Listen up, doctors: Here’s how to talk to your patients

English: An anxious person

English: An anxious person (Photo credit: Wikipedia)

A patient having his blood pressure taken by a...

A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

It is said that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder on investigation.[1] Whether this adage is true or not may be open to debate but it is clear that history and examination skills remain at the very core of clinical practice. This record will aim to provide you with some helpful tips, your patients will teach you the rest.

As this has the potential to be a very broad topic, you may want to go to our dedicated records for more details on:

Most articles on clinical topics will include the relevant aspects of history and examination for that subject.

This is a frequently neglected area but it can be very important.

  • Clear your mind of the last patient as you wash your hands to prepare for the next.
  • Glance through the records before seeing the patient. Patients expect you to know their past medical history, even if it is the first time that they have consulted with you because they know that you have the records. It is certainly worth noting the last consultation and the major problems as displayed on the screen.
  • Think about your timing. Hospital consultants may allow up to an hour for new patient consultations whereas general practice generally allocates a total of 10 minutes for history, examination and explanation (you are doing very well if you manage to fit in some health promotion). Secondary care also benefit from a referral letter whereas you have a “virgin” patient from whom you have to extract a clear and concise story in a brief duration. So it is important to be efficient and focused. It is permissible to take a little over 10 minutes but if a consultation is taking much longer than this, it may be preferable to ask the patient to return, perhaps with a longer appointment.
“Always listen to the patient, they might be telling you the diagnosis.” Attr. William Osler[2]

Communication skills

Remember that these are non-verbal as well as verbal. Your manner, your physical position with regards to the patient’s (this may not be within your control), your body language all contribute to the outcome of the consultation. Be relaxed and smile to radiate confidence. If they have had to wait a long time, a comment addressing this with an apology at the outset is often appreciated; it will give you a much better start and shows respect for their individuality.

Avoid writing whilst the patient is talking to you; if they are saying a lot of relevant things – or there is importance in the temporal order of the narrative – and you need to jot them down, mention it to the patient so that they understand that you are still listening to them, “I’ll just make a note of your symptoms as you go along so that I get the order right.”

Extracting the information

Patients vary greatly in how they present. Many will be anxious. This may manifest itself in a number of ways:

  • The quiet patient from whom only monosyllabic answers can be extracted by direct questioning.
  • The apparently over-confident patient who addresses (or adds to) their anxiety by turning up with an armful of internet printouts, concerned that they have been fatally afflicted by Von Noodles’ disease.
  • The angry patient whose wait for the appointment or in the waiting room has given them time to mull over the worst.
  • The returning patient who needs endless reassurance.

We are encouraged to ask open questions and avoid leading questions. This may pose a challenge in the time-pressed clinic when confronted with the verbose patient who thought that she ought to get herself checked out because Mrs Jones, from number 84 and has a weak heart, also complained of dizziness but then she has also suffered from nerves since her daughter ran away with that terrible boy from Elmshurst …

Gentle steering phrases may be helpful:

  • “That sounds tough. Tell me which one of these problems is troubling you most?”
  • “Perhaps we can come back to that. Tell me a little more about the shortness of breath…”

Note that the first addresses the patient’s concern whereas the second addresses yours. The two may not be the same but each is important. If their greatest concern is not worrying you, jot it down and make sure you address it at the end of the consultation (even if it is just to reassure them). It is worth noting that research has shown that when allowed to complete their opening statement uninterrupted, most people do so in less than 60 seconds.[1]

Staying focused

In a patient-led interview, staying focused can be a challenge. Time will force you to do this. Ask yourself, “Why did this patient come?” There may be hidden anxiety such as a concern about cancer that needs to be explored and addressed. Patients sometimes open the consultation with, “I hope I’m not wasting your time,” which may mean, “I hope I am wasting your time and this is not serious but I am worried”. If the patient enters anxious and leaves reassured, the doctor’s time was not wasted.

Sometimes, but less often nowadays, a patient may present with what he regards as an acceptable opening gambit such as a cold, although the doctor may think otherwise, but really he wants to discuss his erectile dysfunction or fear of cancer. This is usually introduced with, “While I’m here doctor.”

The consultation is an opportunity to explore the patient’s needs and expectations and to educate – all this inside 8½ minutes (1 minute for patient changeover, 30 seconds for hand-washing). Deciding what can safely be omitted for each patient as the consultation is truncated from an hour to 10 minutes and what must be included is a matter at great art and skill. Such matters as the patient’s real agenda and health promotion within the consultation are discussed in the article on consultation analysis.

Common problems

Certain presentations are so common that the doctor should have a protocol to follow for such consultations. This includes presentations of chest pain, breathlessness,dysuria, vaginal discharge and abdominal pain. It is focused and efficient. There are standard questions for rheumatology conditions or wheezing in children or diagnosing asthma in adults. Think about the diagnosis from the outset and once the patient has had a chance to lay out the main problems, ask directed questions to tease out the likely diagnoses.[2]

In recent years, nurses have shown themselves able to provide a great range of safe care by following protocols. Doctors sometimes deride protocols as “painting by numbers”. Much of clinical work is following protocols, even if subconsciously. Protocols are a swift, efficient and effective way to cover the ground with risk management in that they reduce the chance of forgetting or overlooking something important. Doctors need to embrace protocols and to engage in their formulation and implementation.

Past medical history

Patients assume that the doctor has their medical records and is fully conversant with their past medical history. Although major events should be displayed on the screen some may be incomplete and it is worth checking both for completeness and to assure the patient of one’s thoroughness. The habitual loss of medical records means that most records are of remarkably short duration. As mentioned above, unless you are familiar with the patient, it is worth looking at past history and recent consultations before the patient enters.

Drugs

Note current medication – this is important not only as a indication of what they are on but also a reminder of what they forgot to tell you they suffer from (see above). Drugs may contribute to the current problem or influence choice of medication for it. The constipated patient may be taking co-codamol. The computer will record if medication is over or underused and the date of last issue. Enquire about OTC remedies and possible herbal or other treatments. The latter are just as likely as POMs to have toxic effects or drug interactions, perhaps more so as they have not be so thoroughly tested.

Family history

Patients also assume that their family doctor is aware of their family history. Many conditions do have a genetic component, including coronary heart disease, diabetes,atopic eczema, autoimmune disease, glaucoma and some cancers. So if you are reviewing a patient with one of these diagnoses, it may be worth noting the genetic component to them so that family members can be assessed. Obesity is far more environmental rather than genetic but runs in families because they eat together and develop common attitudes to food. Patients may need reassurance that diseases such as schizophrenia, Alzheimer’s and Parkinson’s disease do not have a significant genetic component. The fact that a family member had a disease makes the patient more aware of it and more likely to be concerned about contracting it.

