Taking communication skills seriously


Poor communication during a hospital stay can lead to dissatisfaction among patients, families, and clinicians, but most physicians get little training in how to communicate well. That's slowly changing, however, as some hospitals roll out formal training programs based on evidence about communication skills.

“The quality of physician communication is highly correlated with our overall patient satisfaction scores,” said Kevin O’Leary, MD, MS, FACP, chief of the division of hospital medicine at Northwestern Memorial Hospital in Chicago. “Clearly patients really care about their interactions with physicians, and their adherence to recommended follow-up after discharge has a lot to do with their ability to understand and trust their providers.”

Photo by Thinkstock
Photo by Thinkstock

Launching a communication training program can be challenging, however. First, physicians have to be convinced that attending a daylong training workshop or ongoing class is worth taking time out of their busy schedules. Formal training may also conflict with some long-held cultural beliefs, noted Adrienne Boissy, MD, chief experience officer at Cleveland Clinic Health System's main campus in Ohio.

“There is often an unspoken assumption among physicians that they already communicate very well, and that empathy and effective communication can't be taught,” she said. “It's not easy to engage people in training for skills they don't think they necessarily need or believe they already have.”

Most studies to date on the impact of formal training, including a 2013 effort led by Dr. O’Leary at Northwestern, have been small and failed to tie communication training to significant improvements in patient satisfaction scores. However, results from a study at Cleveland Clinic—the first large-scale analysis of the issue—suggest that formal training can be effective on a number of fronts.

The findings, reported in the February 2016 Journal of General Internal Medicine, show that inpatient HCAHPS scores improved and outpatient patient satisfaction scores increased to an average of 92% for the more than 1,500 physicians who participated in the training compared to 91% in a matched control group. Although the changes may appear small, the authors noted that absolute improvements of 1 to 2 points in patient satisfaction can translate into substantial changes in percentile rank and revenue under Medicare's value-based payment system. Participating physicians also reported significant improvements in empathy and burnout.

“This was the first study of this scale to look at a very specific intervention and its impact on validated metrics,” said Dr. Boissy. “Investing in communication skills training can not only have a return on investment for hospitals, but also significantly increase physicians' job satisfaction.”

Getting started

Before launching a training program it's critical to get buy-in from leadership and physicians, said Calvin Chou, MD, PhD, vice president of external education for the nonprofit American Academy on Communication in Healthcare (AACH), based in Lexington, Ky. To make that easier, start with a voluntary pilot program and enlist division champions to spread the word about the benefits, he recommends.

“Instituting a skills program can be a huge change because you're fundamentally changing the way people talk with each other,” he said. “Before you can address the [satisfaction] scores, you've got to change the culture.”

At Cleveland Clinic, Dr. Boissy and study coauthor Katie Neuendorf, MD, a palliative care specialist who runs the communication skills program, began by regularly providing physicians with their individual patient satisfaction scores. After receiving the scores, physicians often became more receptive to courses to help them improve.

“No matter how brilliant or creative your [communication] program is, physicians won't come unless they're receptive to learning,” said Dr. Boissy. “There is a lot of strategy involved in getting people into the chairs and engaging them once they're there.”

It's also important to establish overall objectives for the course to guide development of the format and content, said Dr. Neuendorf.

“We knew from the outset that our end goal was to make sure physicians had the tools they needed to build relationships with each other and with patients,” she said. “Moving patient satisfaction scores wasn't our objective. We knew that if we gave people the right tools, their own relationships would be richer and an enhanced patient experience would follow.”

At the University of California, San Francisco (UCSF), Diane Sliwka, MD, medical director of patient and provider experience, used a model developed by the AACH, which provides communication resources and facilitates onsite workshops for health care professionals.

“We wanted to provide skill-based training where people walked away with something they could use the next day,” said Dr. Sliwka. “We're presenting them with a new framework for communicating, based on taking the patient's perspective into account and meeting patients and families where they are versus focusing on what the provider needs to get out of an encounter.”

Most physicians have no established framework for patient communication beyond a few skills they picked up in medical school, noted Dr. Chou. On top of that, many physicians eventually struggle with burnout, which interferes with their ability to connect with patients on a personal level.

