How touch and talk can help you connect with patients
From the November ACP Observer, copyright © 2003 by the American College of Physicians.
By Christine Kuehn Kelly
The physician sits down on a chair facing the patient and asks about her osteoarthritis. Was it keeping her from playing with her grandson? Would it affect her upcoming trip family to Disney World? Only after a few minutes did the doctor actually look at the patient's knee.
If you think this sounds like an unusual patient visit, you're right. What physicians, after all, take time to talk to patients about vacations and the emotional impact of illness?
According to research published last summer, the answer to that question is simple: osteopaths. A study in the July 2003 Journal of the American Osteopathic Association found that osteopaths were more likely to discuss preventive measures specific to the patient's complaint; talk about how the patient can improve the condition; discuss how health issues affect family life, social life and work; ask about the patient's emotional state; and talk about alternative therapies the patient was using.
Researchers found that allopaths, on the other hand, were less likely to initiate these discussions but were more likely to discuss scientific literature or the scientific basis for a problem.
While the study didn't try to evaluate whether these differences led to better outcomes, many osteopathic physicians firmly believe that a relaxed and open style of communication is bound to improve the doctor-patient relationship—and, as a result, patient care.
"I'm convinced that many chronic illnesses affect a patient's ability to work and socialize," said Timothy S. Carey, FACP, lead author of the study and professor of medicine at the University of North Carolina at Chapel Hill. "We need to ask patients how their illness is affecting their lives."
While osteopathic educators emphasize what they call a "whole body" approach to practicing medicine, they say anyone can learn the technique. "It's a learned response," said H. James Jones, DO, assistant professor of internal medicine/neurology at Western University of Health Sciences College of Osteopathy in Pomona, Calif.
We talked to some osteopaths and allopaths about how to better communicate with patients. Here are some of their suggestions:
Avoid jargon. When talking to patients, many residents make the common mistake of speaking in a language patients can't understand, according to Darren A. DeWalt, ACP Member, a Robert Wood Johnson fellow at the University of North Carolina at Chapel Hill.
"We've just learned a new language that has made us able to understand medicine and communicate with other health care providers," he said, "but this language is not of particular interest or even helpful to patients." After rounds, he frequently asks residents if they think the patient was really able to understand the terms they just used.
Words that may muddle your message—and some alternative phrasings—include: hypertension (use high blood pressure); benign (won't cause harm, noncancerous); lesion (wound, sore); and procedure (operation).
Communication experts also discourage residents from using words that require judgments, such as "excessive," "progressive" or "moderate." His advice: Use an example instead of an adjective.
Talk to patients at eye level. Whenever possible, sit at the same level as patients so you can look them in the eye. Besides making sure that patients see you, this strategy can remove another barrier to communication: poor hearing.
"Be sure you are seated in a position that makes it possible for patients to look directly at you," said Thomas A. Cavalieri, FACP, an osteopath who is chair of the department of internal medicine at the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine. "Although you may not be aware of it, some patients may be lip reading."
Let patients choose the agenda. When you can't cover all problems in one visit, let patients set the agenda. "This helps reduce the 'by the way, doc' questions when you are leaving the exam room," said Sunil Kripalani, ACP Member, an assistant professor at Emory University School of Medicine in Atlanta. You'll also feel less rushed when you have a manageable number of issues to address.
Consider illiteracy. When residents complain that a patient isn't taking his medications, Dr. DeWalt often asks a simple question: Can the person read?
"About 20 % of our patients read at less than a third-grade level," he said. "It's important to recognize that many older patients are smart but didn't have the educational opportunities we had."
Ruth M. Parker, FACP, a health literacy expert and assistant professor of medicine at Emory, said that physicians won't see illiteracy unless they look for it. Nevertheless, illiteracy is widespread in the United States. An estimated 40 to 44 million Americans are functionally illiterate, while another 50 million have marginal literacy skills that make it difficult to read or calculate numbers.
You can communicate with functionally illiterate patients by using visual models to illustrate a procedure or condition and by asking patients to "teach back" the information you communicated to them. To teach back patients, Dr. Parker suggests telling patients you want to make sure you understand each other. Then ask them to repeat back to you what has been said. Demonstrating procedures patients may need also is useful.
Don't be afraid to touch patients. While the power of touch can put a patient at ease or console someone who is hearing bad news, physicians just starting out are often reluctant to touch patients, said Western University's Dr. Jones. A handshake or a light touch to the forearm or hand can convey your concern and respect for the patient's feelings.
Be sensitive about names. Respectful use of last names is important for older patients and many ethnic groups. Osteopaths are more likely than allopaths to use first names to create a more personal atmosphere, but such familiarity should ultimately be left to the patient.
"I generally tell residents to call patients by their last names," said Chapel Hill's Dr. Carey. "I let my patients make the first move if they want to be less formal."
Use your time with patients wisely. If you have only 10 to 15 minutes to spend with a patient, make sure the time belongs exclusively to that individual. Minimize or eliminate interruptions by closing hospital room curtains or the exam room door. Likewise, make sure you don't take pages or phone calls.
Being on time for patients in clinic also shows you consider them important. Because waiting in exam rooms invariably causes ill will, try to build in a little extra time in your schedule to help take up the slack when other activities intrude.
And if you can't help running late, don't be afraid to let patients know. Make a point of letting them know that no matter how busy you are, their problems are important to you.
When patients themselves are late to clinic, treat them with dignity by asking if they would like to wait for you to finish with the other patients or reschedule.
Multitask. "Talking to the patient during the exam is difficult, but it can be learned," said Dr. Jones.
When examining a patient's ears or throat, you can ask related questions and enter that information into your "mental computer," he pointed out. This enhances your image as a caring practitioner focused exclusively on the patient.
Finally, "The most successful doctors I've worked with are the ones who learned to carefully listen to their patients," Dr. Jones said. "If you listen, patients often will give you the diagnosis."
Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.
If you're looking for an easy way to strengthen your patient communication skills, you might consider focusing on three simple questions.
"Ask Me 3" is a set of three short but essential questions that patients should be able to answer after every visit to the doctor. The questions were developed by the Partnership for Clear Health Communication, a coalition devoted to improving health literacy. (More information is online.)
According to the literature from the Partnership, providers should encourage their patients to understand the answers to:
What is my main problem?
What do I need to do?
Why is it important for me to do this?
"Getting in the habit of covering these questions would be a step forward in patient communication," said William T. Branch, MACP, professor of medicine at Emory University in Atlanta, who has a longstanding interest in patient-provider communications. "Often we end our patient interviews by trailing off the discussion and handing over a prescription or setting up another appointment."
Asking patients if they understand the answers to these key questions will end the encounter on a stronger note, he explained. It will also give patients the opportunity to ask questions.
When patients understand their diagnosis and treatment plans, they are more likely to feel valued by the physician and comply with instructions. Interactions also become shorter and more focused: When given the chance to ask questions, patients typically talk for only two to three minutes, according to the Partnership.
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