Social history

Similarly, patients assume that their doctor knows their social situation. It may be relevant such as the middle-aged spinster caring for disabled and demanding parents, the single mother with a handicapped child or the child with asthma who lives in a smoky, damp and overcrowded environment. Occupation may be very relevant to the aetiology of the disease and its management. It also indicates the person’s level of education and hence ability to comprehend certain issues.

“Just remember one thing. Whether the patient is a patient in real life, or a patient in an exam, the are a human being. A person. At some point, they’ll be you.”[3]

There is no real dividing line between history and examination. During the course of the history, you will gather a wealth of information on the patient’s education, social background and to a lesser extent, there will be physical signs to pick up. Examination needs to be as focused as history. Try to learn and apply good technique. Quite simply, good technique is more likely to give a correct result than poor technique. The yield from examining systems that are not obviously relevant is too low to justify in such limited time.

The first part of any examination is to observe. Learn to observe. Look before you lay on hands. Examination of the cardiovascular or respiratory systems does not start with the stethoscope. You may get valuable information from the facies, skin colouration,gait, handshake and personal hygiene (reflective of physical, psychological and social background). Note the red eye, the freckles on the lips of Peutz-Jeghers syndrome or the white forelock of Waardenberg’s syndrome. A number of endocrine disorders may be immediately apparent.

The doctor should have a protocol for each system. Many forms of examination have their own dedicated article. All general practitioners should have competence in:

In the 1980s, handing over a prescription indicated the end of the consultation. Nowadays you are expected to discuss the illness and options for treatment with the patient.

Investigations[4]

If you want to carry out investigations, think why you are doing so:

  • To exclude or confirm a diagnosis
  • To reassure the patient
  • To satisfy the whims of the hospital doctor to whom you may refer the patient

Clearly, investigations should be justified in terms of costs and of potential risks they may pose for the patient. One of these risks is actually increasing patient anxiety (a well-established risk) – particularly in the event of an ambiguous or false positive result. It is better to establish what exactly your patients’ fears are rather than going on to perform more tests or referring where there may not be the need.

Health promotion

Note the health template on the screen. It should be complete and reasonably contemporary. Just mentioning smoking, alcohol consumption or BMI will remind the patient and make him think about the issue. Linking specific lifestyle advice to the current illness is far more effective so pick your issue.[4] However, be careful not to swamp the patient’s agenda with your own. Health promotion may also affect your practice’s performance under the Quality and Outcomes Framework.

Management is more than just a prescription. It includes health education and advice. This is not simply a move away from paternalism but aids compliance and may reduce unnecessary attendance. Twin-tray laser printers enable printed PILs to be given to the patient to take away.

When considering what to include and leave out when writing your records, ask yourself two things:

  • Will the next doctor who sees this patient follow my train of thought and understand my management plan?
  • Would this stand up in a court?
  • Would I be happy for the patient to read these notes?

In the 1950s history, examination and medication seldom exceeded one line of Lloyd George records. Be concise but do not skimp. Record thoughts such as “could be psychosomatic” or “may need endoscopy” and plans such as “if not better soon, refer”. The notes may be a useful tool for yourself later and if the patient is seen for the same event by another doctor, they need to be able to understand what your thinking was and what management plan you had in mind. Ideally each patient contact should contain a mini management plan. The notes may also be subject to scrutiny in the case of complaint or litigation. The quality of notes can be fundamental to the defensibility of a case. Use abbreviations, but only those that other doctors would readily recognise.

Never record derogatory statements that would cause embarrassment if the patient were to read them or they were to be read out in a formal situation but do not avoid factual statements such as “smells of urine”. Patients now have right of access to their notes.

Poor keyboard skills may tempt some to be more brief when moving from paper to electronic records. Avoid the temptation. Typing errors are easily corrected but even if missed they are more comprehensible that neat doctor’s handwriting, and not all doctors have neat writing.


The ‘difficult historian’

Not everybody can reliably give a historical account of their problem. It is not enough to simply write ‘difficult historian’ (is this a withdrawn elderly lady or a drunken axeman?). State why and depending on the problem, it may be useful to put in a comment of the patient’s mental state via a Mini Mental State examination for example. Almost every patient can make some some sort of comment on their well-being and asking a few very general questions (“Does it hurt anywhere?”) can provide some useful pointers. Where possible, obtain the history from relatives, carers or friends. Where you suspect that there is a mental health problem, try and corroborate the information you are obtaining. If the patient is violent or intoxicated, describe the situation you are in and document verbatim what is said. Try and remain calm under fire. Make sure that the patient is not seriously ill before calling security or the police.

The child

Children vary widely in their ability to communicate: the neonate’s subtle signals may only be perceived by its mother whereas the teenager communicates as an adult. The child’s account should not be assumed to have any less credence than the adult’s.[6]From about three years of age, the child is capable of quite complex thought structures.[4] Ask how the child prefers to be addressed and introduce yourself. Eye contact is reassuring for older children but not younger ones. Have toys handy for the child ± siblings and note, throughout the consultation, how the child interacts with the family. Make sure you know what prompted the referral and what the parent or carer fears or thinks is the matter. Address this.

Relatives

Generally, relatives are there to help and support the patient. Obvious cases are parents of young children or children of elderly parents. They are helpful sources of additional information. However beware that their agenda may be different from the patients’ one. For example, family denial or collusion is a problem that may be encountered in general practice.[4] The family’s difficulty in dealing with a person’s distress at the news of advanced cancer, or their desire to protect them from the news, may be subconsciously masked in statements such as “Don’t tell him, doc, it would kill him”. This may serve to isolate the patient further who may be fully aware of the condition and unable to share this burden with the family who don’t want him to know. The family’s interpretation of events may not always be the same as patients’ in some situations where perhaps social events interplay with illness (as with mental health problems for example).

