Assessing effective physician-patient communication skills: "Are you listening to me, doc?".

Introduction

The education of a physician includes much more than acquiring competence in medical knowledge and technical expertise. Physicians also need to have excellent communication skills in order to communicate with patients. Communication skills form the foundation for a more positive patient-provider relationship, leading to greater patient satisfaction and better patient compliance. In the patient’s eyes, the ability to communicate well forms a major component of a provider’s clinical competence. The ability to communicate effectively with patients can contribute significantly to improved patient outcomes. Because of their importance in the practice of medicine, teaching interviewing and communication skills are a part of the curriculum for medical schools. At the Mayo Medical School, a tool was developed to assist in the assessment of medical students when communicating with patients as they elicit a medical history. This rubric has been very useful for both teaching and assessment, and it may be applicable to other healthcare settings as well.

Patients commonly complain that physicians do not listen to them. “Being a good doctor requires not only knowledge and technical skills, but also communication” [1]. Communication skills are not just restricted to talking, but also to listening and nonverbal communication [2]. Assessment of the provider’s ability to apply communication skills continues to be a concern of medical educators.

Developing a positive relationship has historically contributed a great deal to a physician’s effectiveness and satisfaction within the profession [3]. Such relationships are crucial for successful medical treatment [4]. Good communication skills are a key to establishing these desired relationships, and the inability to display good communication skills has been shown to negatively affect many areas in patient care [5]. On the other hand, good communication skills have been shown to improve patient treatment compliance, thus leading to improved patient outcomes [6].

The benefits of good communication skills have been documented in the literature and recognized by physicians as early as Osler [7], who encouraged physicians to “care more particularly for the individual patient than for the special features of the disease.” Ludmerer [8] noted, “For over a century, the goal of medical education has been to produce thinking physicians, scientifically competent, who are sensitive to the emotional as well as the medical condition of the patient.” Unfortunately, there is evidence that suggests good communication skills are not universally practiced by physicians [5].

Patient satisfaction

Patients’ satisfaction with their healthcare experiences is dependent to a large extent on good communication skills demonstrated by their providers [9,10,11,12,13]. Effective physicians demonstrate a combination of technical and social/interpersonal competence. The technical skills are usually more obvious, and social/ interpersonal competence is usually more subtle, indicated by the ability to demonstrate empathy, compassion, caring, and concern, as well as the ability to communicate information effectively with patients. “Physicians with effective relationship skills will have more satisfied patients [14].”

Nonverbal communication

It is valuable for all healthcare professionals to have a knowledge of nonverbal communication [10]. This refers to such things as eye contact, gestures, body movement, and posture, but it can also include facial expressions, repetitive movements of the extremities, or vocalizations. Nonverbal communication can convey a sense of warmth, empathy, caring, reassurance, and support. On the other hand, it can also reflect a physician’s disinterest, boredom, anger, irritation, or disbelief. According to Borg [15], “Human communication consists of 93% body language and paralinguistic clues, while only 7% of communication consists of words themselves.”

Patient interviews

The medical interview is the most important manifestation of communication in healthcare [14]. Obtaining an accurate patient history is vital both to diagnosis and medical management, and doing so is dependent upon effective communication [16,17]. A common practice for busy physicians is to use a “physician-centered interview,” as they feel (incorrectly) that this approach allows for more efficient use of their time in obtaining information from the patient. This type of interview results in focused questions regarding healthcare issues and frequent interruptions of the patient. A more effective approach is to use a “patient-centered interview.” It utilizes open-ended questions, allows the patient adequate time to respond to the questions, and promotes a more accurate description of the patient’s symptoms. Patients are allowed to talk without interruption as long as they remain on track and are providing useful information. Research has shown that patients who are allowed to more fully share their perspectives frequently are able to achieve better outcomes [18]. “The most difficult diagnostic puzzles are often unraveled by a carefully conducted patient-centered interview [17].” Just as importantly, a patient-centered interview reinforces a sense that the physician has really been listening and has an understanding of the patient’s concerns. “The interview becomes a dialogue between two people driven toward a common goal...a collaborative effort between physician and patient [17].” We encourage medical educators to emphasize patient-centered interviews from the very beginning of medical school and to continue providing such emphasis throughout clinical rotations, residency placements [19], and continuing medical education experiences.

We have developed an interview assessment tool which has been quite effective for us in providing more objective, formative feedback to our students regarding their communication skills. This rubric (Table 1) is presented to the students prior to their initial interview experience in order to provide them with our expectations for effective communication skills and patient-centered interviews. Students are introduced to the format of a medical history and its basic components (major problem, history of present illness, past medical history, social history, and system review). A standardized patient is given a medical complaint to portray and a straightforward framework for a medical history. After faculty members and several classmates observe each student obtaining a medical history, the rubric is completed by a faculty member and reviewed with each student. Once a student has demonstrated competence in effectively eliciting a basic medical history from a standardized patient, more complex scenarios are introduced. In all cases, the interview is critiqued by a faculty member using the rubric. Throughout the process, techniques of good communication are stressed and patient-centered interviews are emphasized.

Table 1.

