Time-Efficient, Evidence-Based Ways for Better Communication with Patients
Luckily, we have put to rest the question of whether evidence supports the efficacy of patientcentered care. A wealth of articles describes the impact of patient-centered care not just on
patient satisfaction and quality of life, but also on hard outcomes such as blood pressure
control, cardiac mortality, and costs of care.1 This evidence is particularly strong in those
studies that used a behavior-based definition of patient-centered care – meaning approaches
that define, group, and sequence physician behaviors have the best chance of meaningfully
impacting patient outcomes2.
In the past, many physicians have dichotomized evidence-based medical care (mainly
prescribing medications) on the one hand, and fuzzy, feel-good patient communication on the
other. Good communication has been deemed desirable, perhaps, but incidental to good
medical care. This stance is clearly outdated. Patient coping, lifestyle changes, and adherence
are becoming more and more important. Physicians realize that pills do not jump into patients'
mouths by themselves, and that there is a science and an art to changing behavior. And even
though most of us already have good relationships with patients, evidence suggest that most
of us also have room for improvement.
However, most physicians feel rushed and under time pressure as it is, and do not want to try
out communication strategies that will slow down their schedule. So what are some ways that
are likely to improve communication, and actually enhance efficiency? I have listed four
below that I have found time efficient and useful: Negotiating the agenda for a visit, asking
“what else”, following validated sequences for difficult conversations, and engaging patients
in conversations about their preferences.
Avoiding door-knob moments – Agenda setting “let’s make a list”
Most physicians have made this experience – you are almost done with a patient visit, when
the patient, with their hand on the doorknob, suddenly mentions “by the way, Doc, I get these
horrible chest pains when I walk a few blocks (or insert any other alarming symptom from
your specialty)……”. Hearing such an alarming symptom, you will have to spend quite a bit
For examples, see: Williams GC et al. research on relationship-centered care and health care outcomes from the
Rochester Biopsychosocial Program, Fam Sys Health 2000, 18:79-90; Stewart M et al. The impact of patientcentered care on outcomes. J Fam Pract 2000,49(9):796-804; and Hojat MP et al.: Physician’s empathy and
clinical outcomes for diabetic patients. Acad Med 2011,86(3):359-364.
2
Smith RC et al.: Behaviorally defined patient-centered communication – a narrative review of the literature.
JGIM 2011; 26(2):185-191
1
of time taking additional history, doing an additional exam, and arranging for urgent
evaluation of this patient. At this point, the schedule for the day is usually off wrecked. These
doorknob moments often are irritating for physicians, because they would have spent their
time differently if they had known about the alarming symptom; they can also unsatisfactory
for patients if they notice the rearrangement of schedules, and there is less time for them.
Deciding the topics for the visit is called agenda setting. For agenda setting, many clinicians
ask “What brings you in today?” and then focus on the first answer. But: patients RARELY
mention their most important concern first. So when the clinician zeroes in on the first
concern, that increases the chances for a door-knob moment. Instead, elicit the entire patient
agenda, and with it the most pressing concern, by suggesting “let’s make a list of all the things
you want to discuss today.” After concerns have been listed, you can make sure everything is
on the table by asking “is there something else?”, or “How did you hope that I could
help/What would a good result from this visit today look like?”3 You may not have time to
discuss all the agenda items the patient has. But at least you have a chance to prioritize among
them once you know what they are.
Improving accuracy of information gathering – What else?
The medical interview is the physician’s most important diagnostic procedure4. However, if
the physician jumps in prematurely with closed questions, important information can be lost.
One helpful technique for those situations can be to ask “what else” 3 times5:
Physician Centered
Patient Centered
Physician: What brings you here today?
Patient: I have headaches.
Physician: Where are the headaches? How long do they
last? What do you do to relieve them?
Physician: What brings you here today?
Patient: I have headaches.
Physician: What else?
Patient: Well, I have problems sleeping.
Physician: What else?
Patient: I am very worried about my son. He is
using drugs.
Asking “what else” is a very quick way to gather additional information, and you can switch
to closed questions easily after having asked what else three times.
