We’ve said it before. We’ll say it again: Doctors provide better, safer care when they listen to — and hear — what their patients are saying.
Some doctors realize this, and one of them wrote about it last week in the New York Times. In an op-ed titled “Dr., Shut Up and Listen,” Dr. Nirmal Joshi said that “A doctor’s ability to explain, listen and empathize has a profound impact on a patient’s care,”
“Interpersonal and communication skills” were recognized as key physician competencies in 1999 by the American Board of Medical Specialties. Medical schools and residency programs then began to train and test students on these skills, but after they’re finished, they’re seldom evaluated further.
Joshi illustrated the problem with the story of one patient, “Betsy,” who saw a series of doctors about her rapid heartbeat and overwhelming stress. Doctor No. 6 finally asked about her use of over-the-counter medicines.
She was taking one to lose weight that contained ephedrine. That’s a decongestant and bronchodilator used to treat asthma and fever, but it’s also a stimulant. But before someone bothered to find out about Betsy’s use of it, she had been referred for psychological counseling to treat her anxiety disorder.
Which she didn’t have. As soon as she stopped taking ephedrine, her problems resolved.
“Asked why she hadn’t mentioned this information before,” Joshi wrote, “she said she’d ‘never been asked.’ Until then, her providers would sooner order tests than take the time to talk with her about the problem.”
Joshi deemed Betsy “fortunate,” because poor communication can have much worse, even dire, consequences than hers. He noted that a report by the Joint Commission, a nonprofit organization that reviews and accredits health-care organizations, found that communication failure, not a provider’s lack of skill, was responsible for more than 7 in 10 serious adverse health outcomes in hospitals.
Listening, empathizing and explaining are part and parcel of what a good doctor does. These skills have what Joshi called “a profound impact on a patient’s care.” But they’re woefully missing in the standard delivery of health care.
A survey Joshi read found that 2 in 3 patients discharged from the hospital don’t even know their diagnosis. Another study found that in more than 6 in 10 cases, patients misunderstood directions after they visited their doctor’s office. “And on average, physicians wait just 18 seconds before interrupting patients’ narratives of their symptoms.”
That’s not just bad manners, it’s bad medicine.
We believe strongly that patients are responsible for their health care, responsible for reading labels and directions, for asking questions about treatments and side effects, and what tests are supposed to measure, their risks and their benefits. But patients taking responsibility does not excuse doctors from helping them do so.
Joshi and his colleagues in Harrisburg, Pa., started a communication program in a large urban hospital challenged by a high poverty rate among its patients, a high rate of childhood obesity and a high rate of uninsured patients. They started by assessing how doctors communicated with their patients, and it wasn’t a happy result.
Physicians introduced themselves in only about 1 in 4 encounters. So of course the overwhelming majority of patients later were unable to identify their doctor. Physician encounters routinely were brief and rushed. Patients had limited opportunity to ask questions. And professional empathy was in short supply: One tearful patient related the recent death of a loved one, right after which the doctor said, “How is your abdominal pain?”
Joshi’s team established a physician training program involving actors as patients in a variety of situations. They had a “physician coach” sit in on real patient interviews to provide feedback.
And it worked. Patient satisfaction with doctors, as measured by a standard questionnaire, rose 40 percentile points on a national rating scale.
Happier patients are healthier patients, Joshi noted; one study published in The New England Journal of Medicine, he said, showed “that higher patient satisfaction was associated with improved outcomes for several diseases, including heart attacks, heart failure and pneumonia.”
Joshi acknowledged that a lot of his peers reject communication programs such as his because they’re too intrusive on their clinical practice, and/or too time-consuming. “But,” he wrote, “we need to move away from the perception that social skills and better communication are a kind of optional extra for doctors. A good bedside manner is simply good medicine.”