu-dents entered medical school with good interpersonal skills and inter-ests but that during the second year, these skills and interests were “flag-ging.” Notable worsening occurred
by year 3 of medical school, and by year 4, communication skills were
“terrible.”
Maguire and Rutter36 analyzed the nature of student performance
of the medical interview Fifty
Trang 8fourth-year students who had
com-pleted all of their major clerkships
met with a standardized patient and
were asked to complete an
inter-view in 15 minutes The results
were as follows: 24% failed to elicit
the main problem, 22% did not
greet the patient, 12% did not use
the patient’s correct name, and 30%
failed to give the patient their own
names In all of the domains
ana-lyzed, poor or very poor
interview-ing competencies were identified in
the majority of the interviewers.36
The absence of effective
commu-nication skills extends into practice
Beckman and Frankel37 evaluated
the medical interview in primary
care practice settings Even though
open-ended questions are associated
with patient satisfaction and with
eliciting more information than are
closed-ended questions,37the
aver-age patient was interrupted within
18 seconds of the beginning of the
interview Furthermore, the typical
patient had three problems in mind,
yet on average only two of the
prob-lems were elicited
To determine whether the
med-ical encounter in a surgmed-ical setting
differs from that in primary practice,
Levinson and Chaumeton2 analyzed
the quality of the medical encounter
in the offices of 39 orthopaedic
sur-geons and 27 general sursur-geons
Audiotapes of 676 encounters were
evaluated using a standardized
cod-ing system that evaluated four
con-ceptual categories: content, process,
affect, and social conversation The
mean duration of an orthopaedic
visit was 12.7 minutes Social
open-ings were typically brief, with a
mean of 45 seconds The
history-taking phase lasted a mean of 3
min-utes 31 seconds, but in 9% of the
encounters, the physical
examina-tion was started before any history
had been taken Patient education
and counseling accounted for almost
half the phase (5 minutes 24
sec-onds) and usually was characterized
by “relatively lengthy periods of
information given by physicians and
by brief physician questions.” Less than 10% of the length of the visits was devoted to lifestyle issues, the impact of the condition on the pa-tient’s work, or the papa-tient’s general emotional health In fact, only 1.3%
of the interview times dealt in any way with possible psychosocial issues.2
Case Study
A 58-year-old businesswoman with rheumatoid arthritis was eval-uated for right hip pain Although the orthopaedist spent time dis-cussing the indications, complica-tions, and likely results of THA, he was pressed for time, and his cur-sory assessment suggested that the patient had no other medical prob-lems An uneventful THA was per-formed Postoperatively, however, the patient had notably greater out-put from her drainage tubes than would be expected When the tubes were pulled 48 hours after surgery, there was increased pain By post-operative day 4, the patient had pain that did not respond to large doses of morphine Neurologic examination suggested decreased function of the sciatic nerve With a presumptive diagnosis of gluteal compartment syndrome, the wound was explored, and more than 1,000
mL of hematoma under pressure was evacuated The patient’s symp-toms resolved On closer question-ing, she revealed that she had had abnormal bleeding after two other operations many years earlier but had not thought this was important, nor had anyone asked her explicitly about abnormal bleeding Further evaluation revealed an unusual de-ficiency in fibrinogen
Teaching Communication Skills
The development of effective physician-patient communication skills should start in medical school
Although an explicit curriculum and evaluation of communication
skills have been rare in American medical education, in the past de-cade, advances in teaching commu-nication skills have taken place However, a survey conducted in
1999 by the American Association of Medical Colleges5showed that only
5 of the 115 responding schools taught history-taking; the remaining schools used diverse teaching tools (Table 4) Nearly one half of the schools reported that rounds were a common way of teaching communi-cation skills The report noted that many of these teaching methods were useful but that in the absence
of explicit expectations and feed-back as well as precise assessment methods, these methods were likely
to have uncertain results (Table 5)
In fact, there is a marked discrepancy between the clinician-educator’s communication skills and his or her expectations for students Cote and Leclere38found that the behavior of teachers often did not role model the very behaviors they were seek-ing to reinforce in their students Teachers often had difficulty de-scribing the interviewing behaviors they hoped to teach their students
An international conference on teaching communication in medi-cine attempted to develop educational tools to improve communication skills in physicians.39 The partici-pants agreed on eight consensus statements to guide the development
of medical school curricula: (1) Teaching and assessment should be based on a broad view of communi-cation in medicine Teaching should include written and oral skills as well
as interprofessional communication and telephone skills (2) Communi-cation skills teaching and clinical teaching should be consistent and complementary (3) Teaching should define and help students achieve patient-centered communication tasks (4) Communication teaching and assessment should foster per-sonal and professional growth (5) There should be a planned and
Trang 9co-herent framework for
communica-tion skills teaching (6) A student’s
ability to achieve communication
tasks should be assessed directly (7)
Communication skills teaching and
assessment programs should be
evaluated (8) Faculty development
should be supported and adequately
resourced.39
These broad concepts have been
put into operation using some