Follow a validated sequence for difficult conversations – prognosis
Fortin AH et al.: Smith’s Patient-Centered Interviewing – An Evidence-Based Method. 3d ed. McGraw Hill
2012, p. 312
4
Frankel RM, Stein T: Getting the Most out of the Clinical Encounter: The Four Habits Model. The Permanente
Journal 1999; 3(3); accessed at xnet.kp.org/permanentejournal/fall99pj/habits.html on 5/6/2013
5
Barrier et al. Two Words to Improve Physician-Patient Communication: What Else? Mayo Clinic Proceedings
2003;78:211-214
3
For many patients and physicians, conversations about prognosis can be difficult and
uncomfortable. There is a fine line between taking away all hope and making sure patients
don’t have unrealistic expectations. Anthony Back and his group have collected many
validated ways of talking about this and other topics to patients, and published annotated
example conversations. One example follows below6:
Speaker Conversation
MD
Would you like to talk about the
prognosis for this kind of cancer?
What kind of information would
you like me to cover?
PT
I need to know how long I’m
likely to live. I have plans.
MD
If you don’t mind telling me a bit
about your plans, I might be able
to give you information that is
more useful
PT
We have a trip planned (…) in the
fall, and my granddaughter is
graduating in the spring
MD
OK, that’s helpful. So I think it is
very likely you will be able to go
on your trip, since that is coming
up in a few months. I even think
you have a reasonable chance of
making your granddaughter’s
graduation (…)
PT
(Silent)
MD
Is that what you were expecting?
Commentary (Physician thoughts in italics)
The opening question
He is a patient who wants explicit information
Negotiating the content of the discussion
This is the personal context for the
information
Providing the information
What is he thinking?
Acknowledging the patient’s reaction by
empathetic exploration
PT
MD
I am just relieved, I guess
I know that talking about
Another empathetic response
prognosis can be …, well, touchy
MD
Do you want to discuss more
today?
PT
Not really. But I might another
time
MD
So tell me what you’re going to
Checking for understanding
tell your wife about this
conversation.
Excerpt from: Table 1 from ref. 5 Back AL and Arnold RM; MD: physician, PT: Patient
Diagnosing preferences correctly: What is most important to you?
6
Back AL and Arnold RM: Discussing prognosis. J Clin Onc 24(25;1):4209-4213
Studies have shown that there are large gaps between what patients want and what doctors
think they want7. For example, in one study, doctors believed that 71% of patients with breast
cancer rated keeping their breast as a top priority. The actual number reported by patients was
just 7%6. These gaps are particularly important in conditions where the right treatment
decision depends on tradeoffs between life expectancy, side effects, and risks of invasive
procedures, such as prostate cancer in men with limited life expectancy, surgery for
degenerative joint disease, or the treatment of chronic stable angina. Matching treatment
options correctly to what a patient prefers is associated with higher compliance, more
satisfaction, and a more efficient use of healthcare monies.
One efficient way of structuring a conversation about treatment choices is to use decision
aids.8 Elwyn et al. recommend that a conversation around treatment should have the following
steps:9
1. Choice Talk: “Now that we have identified the problem, it’s time to think about what
to do next. (…) Treatments have different consequences…. Some will matter more to
you than to other people…. Treatments are also not always effective, and the chances
of experiencing side effects vary.
2. Check reaction: “Shall I tell you about the options?”
3. Option Talk (and provide decision support, if available)
4. Focus the patient on preferences: “What, from your point of view, matters most to
you?”
5. Decision Talk: Are you ready to decide?
Obviously, there are many other ways to engage patients and save time. If you have tried out
other techniques that you have found helpful, please email me (address below). Another place
where physicians can exchange information about ways to improve communication is at
www.planetreegrove.com. Physicians who work at Planetree institutions can sign up free of
charge for membership at the site.
Dorothea Wild 5/6/2013. dwild@planetree.org
7
Mulley AG et al.: Stop the silent misdiagnosis: patients’ preferences matter. BMJ 2012;345:e6572
I will write about those in a later article
9
Elwyn et al.: A Model for Shared Decision Making. JGIM 2012;1361-1367.
8