The angry patient

Patients may get angry if:

  • There has been excessive delay in appointment times or in the waiting room
  • There are perceived medical failings
  • They do not feel that they have been taken seriously (or they have not received the treatment they felt entitled to)
  • Guilt (eg with regards to a sick relative)
  • Grief following a diagnosis
  • A simple misunderstanding

It is important to recognise the anger, both in the patient and in yourself. Do not leave it unexplored. Recognising when the consultation is dysfunctional and addressing this with the patient can provide insight, and may save time in the long run. Try questions such as “can you explain in your own words what is upsetting you”, or “can we start from the beginning again” then listen attentively (particularly to any grievances) and negotiate subsequent actions/plan with the patient. Maintain non-threatening eye contact, breaking this off intermittently when you speak. Deal with the main issue first, summarise the remaining points and then deal with each. Acknowledge honestly any faults (self, system), and work on how to resolve the issues. Often, just airing the problems will have done a lot to diffuse the situation.

If you feel that there is a real threat of violence, get away or use the panic button.

Handling sensitive issues

These are difficult to deal with, especially within a short time frame. They may arise, for example, if the patient you are seeing clearly has symptoms and signs relating tochronic liver disease: you will need to ask questions relating to risk factors (‘She thinks I’m an alcoholic‘). If an elderly, bereaved man has lost weight, you may have to explore the possibility of depression and want to refer to psychiatrists (‘He thinks I’m mad’).There is no textbook way of dealing with these and over time, you may develop your own set phrases. If you are lucky enough to know in advance what you are going to have to say, plan it. Establish a rapport, cover all other aspects first and then deal with the issue gently but explicitly.

Bad news

This is not easy to do as it is distressing to us to cause distress in somebody else. First of all, allow time and make sure (to the best of your ability) that you can be in a private place where you will not be interrupted. You will have to gauge from the patient quite what they are prepared to hear; as a rule of thumb, honesty is the best policy. Make sure that when you are explaining the problem, you frequently check the patient’s understanding (see below). You will develop your own style but here are some tips. Avoid:

  • Not doing it or leaving it to somebody else
  • Putting it off (“Let’s do a few more investigations”)
  • Baffling the patient
    Surgeon: “I’m sorry Mrs J, we found a mitotic growth.”
    Grateful patient: “Thank goodness, doctor, I thought you were going to tell me I had cancer!”
  • Deliberately not picking up on patient cues
  • Excessive solemnity or gloom and do not remove all hope
  • Take care with prognosis and never give a specific time period

Follow up after breaking bad news is particularly important.

Somatising patients

Difficulties may emerge as a patient repeatedly presents with ongoing physical symptoms for which no cause can be found. Whilst some of these may be the harbingers of something sinister, common things are common and there may be an element of normal problems of daily living being turned into symptoms by an anxious patient. There is a risk of medicalising the patient in attempt to answer their question: “What are you going to do about my [symptom], doc?” These patients may get dissatisfied with their own doctor and present to others. At some point the system cracks under the pressure of their demands and a test leads to a procedure which leads to a complication and a fresh round of presentations. Whilst following well established paradigms of managing these patients (eg be on your guard against manipulative behaviour, avoid referral or multiple doctor input, keep good records, communicate with colleagues), be aware of the new emergence of an actual disease entity and also of the underlying message (‘I am depressed following my divorce and miss the attention I used to get’).

It is widely taught that diagnosis is revealed in the patient’s history. ‘Listen to your patient they are telling you the diagnosis’ is a much quoted aphorism.

The basis of a true history is good communication between doctor and patient. The patient may not be looking for a diagnosis when giving their history and the doctor’s search for one under such circumstances is likely to be fruitless. The patient’s problem, whether it has a medical diagnosis attached or not, needs to be identified.

It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned as part of the comprehensive and systematic clerking process outlined in textbooks. A good history is one which reveals the patient’s ideas, concerns and expectations as well as any accompanying diagnosis. The doctor’s agenda, incorporating lists of detailed questions, should not dominate the history taking. Listening is at the heart of good history taking. Without the patient’s perspective the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.

Often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A good example is with the complaint of headache where the diagnosis can be made from the description of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations.

To get a true, representative account of what is troubling a patient, and how it has evolved over time, is not an easy task. It takes practice, patience, understanding and concentration. The history is a sharing of experience between patient and doctor. A consultation can allow a patient to unburden himself or herself. They may be upset about their condition or with the frustrations of life and it is important to allow patients to give vent to these feelings. The importance of the lament, and how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool for both patient and physician, has been discussed in an excellent paper.[2]

The skills required to get the patient’s true story can be learned and go beyond knowing what questions to ask. Indeed ‘questions’ may need to be avoided, as they limit the patient to ‘answers’. There is a lot written about consultation skills and different models of consulting. These have been developed through consultation analysisand now form an important part of undergraduate medical training and GP training in the Curriculum for Speciality Training for General Practice. There are many examples of aspects of consulting which may assist history taking for doctors working with patients in all specialties.

Setting

  • The layout of the consulting room can assist good consulting. It can facilitate establishing rapport with patients by, for example, allowing for good eye contact, enabling easy access to computers or notes and avoiding ‘distance’ between the doctor and patient.
  • Take care with the opening greeting as this can set the scene for what follows. It may assist or inhibit rapport. Generally, it helps to be warm and welcoming so as to put the patient at ease. Good eye contact, shaking hands with the patient and showing an active interest in the patient should help to establish trust and encourage honest and open communication.
  • Take care not to let the computer intrude on the consultation. This can be difficult when there is useful information available on a screen. Make use of the time before and after consultations to get information from the computer.

Listen first and listen second

Let the patient tell you the story they have been storing up for you. This can be encouraged by active listening.

  • This implies that the doctor is seen to be interested and attentive by the patient.
    Give the patient a chance to tell you their pre-constructed narrative, rather than diving in with a series of questions to delineate detail (such as the exact frequency and colour of their diarrhoea). This approach affords a better chance of getting a true ‘flavour’ of their experience of an illness, its temporal development, and the relative importance to the sufferer of the symptoms that they have (which ultimately is what, from their viewpoint, you’ll be attempting to cure, not ‘the diagnosis’, about which most patients do not really care).
  • It is important to be able to ask discriminating, delineating questions about particular symptoms to verify their actual nature and give enough information to support the process of reaching a diagnosis; however, timing is everything. Get down a record of each of the major symptoms in the order that they are presented to you by the patient. Then go back to this overall picture and break down any aspects of the history that you need to from there. This is a much better way of doing things than interrupting (and probably losing forever) the patient’s initial narrative.
  • Listening does not just involve using your ears. Use other clues such as facial expression, body language and verbal fluency to give you cues as to what is really troubling someone, and suggest other areas in which the history might need to proceed. This is very useful where there is a psychological origin for physical symptoms, of which the patient may be unconscious, but you could get at if you noticed that talking about a certain aspect of their story makes them uncomfortable or hesitant. Remember that speech is not the only means of communicating, especially where someone has a poor command of the language in which you are taking the history, or has hearing impairment. Make full use of communication aids such as translators, sign-language interpreters, picture boards, drawings done by the patient showing where the pain is, when this is a more appropriate form of discourse.
  • Some patients do not come readily prepared with a narrative of their illness and, in this situation, it is unavoidable to use questioning and clarification of details to ‘draw out’ the history. However, if your prompting sparks off a narrative, then try to hear it out if it seems to be relevant.