well-studied methods for teaching
com-munication skills Lipkin et al7have
developed a prototype that involves
carefully supervised group
discus-sions, encounters with actual
pa-tients, role playing, videotapes,
con-tinuous feedback, and formal
evalu-ation The goal is to use a workshop
approach to focus on skills such as
interviewing, knowledge, and
physician attitudes Roter et al40
uti-lized this workshop model with
pri-mary care physicians An
experi-mental group received 8 hours of
training The trained physicians
were then compared with untrained
physicians in a randomized
con-trolled field trial using audiotapes
of patient encounters to assess physicians’ skills in problem defini-tion and managing patients’ emo-tional distress The trained group had markedly greater skills in prob-lem definition, managing emotional distress, counseling, and referral
behavior The results of training were durable when tested at 2 weeks, 3 months, and 6 months These data strongly support the concept that adult learning occurs optimally in a nonjudgmental work-shop setting
The major impetus that will change medical curricula, however, will come from the inclusion of com-munication skills as part of licensure examinations The National Board
of Medical Examiners has been working on a standardized patient test, part of which will focus on communication as a component of the United States Medical Licensing Examination.41 The clinical skills tests of the Educational Commission for Foreign Medical Graduates already addresses the effectiveness
of physician-patient communica-tion.42 By linking licensure examina-tions to effective communication skills, greater attention is apt be paid
to this area in medical education Such an approach also is being ex-tended to residency and continuing medical education programs In some medical specialties, explicit curricula are being developed for residents that ultimately will include
Table 4
Methods for Teaching Basic Communication Skills
Teaching Methods in Use Schools Reporting (%)*
Small group discussions/seminars 91.0
Lectures/presentations 82.0
Student interviews with simulated patients 78.7
Student observations of faculty with actual patients 74.2
Student interviews with actual patients 71.9
Role playing with peers 59.6
Video trigger tapes for discussion 42.7
Videotapes of student interactions 40.4
Instructional videotapes 30.3
Required attendance at community activities 23.6
Journals (ie, written reflections) 19.1
Patient advocacy 13.5
Storytelling by students 13.5
Storytelling by patients (ie, patient narrative) 10.1
* Total number of schools = 89.
Reprinted with permission 5
Table 5 Methods of Assessing Basic Communication Skills
Assessment Methods in Use Schools Reporting (%)*
Faculty feedback during teaching sessions 92.4 Formalized faculty observation of students 78.3 Patient or simulated patient feedback 76.1 Assessment with simulated patients (ie, OSCE) 69.6 Student self-assessment with videotapes 38.0 Peer assessment 38.0 Multiple-choice examinations 34.8 Formalized feedback from nurses, etc 23.9 Essay/written examinations 22.8 Student self-assessment without videotapes 20.7
* Total number of schools = 92.
OSCE = objective structured clinical examination.
Reprinted with permission 5
Trang 10evaluation of communication skills
in the specialty certifying
examina-tions Similarly, greater emphasis is
being placed on communication
skills in recertification examinations
Also, because of the impact of poor
communication on the quality of
medical care, some health
mainte-nance organizations are mandating
communication training for their
staff physicians
What are the Practical
Applications for
Orthopaedic Surgeons?
The American Academy of
Ortho-paedic Surgeons’ survey of
ortho-paedic surgeons3demonstrates that
the orthopaedic profession values
effective communication It also is
clear that there is a gap between
orthopaedists’ self-perception and
patients’ perceptions of these
com-munication skills Recognizing that
there is a problem is an important
first step A second step is
under-way: to further increase awareness
through regular feature articles on
communications Effecting true change in behavior will probably require a far more explicit approach, including continued emphasis in medical school curricula on commu-nication, formal residency training in communication, and the opportunity for those in practice to refresh their communication skills For the prac-ticing physician, the workshop approach appears to be the most effective means to improve these skills.43-45 A variety of techniques is used, including role-playing, video-tapes of simulated physician-patient encounters, and peer discussions, all elements of successful adult learn-ing Although the amount of time required to change behavior is a mat-ter of debate, there is consensus that the data support this approach as far more successful than lectures The American Academy of Orthopaedic Surgeons is a leader in developing workshops to improve communica-tion skills among its members.46 Such an approach is consistent with the orthopaedic profession’s desire
to be seen not only as technically competent but also as vitally
con-cerned about our relationship to our patients
Summary
Effective physician-patient commu-nication serves three basic functions: gathering information, developing and maintaining a therapeutic rela-tionship, and counseling the patient (including negotiating plans for treatment) Good communication results in several benefits, including patient and physician satisfaction, improved patient compliance, ap-propriate medical decision-making, increased likelihood of good out-come, and reduced risk of malprac-tice suits Effective physician-patient communication also likely contrib-utes to the cost-effectiveness of care delivery To improve the status of medical communication, communi-cation skills must be included in the curricula of medical schools, and practicing physicians should be encouraged to attend workshops that refresh and enhance mutually beneficial communication skills
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