Communication: beyond nice bedside manner

July 19, 2019 Jane Coutts

It’s a sign of changing times that one of medicine’s most important skills has only recently started being taught in medical school — but that’s the situation with doctor-patient communication. What was once regarded as something of a frill — a “nice bedside manner” — is known now to be an essential tool in patient care.   

Historically, there was little attention paid to physicians’ ability to communicate. A review of research on doctor-patient communication, by Jennifer Fong Ha and Nancy Longnecker, blames the traditional paternalism of the medical profession for physicians’ shortcomings in talking to patients: their role was to dispense medication, instructions and good or bad news. Efforts to connect, consult and collaborate were for colleagues, not patients.

Those attitudes continue to cast a shadow, according to a paper on shared decision making. It notes even affluent, educated patients are conditioned to be deferential to doctors:

“Although many participants viewed receiving health care as a service, they also recognized the inherent power differential between physicians and patients. Participants frequently described adopting deferential positions to avoid “displeasing” or “disappointing” their physician by asking too many questions or by disagreeing with a recommendation.” That deferential reaction may also be common among older patients, newcomers to Canada and people frightened by what’s happening to their health.

On top of the history that keeps doctors and patients from communicating well, the conditions physicians encounter on the job are not likely to foster easy rapport. Ha and Longnecker quote a paper M.R. DiMatteo, which reported medical students’ skill in talking to patients declined as their training progressed. It went on to say the “emotional and physical brutality of medical training” can undermine empathy and even lead to hostility toward patients. Once out of training, physicians struggle with time pressure, limited resources, patients who don’t speak their language and many other obstacles to good communication.

A paper by Wendy Levinson and colleagues in Health Affairs says the move toward patient-centred care is the reason for increased focus on improving communication between doctors and their patients and says the benefits are clear.

“A substantial amount of evidence demonstrates that patient-centred communication has a positive impact on important outcomes, including patient satisfaction, adherence to recommended treatment, and self-management of chronic disease.”

Levinson and her colleagues say communication skills “should be taught in a systematic way, including practice and constructive feedback…once they have left medical school, most physicians never get feedback about their interactions with patients.”

That gap is nicely illustrated by Ha and Longnecker, who mention a study that found 75 per cent of orthopedic surgeons surveyed thought they communicated satisfactorily with their patients, but only 21 per cent of the patients reported satisfactory communication with their doctors.

The authors of both papers emphasize the importance of being genuine. Ha and Longnecker say “Communication skills involve both style and content. Attentive listening skills, empathy, and use of open-ended questions are some examples of skillful communication.” Some research, they note, say medical education doctors to respond to each patient’s unique experience.

Levinson and her colleagues say physicians have to communicate at several levels, which “cannot be accomplished by mechanically applying skills. Rather, they require genuine personal engagement and emotional involvement.”

Ha and Longnecker emphasize the need for continued training and feedback, because physicians’ communication skills tend to fade over time. Doctors, they say, would learn and practice communication skills if they were self-aware enough to recognize their shortcomings and motivated to practice improvements. Levinson describes some new approaches used in medical schools and continuing education.

There are lots of do-it-yourself guides to improving communication skills available online. On the Medical School Life section of its website, the American Medical Association offers “Six simple ways to master patient communication,” through an acronym developed by communications expert Randa Zalman:

R—Rapport.  You want patients to feel that “we’re in this together.”

E—Explain. Ask patients a variety of questions that encourage them to explain more about their health and habits

S—Show. Rather than criticizing or telling them what to do, show patients collaborative thinking, and work with them in an active way.

P—Practice. Consciously practice your communication skills and rehearse tough conversations with patients. 

E—Empathy. Don’t be judgmental — offer encouragement to your patients.

C—Collaboration. Partner with your patients. People respond better to recommendations and questions in collaborative settings.

T—Technology. Don’t inundate patients with messages; use technology with restraint.

The website KevinMD.com has five subconscious thoughts every doctor should have in mind while talking to a patient: I am competent; I am not in a hurry; I am not motivated by money; I am more interested in listening than in talking; and I truly care about you.

For those looking for more detail, an article in Family Practice Management offers 20 tips for communicating with older patients. They’re explained in detail on the website, but the 12 for physicians (the rest are for staff) are:

  1. Allow extra time for older patients.
  2. Minimize visual and auditory distractions.
  3. Sit face to face with the patient.
  4. Don’t underestimate the power of eye contact.
  5. Listen without interrupting the patient.
  6. Speak slowly, clearly and loudly.
  7. Use short, simple words and sentences.
  8. Stick to one topic at a time.
  9. Simplify and write down your instructions.
  10. Use charts, models and pictures to illustrate your message.
  11. Frequently summarize the most important points.
  12. Give the patient a chance to ask questions.

Of course, the checklists that serve doctors so well in surgery may seem a bit out of place in human relations, and you definitely shouldn’t check each item off on a clipboard with the patient right there. But making eye contact, listening not interrupting, sitting face to face, inviting questions — that’s basic good manners. Sticking to one point, writing down instructions, using pictures or models, and summarizing your points are basic principles for sharing information. It isn’t ability to communicate well most people lack; it’s taking that moment to focus and make it happen.

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This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about physician-led innovation? Please connect with us at jouleinquiries@cma.ca.

About the author

Jane Coutts is an Ottawa-based writer and editor who specializes in healthcare issues. She worked as a journalist for 15 years, mainly at The Globe and Mail, where she was the health policy reporter for five years. Since she founded Coutts Communicates in 2002, Jane’s work has focused on making healthcare policy and research more readable and relevant. Jane also leads workshops plain-language writing.

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