Open questions

These are seen as the gold standard of historical inquiry. They do not suggest a ‘right’ answer to the patient and give them a chance to express what is on their mind. Examples include questions such as ‘How are you?’. There are other similar open questions, but it may be effective just to let the patient start speaking sometimes.
Open questions can be used to get specific information about a particular symptom as well. For example: ‘Tell me about your cough’ or ‘How are your waterworks bothering you?’. Open questions cannot always be used, as sometimes you will need to delve deeper and obtain discriminating features that the patient would not be aware of. However, they should be kept foremost in the mind as a way to broach a subject or unexplored symptom.

Questions with options

Sometimes it is necessary to ‘pin down’ exactly what a patient means by a particular statement. In this case, if the information you are after cannot be obtained through open questioning, then give the patient some options to indicate what information you need. For instance, if a male patient complains of ‘passing blood’ and it is difficult to tell what he means, even after being given a chance to expand on the subject, you could ask: ‘Is that in your water or your motions?’. This technique must be used with care as there is a danger of getting the answer you wanted rather than what the patient meant (he might be having nosebleeds). Try to avoid using specific medical terms such as ‘coffee grounds’ (one of the options you might give if trying to find out if a patient is vomiting blood). If you can use an open question such as: ‘What colour was the vomit?’, rather than suggesting options, it is more likely to give you a true picture of what the patient has experienced; however, sometimes questions suggesting possible answers cannot be avoided.

Leading questions

These are best avoided if at all possible. They tend to lead the patient down an avenue that is framed by your own assumptions. For instance, a patient presents with episodic chest pain. You know he is a smoker and overweight so you start asking questions that would help you to decide if it’s angina. So you ask: ‘Is it worse when you’re walking?’, ‘Is it worse in cold or windy weather?’. The patient is not sure of the answer, not having thought of the influence of exercise or the weather on his pain, but answers yes because he remembers a cold day when he walked the dog and his pain was bad. You may be off on the wrong track and find it hard to get back from there. It is much better to ask an open question such as: ‘Have you noticed anything that makes your pain worse?’. When the patient answers: ‘Pork pies’, you are on firmer ground in suspecting that this may be chest pain of gastrointestinal origin.

After taking the history, it’s useful to give the patient a run-down of what they’ve told you as you understand it. For example: ‘So, Michael, from what I understand you’ve been losing weight, feeling sick, had trouble swallowing – particularly meat – and the whole thing’s been getting you down. Is that right?’. If there is a nod of approval or expressed agreement with the story then it’s fairly certain you’re getting what the patient wanted to tell you. If not, then you may need to try another approach. This technique can avoid incorrect assumptions by the doctor.

It’s always a good idea to ask the patient if there’s anything they want to ask you at the end of a consultation. This can help you to impart further information if there’s something they haven’t understood, and can reveal something that’s been troubling them that hasn’t been touched upon or got to the bottom of. It is an opportunity to confirm that a shared understanding has been reached between doctor and patient.

  • Try to let patients tell you their story freely.
  • When you use questions, try to keep them as open as possible.
  • Use all of your senses to ‘listen’.
  • Check that what you think is wrong, is what your patient thinks is wrong.
  • Keep an open mind and always ask yourself if you’re making assumptions.
  • Be prepared to reconsider the causes of symptoms that you or a colleague have decided upon.

Patients need compassion and dignity, but too many doctors act like mechanics. Here’s how we’d like them to behave
MARY ELIZABETH WILLIAMS

Listen up, doctors: Here’s how to talk to your patients
(Credit: Everett Collection via Shutterstock)
My doctor always walks into the exam room smiling. It’s not necessarily the countenance you’d expect from a man who spends much of his time working with people with Stage 3 and Stage 4 cancers — the kind that haven’t responded to other forms of treatment. Yet even when we speak on the phone, I sometimes swear I can hear him smiling. Granted, I’ve given my doctor something to smile about – I’ve been doing spectacularly well in my Phase I trial, delivering CT scan results that he appreciatively refers to as “neat.” Yet the extraordinary thing about my doctor is that he was smiling the day I met him, when I was facing a diagnosis that put my long-term odds of survival in the “probably not going to happen” range. And from that first grin, he deflated my terror and made me believe I was in the hands of someone not just invested in my wellness, but downright optimistic about it.

A natively cheerful demeanor isn’t a requirement for being a competent healer. But what is far too often lost in our grueling, impersonal and cost-driven healthcare system is the basic fact that a human being in the chaotic and scary world of injury or illness deserves sensitivity and compassion. That a shivering person in a paper dress deserves dignity. So if you’re a doctor, nurse or technician, here’s your reminder. And if you’ve ever been a patient, we’d love to read your own additions to the list.

Take your hand off the goddamn doorknob already.

We know you are incredibly busy and important and that your office has wildly overbooked your schedule today. You know what, though? It’s not our job to streamline your day. Conveying information while you’re walking out the door may work if you’re a character on “Revenge,” but it’s a crummy way to have a conversation with a person about his or her health. We just sat out in the waiting room for 45 minutes reading last week’s hype-trolling issue of Time magazine; we’ve sat here in a robe for a half-hour looking at the pain assessment chart. Now you can at least pretend to give us your full attention for the five minutes you’re prodding our vulnerable, unclad bodies. You’ll immediately rise in our esteem.

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Dr. Carma Bylund, director of the CommSkil program at Memorial Sloan-Kettering, notes that studies have shown that “when a doctor comes into the room and sits down with the patient, the patient perceives the visit as longer. The doctors are at eye level; they’re attentive — and they can’t put a hand on the doorknob.”

Remember that this random collection of faulty parts is a person.

At a Times talk last winter, Will Reiser, the writer of “50/50,” admitted he’d loosely based the poker-faced oncologist of the film on his own doctor, referring to him as “a mechanic” who saw him as the car he had to fix. It was a generous assessment of clinical sangfroid, one that acknowledged that nobody wants a doctor who’s lacking in the professional boundaries department. But that doesn’t mean you should let yourself turn into a robot.