“Communication courses should enhance the ideas of compassion and empathy that are so important to medical practice,” said Dr. Chou. “It starts with teaching a few simple skills, like greeting the patient when they walk into the room and making sure they understand what's happening.”

The focus should be on acquiring skills versus passive learning, added Dr. O’Leary. “Physicians have to practice communication skills and get feedback in order to improve,” he said. “This is not just about reading a book or listening to a lecture.”

Finding the right format

Creating a successful program requires balancing content with time, said Dr. O’Leary. Physicians should see the training as a worthwhile time commitment and not overly burdensome.

Based on input from division leaders at Northwestern, Dr. O’Leary opted for a 3-part format, with the first session taking place during hospitalists' regularly scheduled division meeting on Friday afternoons. The introductory session was held on 3 consecutive weeks to ensure that everyone had an opportunity to attend.

Dr. O’Leary led the first session, giving an overview of patient satisfaction measures and the Acknowledge, Introduce, Duration, Explanation, and Thank You (AIDET) training model, developed by Studer Group. The second session, facilitated by staff in the patient experience department, included small-group role-playing and expert feedback. Part 3 offered personal coaching and feedback from unit medical directors in the clinical setting.

“We got the majority of our group to participate by using an existing meeting and making participation an expected part of physicians' jobs,” said Dr. O’Leary. “Since we didn't have a separate budget for this, we leveraged the skills of our medical directors and existing staff.”

Other hospitals have daylong workshops rather than separate sessions. Cleveland Clinic, for example, developed an 8-hour skills training workshop based on the CME-accredited Relationship: Establishment, Development, and Engagement (REDE) model, using AACH's teaching methods. Each session was led by 2 trained clinician facilitators and included a maximum of 12 participants.

The day's agenda included improv, brief videos, interactive presentations, and skills practice, among other methods. Physicians could sign up for additional sessions focusing on specific communication challenges.

Having skilled facilitators is crucial, whether they are brought in from outside or trained internally, said Dr. Neuendorf. “We spend a lot of time with our facilitators making sure they model the skills we want to teach,” she said. “The idea is to facilitate learning, not to dictate it.”

UCSF also opted for a day-long workshop format, where physicians spend most of the time in small groups practicing communication skills with peers and getting feedback from facilitators, said Dr. Sliwka. The day is divided into 3 sections that focus on skills used in the beginning, middle, or end of a typical patient encounter. During the final hour, the facilitator brings everyone together to role-play a particularly challenging clinical scenario.

To start, physicians practice simple techniques, such as greeting the patient, said Dr. Sliwka. By the end of the day, they are prepared to tackle more challenging situations, such as how to talk with the mother of a critically ill child who is angry or distrustful of the care team.

“Difficult encounters cause physicians a lot of angst,” she said. “Having the skills to deal with them effectively can help alleviate their anxiety and frustration.” Additional skills are offered through longitudinal “booster” courses and 1-to-1 coaching at the bedside, Dr. Sliwka noted.

Seeing a difference

Physicians often come into the classes believing that they already handle routine situations pretty well, said Dr. O’Leary. However, many discover flaws in the standard scripts they've been using to communicate.

For example, Dr. O’Leary used to leave a patient with a brief “See you later” but realized after taking the course that patients probably wanted more specific information. Now, he makes sure they know that, even though he may not return to their room later that day, he will be checking on their test results and talking with other care team members throughout the day.

“Many of us were saying the same thing over and over without ever reflecting on how it impacted the patient,” he said. “Patients want to know what's likely to happen during the day and what they should do if they have questions.”

For many physicians, participating in training illuminates “blind spots,” said Dr. Chou. It gives them an opportunity get feedback about their communication style, which is rare in regular practice.

“Most physicians are doing a wonderful job in the patient encounter but need to shore up those areas where they can be even more effective,” he said.

Communication skills training allows physicians to better connect with patients, which is crucial to their ability to perform their jobs well, added Dr. Sliwka.

“When physicians can connect with patients and feel good about that interaction, they reconnect to the human aspect of care,” she said. “When that happens, many other frustrations pale in comparison.”