A recent Commentary in JAMA, Patient-Physican Communication: It’s About Time, by Wendy Levinson, MD, and Philip A. Pizzo, MD, is a critical call for physicians to be taught how to talk to and engage patients. It may seem silly that promonent academic leaders need to say this even now, but it still rings true. In our current fragmented care, where provider time is at an all time low, it’s ever more important.
Just last week I worked with a resident who was clearly irritated by a patient. “He’s basically a healthy guy” he said, “but he brings in pharmaceutical ads, and he underlines all these words…..and it takes so long to go over everything and some of these aren’t that important.” Not lost on the huge teaching moment here, I thought carefully about how to persuade the resident that this engaged, activated patient is the goal in healthcare, and that listening to the patient’s concerns would not only help the patient-physician relationship, it would improve patient satisfaction and lead to better outcomes. I tried not to dwell on the lost opportunity to model the ideal conversation, or videotape resident encounters so as to offer feedback. So I talked about how important it is for providers to encourage patients to ask lots of questions, and said patients searching online (or offline) for answers is great, and that it’s OK to just reasure or re-direct. With residents needing “the evidence”, I assured him that research on this was ample.
Back to the JAMA commentary. Wendy Levinson is a favorite role model of mine, a fantastic researcher and leader in medicine. Years ago I had the privilege of practicing general internal medicine alongside her at Legacy Health Systems in Portland, Oregon. A key influence in my decision to head to Seattle for a research fellowship, Wendy left Legacy (Portland’s loss) and is now Chief of Medicine at the University of Toronto. She is a force in medical education, driving for better physician-patient communication. Her research, The Relationship With Malpractice Claims Among Primary Care Physicians and Surgeons, found fewer malpractice claims among primary care doctors who encouraged patients to talk, had more humor and spent a bit more time in visits. Her work is legendary, quoted by Malcom Gladwell in his book “Blink”.
Wendy’s Commentary is so important, I’ve excerpted some here:
Effective communication with patients takes time. ‘Active listening,” a core skill in effective communication, requires that physicians listen deeply to patients telling the stories of their illness and how it has affected them. Most physicians in clinical practice, as well as faculty members in academic medical centers, express a desire to spend more time with patients, but acknowledge that they are under intense pressure to be productive, measured in numbers of patients observed in units of time. Perverse incentives have contributed to physicians developing “efficient styles” that squeeze out time to listen because it is perceived to take too much time. Frequent handoffs in transitions of care, increasingly common today, make time to connect with patients even more challenging. Second, medical schools and residency programs provide relatively little education about effective communication skills compared with the educational time devoted to teaching science and technology. Furthermore, medical students and residents are rarely observed during their interactions with patients or given specific feedback to improve their communication.
The authors call on policy makers and accrediting bodies to remedy the situation. Here’s a few of their ideas –
– Reward faculty for patient-centered care innovations and science
– Have transparent peer and patient communication skill reporting
– Use validated measures on patient satisfaction
– Increase trainee communication standards, require competence
– Teach advanced communication skills
– Celebrate excellence in communication
– Have reimbursement that incents great communication
This list is critical but insufficient to achieve true Participatory Medicine. There is another key ingredient. Patients, consumers, family members and informal caregivers must be brought into the design of these changes – even (especially) in academic medicine. We don’t want just patient-centered care, we want patient-centered design. Organizations such as the Society for Participatory Medicine should position themselves to help academics and healthcare build a better design…and make sure we get to the right place – finally.