Early in my treatment, I had a doctor on my clinical trial bring in a team of research fellows to look at “the tumor.” That the tumor had a sentient human host seemed utterly irrelevant to him. And when my friend Ariel had a miscarriage, the sonogram technician confirmed it by briskly announcing, “Yup, no heartbeat,” and walking out of the room. This is what is known, in medical terms, as a nightmare.

You may deal in tumors and miscarriages in a revolving door of horrible things all day long, but your patients live in a very different world. Their tumors and miscarriages and dying parents are pretty important to them. The moment they become trivial to you, seriously rethink why you ever wanted to do this for a living.

Consider that the patient is telling you something the charts don’t.

“I had one endocrinologist clearly point out during my exam all of the physical characteristics that lead him to believe I was hypothyroid and had adrenal function issues,” says my friend Alice. “He pointed out stretch marks (without childbirth). He pointed out dry skin. He pointed out my premature gray hair (specifically a prevalent streak near my forehead). My weight gain and inability to lose weight. Quite a few other characteristics. But the lab tests came back ‘normal’ and that is literally what he offered me. ‘Your tests say normal so there is nothing wrong.’” Can you understand why Alice was exasperated?

Most of us truly get it that doctors don’t know everything. We don’t expect all-seeing miracle workers. And we understand that some patients are either incapable of giving accurate information or are just plain wrong about what they believe they have. But a person who is suffering, who is symptomatic, is entitled to a fair and thorough investigation – and if you can’t provide it, please, suggest somebody who can. Don’t shrug off pain with a blasé suggestion of Tylenol or cutting out dairy and not even look at the person. Instead, be like the doctor who once told me, “There’s always something more we can do for a patient.” Do something more.

Accept that we didn’t go to medical school

You know how you’re rattling off protocols and surgery plans and fancy words for body parts we didn’t even know we had? Whoa whoa whoa – slow down there, partner. You’re talking to someone who may not know a colostomy from a semicolon. Your rapid-fire delivery is intimidating and scary. It makes us feel stupid and bothersome, like we should know all this stuff and not ask questions.

“Doctors forget that the minute a patient hears bad news or that there’s a problem, patients stop listening,” says my doctor friend Joe. “Or if they hear anything, they’re hearing incomplete info. The onus then is on us to find ways to help patients understand what just happened, whether it’s writing down instructions, calling a patient later in the day after the dust settles, or simply asking a patient to repeat something back.”

“Healthcare providers often have a kind of script,” adds Dr. Bylund. “They may have certain things they may always say to everybody. We teach doctors to check patients’ understanding and use that to tailor consultation to the person’s needs. Say things like, ‘Tell me what you know about your disease,’ or ‘Tell me what your last doctor said.’ And we show them how people’s past experiences may impact their choices now.” Maybe we don’t know anything about Parkinson’s. Maybe we know a harrowing amount because of what Mom went through, and we’re frightened to death of it. Start with what we know before you dump everything you know on us.

Leah Berkenwald, a health communication student and writer, says, “What good is the diagnosis or treatment if a patient cannot understand it or follow instructions? What is often deemed noncompliance is often a result of a failure to communicate.” And, she says, “It doesn’t matter how good a physician is at diagnosis or treatment if the patient doesn’t understand what they’re supposed to do, how to do it, or why it matters. Medical knowledge and clinical skill become moot when a physician makes assumptions about their patients’ cultural values, beliefs and practices.”

Talk frankly about how we’ll pay for this – and don’t assume anything

As Salon reader Lila says, “The calculation about what choices are available to me seems to be made before I hear the medical advice … Don’t get me wrong, it can be tricky for individuals to figure out how to afford healthcare, and I’m glad for healthcare professionals’ sensitivity to that. But when my husband was being sent home from the hospital — too early, we felt — a problem came to light: The doctor finally said she too felt it was too early but said the insurance wouldn’t pay another day. In fact she was wrong (and the insurance ultimately did pay another day), but more problematic is that she made a decision to discharge based upon something other than medical reasons — and we didn’t know that was happening.”

Nobody – on either the medical or patient end – wants to get walloped with a contentious bill. So talk to us so we can work together to get the most care for the buck. Don’t treat us like dirtbags if we’re out of network or uninsured, either; work with us to find other options. And you can pass that tidbit on to your office staff. Imagine what it feels like to be both sick and poor — now imagine what it’s like to add “demeaned” to your list of problems.

All of us, even the strongest among us, find ourselves on the business end of the stethoscope sometimes. And though it seems pretty basic, I’ll let a real doctor say it so you take it seriously: “Ultimately, health and wellness have a lot to do with the comfort a patient has with a doctor. You’ll give better information when you have a doctor who makes you feel secure,” says Dr. Bylund. When you’re compassionate to us, we’ll show up for our checkups. We’ll be honest about conditions and circumstances, because we aren’t afraid of being shamed or judged. We’ll still put our faith in science, and accept that pain and sickness are sometimes unavoidable. But we’ll be less scared when we walk through those very scary doors. And though we’ll do our best to ward off disease, we’ll gladly submit to something infectious – the power of being decent, and your faith in us.

 

HOW TO TALK TO TEENS

Doctors can be intimidating to teens and it is important to help them tell you what’s on their mind. Health care practitioners caring for adolescents should follow these tips on how to talk to their teen patients.