Interview Rubric

Category	1	2	3	4	Score
Introduction	Gave no introduction	Introduction was given, but it was either too short or too long	Introduction given of appropriate length, but it was lacking in sincerity	Gave sincere introduction of appropriate length
Eye contact with patient	Made no eye contact	Made some eye contact	Made eye contact, but disengaged several times	Maintained appropriate eye contact throughout interview
Nonverbal communication	Leaned away from patient with arms crossed	Leaned away from patient	Leaned toward patient, but was either too far or too close to patient	Leaned toward patient from a comfortable distance
Listening	Appeared to be consistently distracted	Was occasionally distracted	Was not distracted, but did not seem to be fully engaged with patient	Listened actively to patient at all times
Questions	Asked appropriate questions	Asked appropriate questions, but none were open-ended	Asked appropriate, open-ended questions, but some were not understandable	Asked questions which were appropriate, open-ended, and understandable
Wait-time	Gave patient insufficient time to answer questions	Gave patient sufficient time to partially answer questions	Gave patient sufficient time to fully answer some questions	Gave patient sufficient time to answer all questions
Concern	Appeared hurried and/or not interested in patient	Took the necessary time, but did not seem interested in the patient	Showed some interest in the patient but inconsistently so	Showed consistent interest and concern towards the patient
Organization	Seemed totally unprepared	Seemed prepared, but carned out interview in a random manner	Seemed prepared and somewhat sequential	Demonstrated a prepared, well-organized, sequential approach to the interview
Information gathering	Assumed patient had only one health concern	Addressed individual concerns as they arose	Created comprehensive list of patient's health concerns	Created comprehensive list of health concerns, prioritizing when necessary
Focus	Allowed patient or other to completely take control of the interview	Frequently allowed the patient or other to dominate the conversation	Occasionally allowed the patient or other to dominate the conversation	Kept the patient productively focused throughout the interview
Empathy	Showed no interest in the patient's emotional needs	Showed interest in the patient's emotional needs, but did not respond to them	Responded to the patient's emotional needs, but lacked warmth and sincerity	Demonstrated appropriate, sincere interest in the patient's emotional needs
Awareness of unspoken issues	Seemed to be totally unaware of unspoken factors	Seemed aware of unspoken issues, but did not explore them	Explored unspoken issues, but did not establish their significance	Was aware of unspoken issues and addressed them appropriately
Closure	Ended interview abruptly	Effectively ended interview, but did not summarize patient's concerns	Summarized patient's concerns, but did not ask if patient had any other concerns or questions	Summarized patient's concerns and asked if patient had any other concerns or questions
Total score

1. Introduction

An effective introduction does much to lessen patient anxiety [17]. The first few minutes of the patient-provider interaction can be the most important part, because the foundation of the interview is crafted within it.

2. Eye contact with patient

It is important for an interviewer to establish consistent eye contact with the patient; in order to accomplish such contact, the provider’s eyes and the patient’s eyes should be at approximately the same level [16]. While it may be necessary to occasionally look away from the patient in order to take notes or to interact with the electronic medical record, consistent eye contact indicates engagement on the part of the listener.

3. Nonverbal communication

This refers to a demonstration of emotion by the physician through facial expressions, nodding of the head, posture, body position, or movements of the extremities. It can give the patient information regarding how interested and empathetic the provider is toward the patient by conveying a sense of warmth, caring, reassurance, and support. On the other hand, it can also reflect a physician’s disinterest, boredom, anger, or irritation.

4. Listening

Not being listened to is “a major source of patient dissatisfaction [20].” The provider should do whatever is necessary to help patients feel they are receiving the physician’s attention throughout the interview.

5. Questions

“History building requires the physician to make conscious decisions about the phrasing of questions [18].” Healthcare professionals should concentrate on replacing medical jargon with everyday language when talking with patients [16,17]. Questions should be asked to facilitate and clarify, rather than to simply cause the patient to fill in the blanks.

6. Wait-time

Allowing enough time for the patient to answer one question before asking the next question is important. It is essential to give patients adequate time to fully answer questions posed to them, because “When doctors are in too much of a hurry to talk, they cannot get to know patients [21].”

7. Concern

Demonstration of interest in the patient as an individual is extremely helpful in building a positive relationship with that patient. Providers should consistently demonstrate interest in every patient.

8. Organization

The interview should be conducted in an organized manner. Being prepared is essential, but being organized should not be confused with being rigid.

9. Information gathering

Healthcare providers should establish an agenda for the patient’s visit. Once this list is established, it should be reviewed in order to determine if it is reasonable to discuss all of the concerns in the time allotted for the current medical visit.

10. Focus

While the patient ought to be interrupted as little as possible, the provider also should maintain some subtle degree of control over the direction of the interview. It is important to facilitate the discussion rather than to direct it, exerting “only as much control over the interview as is needed [17].”

11. Empathy

Empathy, or the ability to understand the patient’s feelings and put those feelings into words, is at the heart of medicine. Demonstrating empathy to patients is an essential part of effective communication [22].

12. Awareness of unspoken issues

Often the most important part of communication can be the ability to grasp what is not specifically said. Reading between the lines and gently probing when necessary can frequently unearth significant medical issues, so it is important to sometimes “follow the patient” [16] by watching for emotions and concerns that lie below the surface of the conversation.

13. Closure

The provider should always bring an appropriate closure to the interview in order to review what was discussed. Closing interview comments are important to ensure the patient has no lingering issues. Welcoming body language can be helpful in soliciting additional patient concerns [23].

Conclusion

Good communication skills play an important role in establishing a quality provider-patient relationship. These skills can be taught [5,14,17] and learned [24,25]. Improving these communication skills can result in marked improvement in healthcare outcomes [13]. We have found that the rubric we developed can be effective in helping physicians become comfortable with the use of patient-centered interviews. In order for providers to develop positive relationships with their patients, it is important for them to practice their communication skills with the assistance of an appropriate assessment tool. Assessment of these communication skills is a vital part of the learning process, because in the words of George Bernard Shaw, “The single biggest problem in communication is the illusion that it has taken place [26].” We encourage the use of this rubric (Table 1) as a foundation for instruction and assessment of communication skills.