  • Remind your patients that, by law, you cannot disclose anything discussed between you and your patient. This will make teens feel more comfortable talking to you.
  • Don’t be shocked (or at least show your shock). It is difficult for a teen to talk to a doctor who looks shocked. Just because you’ve never met a pregnant 10 year old does not allow you to look her in the eye with a stunned look and say nothing. (This tip is especially helpful in the case of problems to do with sex.)
  • Let your patient know, through both body language and words, that they can discuss anything with you. Teens need to know that their doctor is accessible to them.
  • Doctors, in my experience, refrain from discussing their patients’ sexual pasts with them. This is probably because any adult, or anyone for that matter, is uncomfortable hearing about anyone’s sex life, especially an adolescent’s. Not until I began visiting the doctors at college did a doctor ask me about my sexual activity without my prompting a question that would lead them to ask. When a patient comes for a simple check-up, doctors should make sure that their patient is entirely healthy. A good way to make sure is to ask about their patient’s sexual activity.
  • Believe what their patients say. On one occasion, a doctor who asked me if I was pregnant, did not listen to me when I told him that I was not sexually active, and kept pressuring me. Unless you are absolutely sure that a patient is not being truthful, do not prod them into telling you what you want to hear.
  • If a parent is present in the exam room, ask them to leave or ask your patient if they would prefer to have their parent(s) present or not. If a parent is either present or not, it can change the patient’s comfort level, and change whether or not you hear what is actually bothering the patient.
  • Treat teen patients in a way that is right for their age. Because most teens still see pediatricians, many pediatricians make the mistake of talking to their teen patients like the 4 year olds they treat. Teens are almost adults, and like to be treated like they are adults.
  • Parents and doctors should explain the procedure of a pelvic examination and their feelings and experiences with it so that the teen understands that other people have survived them. Also, one important thing to tell patients ahead of time is that a female nurse must be present during the procedure when the examination is performed by a male doctor. Many of my friends have made gynecologic appointments and have been seen by male doctors. They have been scared of being seen by men and are frightened of molestation. Knowing before the examination that by law a woman must be present can calm the patient.
  • END OF LIFE DISCUSSIONThe failure of doctors to talk to their patients about end of life decisions perplexes me.  This gap in vital communication results in poor care, uncontrolled pain, futile treatment and death in hospital or nursing home, where no patient wants to be.  Certainly, for oncologists, every patient they see is concerned about dying and by not opening the topic it leaves each isolated.I have generally taught my students that this failure results from a “culture of cure.”  Doctors and patients focus so hard on treatment, whether its fighting cancer, heart disease or even Alzheimer’s, that they ignore the reality that all life eventually ends.  Lost is the opportunity to plan for end-of-life needs, which can deny the patient and family a gentle passing.  Doctors falsely see death as the great enemy, instead of suffering and disease. Often the illogical emphasis on cure at any cost is key to poor end-of-life communication.Recently I have been considering a slightly different perspective on this problem, based in the works of psychoanalysts, Sigmund Freud and Otto Rank, and how they saw human personality.  They proposed that man is, in a sense, a demi-god.  Half god and half-animal.  By god, they did not mean infinite and all-powerful.  Rather they observed that man has characteristics that are god-like and therefore unique among all creatures.These god-like traits include the ability to imagine something in the abstract and then make it happen.  For example, one can dream of a two-floor red house, and then build it or envision a five layer chocolate cake and then bake it. Second, man can, in his mind, travel to any time in the future or the past, including the world before or after his life. He can also move his mind to any place in the Universe that he imagines.  Finally, at the most basic level, man is self-aware of his own existence and mortality. As we understand life on this planet, these are remarkable and special god-like abilities.On the other hand, man is an animal. He is born, grows, can be injured, ages, and gets sick.  He eats, has sex, shivers when a frigid wind blows and has to move bowels and urine. Finally, eventually, the animal that is man dies.

    Psychoanalysts believe that emotional trauma in human life is because man is not really a god and is something more than just an animal. He is a demi-god and being a demi-god is hard.  He can create and appreciate goodness, enjoy the wonder and awe of each day; teach, learn, and dream, but at the same time, he can see into the future and knows his fate.  His mind can conceive flying through the air, staying awake for days or living to be 10,000, but he is denied by the limitations of his flesh.  This results in life long stress and in order to cope man uses various psychological strategies, including repression and denial, to focus on each day and each moment and not go truly mad.

    When someone becomes ill with a life threatening illness such as cancer, their ability to deny the animal part of their existence may collapse.  Suddenly they are less god than ailing beast. This can cause terrible anxiety, confusion and depression, as their personality is threatened by physical deterioration and critical coping mechanisms fail.  At these critical times, the support of a physician who understands the core balance of the human condition can be most valuable.

    However, it seems to me that doctors do not talk about death to their patients, not because they do not care, but because doctors do not know how to deal with the god, they only understand the animal. They are scientists who base decisions on anatomy, physiology and chemistry, which are the building blocks of the biological body.  Even psychiatrists talk about chemical imbalances causing depression.

    Doctors receive almost no training on the mechanisms, drives and weaknesses of the mind, where-in lies the god-like powers of man.  Like veterinarians who are unable to talk to their patients, doctors continue to focus on the body and despite their best efforts, do not offer desperately needed connection and support.  Paradoxically in their efforts to heal, they drive the body to a point that causes unneeded suffering.

    As long as the sole focus of physicians is on the animal body of man, they will have great difficulty having the kind of vital discussions needed to assist their patients at the end-of-life.  On the other hand, this offers a nearly infinite opportunity to reach out to the hearts of their patients. By connecting and supporting the primary emotional needs of the demi-god soul, physicians can help patients to live better.  This will require not only physician awareness of the possibilities, but training about drives and coping mechanisms.  Medical education needs to recognize that by understanding the primal needs of patients, and the complex psychic battles which each of us face, doctors can help provide quality life, even at its end.

  •  

     

    Recently one of us attended a daylong retreat designed to help doctors communicate more effectively with patients. The course was taught by a colleague with whom we had consulted in the past on patient-related matters but who was known better by his reputation, which was almost laughably stereotypical: brilliant technically, but stunted when it came to interacting with people.

    A close family friend with cancer had gone to see him some years back. When the friend started asking questions about the treatment plan, the doctor had stopped him midsentence, glared at him and said, “If you ask one more question, I’ll refuse to treat you.”

    “What could I do?” the friend later said. “He’s the best, and I wanted him to take care of me, so I shut up.”

    Now that same doctor greeted us as we filtered into the conference room by looking us in the eyes, smiling and shaking our hands.

    “Did you have any trouble finding the place?” he asked warmly, waiting for a response. Those of us who knew him were left speechless by his new demeanor. “Great! We’re going to have fun today. Why don’t you go get something to eat and grab a chair. I’m looking forward to working with you.”

    A wealth of research suggests that physician communication about important topics like end-of-life care is associated with a better quality of life for patients, and a better quality of dying, with less intensive use of unnecessary tests and treatments.

    Teaching communication skills to doctors, though, isn’t easy.

    Physicians and medical students often have limited insight into how they come across when talking with patients, and little opportunity for formal feedback. While most doctors really are invested in their patients making the right decisions for their circumstances, many lack the skills to show that they care.

    After all, their admission to medical school was not based on a validated assessment of their ability to relate to other human beings.

    In response to the growing recognition that effective communication with patients is a basic competency of our profession, and that doctors often have inadequate training in it, medical schools and hospitals have invested substantial resources over the past decade to teaching communication skills.

    But some place the blame for the stilted way we interact with patients squarely on the shoulders of our training, which teaches us methods for objectifying and quantifying symptoms. Prior to medical school, if we saw a neighbor fall and hurt their leg, we would likely run over and say. “Are you O.K? That looked painful. What can I do to help you?” As doctors, we ask, “On a scale of one to 10, how bad is your pain? What makes it worse? Does it radiate to your foot?”

    But can giving doctors a script for empathy actually make them more empathetic? Our patients know better.

    A recent study published in JAMA highlights the difficulties of teaching effective communication. In the study, 472 internal medicine and nurse practitioner trainees were randomly assigned to either participate in an eight-session, simulation-based communications course, or to forgo communications training. Patients with end-stage cancer and other fatal illnesses or their families then evaluated the quality of their caregiver’s communication and their end-of-life care. Patients were also evaluated for signs of depression.

    The results? Physicians and nurse practitioners participating in the course were no better at communicating or providing end-of-life care than those who did not receive communications training. And patients cared for by health care providers receiving such training were more likely to be depressed.

    How could this occur? It is possible that those receiving advanced communications training spent more time talking about impending death in their end-stage patients, and that this was depressing. Perhaps those residents participating in the study were too early in their training to lead these sorts of difficult conversations and participation in the study emboldened them in inappropriate ways.

    It is also possible that, as we devote more time to teaching students and doctors effective communication techniques, we risk muting their authentic human voices, and instead of learning to connect they apply rote tools and scripts.

    In the communications training course that one of us took, the doctor who at one time refused to take patient questions but who was now leading the course began speaking.

    “Today we’re going to review some techniques to better communicate with our patients,” he said. “This has really helped me in my practice and has made me much happier at work. And believe me,” he paused and smiled, “if I can learn to do this, anyone can.”

    He then turned to a woman who sat beside him, an actor who had been hired to play the role of a patient for the day, asking the same question we had heard before — “Did you have any trouble finding the place?” – before asking her what brought her here today.

    “I had a belly pain and my doctor told me I may need an operation,” she told him.

    “Go on,” the doctor said.

    “My doctor said I may have a tumor.”

    “Go on.”

    “But he said it’s curable with surgery.”

    “Go on….”

    It was hard to imagine relating to another human being like this. The doctor sounded stiff and his repetition of the phrase “go on” contrived, though he did encourage the patient to tell her story. And to ask questions.

    It was hard not to wonder what might have motivated this doctor to change his ways. Did taking the course cause him to “see the light,” and now he was truly a changed man? Or was he pressured into taking and then leading the course because of patient complaints?

    No communications course will magically transform lifelong introverts to hand-holders and huggers. At the same time, we must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care. Having physicians sound like customer service representatives is not the goal.

    For those doctors who are emotionally challenged, communications courses can provide the basics of relating to other human beings in ways that, at the very least, won’t be offensive. But for the rest of us, we should take care to ensure the techniques and words we learn in such courses don’t end up creating a barrier to authentic human contact that, like the white coats we wear, make it even harder to truly touch another person

  • Good medical care begins with good communicationAccurate and open communication is the beginning of good medical care. This is especially true for headache patients, because a correct diagnosis depends almost entirely on information the patient gives the doctor. Unfortunately, both doctors and patients can fail to express their thoughts clearly and accurately. Doctors may not clearly explain their diagnosis and treatment recommendations. Patients may not clearly express their fears and concerns about their headaches. Patients may also be so anxious that they don’t hear or understand what their doctor is telling them. Doctors often complain that they simply don’t have enough time to deal with all of the questions many patients ask. Unfortunately, patients may react by thinking that their doctors are ignoring their needs and concerns.Often, what doctors say is very different from what patients hear. For example, a doctor trying to reassure a patient that her headaches aren’t caused by a serious problem might say, “You don’t have any serious medical problems.” In response, the patient might think, “Oh no! Everybody thinks I’m faking my headaches. I can’t even find a doctor who takes me seriously.” Or, if the doctor explains that migraine is a condition caused by abnormal blood vessels in the brain, the patient might think, “Oh no! My uncle died of a burst blood vessel in the brain.”There is even a difference between what patients want most from their doctors and what doctors think patients want from them. A study has shown that what patients want most from their doctors is a willingness to answer questions and a willingness to teach them about their treatment. On the other hand, doctors think that what matters most to their patients is headache expertise and understanding and compassion.Both you and your doctor need to communicate clearly to effectively treat your headaches. Here are some simple steps you can take to improve your communication skills so your concerns are expressed and your needs are met.

    1. Stay focused on the most important questions.

    When you are first discussing headaches with your doctor, you will be asked many questions about symptoms, other illnesses, family history, and headache triggers. It takes a long time to answer these questions, but the information your doctor obtains is very important for reaching a correct diagnosis and recommending effective treatment. Don’t try to get all of your questions answered during the first visit. Decide what you need to know at this visit and what questions can be saved for a later visit.

    2. Learn as much as you can about your headaches.

    It’s important to understand your diagnosis. Ask your doctor directly, “What’s causing my headaches?” You should understand, though, that you may not get an answer during your first visit. Modern medicine is very good at figuring out what you don’t have. With headaches, it is often more difficult to figure out what you do have. Headaches are diagnosed by matching your headache description to typical headache patterns. When your headache pattern is not typical, this can be difficult. Your doctor may need to review old tests, order new tests, or confer with a colleague. Even if you don’t receive a specific headache diagnosis, this doesn’t necessarily mean that your headaches are caused by something serious or are not treatable. You can help by understanding as much as possible about headache types and what causes them. On the other hand, if you don’t describe your symptoms accurately, it might delay diagnosis. If, for example, you say your headaches come back several hours after treatment when you really have rebound headaches (which are caused by medication overuse), proper diagnosis and treatment might be delayed.

    3. Share your concerns and reactions.

    Don’t be afraid to rephrase what your doctor has told you to be certain you have understood it correctly. Doctors find it much easier to answer direct, specific questions like, “Do you mean to say I have a serious disease of the blood vessels?” Or, “I don’t think I’m depressed; I’m just very frustrated with these headaches, but my family doesn’t take me seriously.”

    4. Learn as much as you can about your treatment plan.

    Headache treatment can be complicated. Acute care medicines cannot be taken more than a few days per week, while preventive medicines must be used daily in order to work. Acute care medicines are taken to stop a headache that has already started, while preventive medicines are taken every day to prevent headaches from recurring. Some doctors will have their nurses explain medication instructions to you. Many patients find written instructions to be most helpful, so feel free to ask for them. Remember, you can also ask your pharmacist to answer any questions about your medication that weren’t answered in the doctor’s office.

    5. Build an open and trusting relationship with your doctor.

    Successful headache treatment depends upon an open relationship with your doctor. That relationship will be built over time. Your goal should be to have a few important questions answered during each visit, knowing that there will be future visits for addressing additional concerns.

    Both doctor and patient need to learn how to convey clear messages to each other. As a patient, you can help your doctor respond more clearly by asking direct, specific questions and making certain that you understand the answers.

    What you should expect from your doctor

    Duckro PN, Richardson WD, and Marshall JE.
    Taking control of your headaches. How to get the treatment you need.
    New York: The Guilford Press, 1995

    Any healthcare professional who is going to treat you for chronic headache should also be a person you feel comfortable with. The following are some characteristics that often contribute to a positive doctor-patient relationship. They are essential qualities in a comprehensive headache clinic. You have a right to expect such characteristics in the person to whom you are entrusting so much.

    Your doctor should:

    • Demonstrate genuine care for you and interest in your problem.
    • Be a good communicator, educating patiently and understandably.
    • Be able to discuss psychological factors without giving you the message that your pain is not “real.”
    • Be flexible and listen attentively to your questions and observations.
    • Adjust the treatment plan to reflect new information.
    • Not answer every increase in headache only with new or more medication.
    • Work patiently with you even when the headache does not lend itself to a quick solution.
    • Be willing to consider multiple factors contributing to the same headache problem.
    • Be ready and able to coordinate efforts with all other members of the treatment team, including you.
    • Include you in goal setting.
    • Take time — to listen to you, to follow through on coordination of treatment, to give you feedback, to educate you.

    What they say vs. what they mean: How doctors and patients can miscommunicate

    What They Say
    Doctor: Tell me about your headaches, Mrs. Jones.

    Patient: Well, it all started when I was 3 years old. …

    Doctor: Yes, yes, that’s fine. How frequent are your headaches? Do you have an aura?

    Doctor: I see you brought your MRI scan. I’ll show it to you. See, this is the brain, and this is the skull. And see these little white spots? They’re high-signal intensity abnormalities on T2- weighted images that can occur with headache.

    Patient: Oh.

    Doctor: Migraine is caused by abnormal blood vessels in the brain. Serotonin imbalance within the brain causes the blood vessels to react abnormally and cause headache.

    Patient: So will I need surgery? Is it serious? Is it fatal?

    Doctor: You don’t have any serious problem and you don’t need surgery. Are you depressed?

    Patient [with tears welling up in her eyes]: Not at all!

    Doctor: For people with your particular condition, we often use antidepressants. And we’ll have you meet with the psychologist. They have good treatments for you. Biofeedback and relaxation are also effective migraine therapies.

    Patient: How do I take these?

    Doctor: Just take one pill before you go to bed and I’ll see you back in 4 weeks.

    Patient: Okay. Before you go, I wanted to ask a few questions. Here’s a list I wrote down for you.

    Doctor: Here’s a couple of pamphlets and we’ll answer any questions you may still have at your next visit.

    What They Mean
    A new headache patient—and I’m already 20 minutes behind!

    I brought 10 years worth of charts for him to review and he never even looked at them!

    Doesn’t she realize I’ve already read 10 years worth of records about her? Why did she bring all of these if she’s going to tell me every detail that’s in them anyway!

    This is a normal MRI scan. There is no tumor or abnormal blood vessels. Often small white spots are seen in patients with chronic migraine, but they are not a sign of any disease or damage.

    Does he think I have a brain tumor? Are those spots an infection?

    Migraine is not serious. There is no reason to worry.

    Abnormal blood vessels! My uncle died of a brain aneurysm — is that what I’ve got? What’s serotonin, and how did I get it?

    She’s not even listening to me! She seems very anxious and high-strung. Could be a mood disorder — not unusual with chronic headache. Maybe that’s why she’s not focusing on what I’m telling her. Luckily some migraine medications treat both.

    Not again! My husband doesn’t believe me, my boss thinks I’m a faker. I can’t even find a doctor who’ll take my headaches seriously.

    She’s in denial. Maybe this mood problem is more serious than I thought! Antidepressants are great headache preventive medications, so that would be a good choice.

    He really does think I’m just crazy. I’ll try these pills and see if they help. I’m so desperate at this point I’d try anything!

    She needs to take this every day for several weeks before it will work.

    I wonder what the side effects are. I’ll take it a couple of times and see if it works.

    She brought 4 pages of questions! I don’t have time to answer 4 pages worth of questions today…

    Dawn A. Marcus, M.D.

  • It’s something patients have grumbled about for a long time. Doctors are rude. Doctors don’t listen. Doctors have no time. Doctors don’t explain things in terms patients can understand.It’s a familiar litany. But here’s what is new: The medical community is paying attention.That lack of communication, after all, isn’t just frustrating for patients. It can hurt the quality of care, drive up costs and increase the risk of lawsuits. And under new Medicare rules, providers won’t get as much money if they rack up poor patient-satisfaction scores or too many preventable readmissions.So, medical schools, health systems, malpractice insurers and hospitals are trying to help doctors improve their bedside manner. They’re setting up education programs for everyone from medical students to seasoned pros who have spent years talking to patients. The efforts take a variety of innovative approaches, such as putting doctors through role-play sessions with actors to teach basics like always facing the patient, letting them speak uninterrupted for two minutes and using key words to show compassion and empathy. (“I am so sorry you are in pain.”)

    More than a third of pest-management companies in the U.S. were called in by hospitals in 2012 to exterminate bedbugs, according to a new survey by the National Pest Management Association. MarketWatch’s Jim Jelter reports. (Photo: AP)

    “We can’t make things better unless you train physicians in these skills,” says Robin DiMatteo, a researcher at the University of California, Riverside.

    While long thought of as a “soft” science, communication is increasingly understood to be at the root of many of health care’s failures—and a leading culprit in rising costs.

    Research shows that when doctors don’t listen to patients, they miss important health cues and misdiagnose illness. Meanwhile, patients who don’t understand what their doctors say fail to follow their regimens, leading to preventable hospitalizations, complications and poor outcomes. And a breakdown in physician-patient communication is cited in 40% or more of malpractice suits.

    “If a doctor and patient have a strong relationship, even if something goes wrong, they are less likely to sue for it,” says Robin Diamond, chief patient safety officer at Doctors Co., which provides malpractice insurance for 73,000 physicians.

 

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