For orthopaedic surgeons, effective communication with patients should
be an area of concern. In a study on the office practices of orthopaedic
surgeons, Levinson and Chaumeton determined that the mean duration
of an office visit was thirteen minutes and that the surgeons talked
more than the patients did1. They
also observed that, even though a substantial amount of patient
education occurred during these visits, orthopaedic surgeons infrequently
expressed empathy toward the patient and usually asked only closed-ended questions,
allowing for only brief social conversation. According to Vaughn
Keller, Associate Director of the Bayer Institute for Health Care
Communication, the problem often starts within seconds of a consultation: the
patient starts talking about a problem (usually not the important
issue, which the patient is saving for toward the end of the visit)
and the doctor interrupts within eighteen to twenty-four seconds
and begins firing a series of questions at the patient. The big
issue, therefore, never gets discussed2.
The role of effective physician-patient communication
in achieving the best medical outcomes and promoting patient satisfaction
is well established in the literature and is confirmed by our personal
experience as physicians. In a public opinion survey on what makes
a good doctor, conducted by the American Association of Medical
Colleges, the participants indicated that important attributes of
the physician were a caring attitude and communication skills (85% of
participants), the ability to explain complicated medical procedures
(77%), good listening skills (76%), and an open
mind about alternative therapies (29%)3.
The importance of communication has received a great deal of attention
among primary-care providers but little attention until recently
among specialists, especially surgeons. Research in the primary-care
setting has established that effective communication enhances patient
recall of information, compliance with instructions, satisfaction,
and psychological well-being and it improves outcomes1. New knowledge about the impact of
ethnicity, age, and gender on health-care utilization has further
confirmed these observations1.
There is no doubt, according to Levinson and Chaumeton, that a trusting
relationship between a physician and a patient is the bedrock of
medical care1. The purpose of
communication is not to convince the patient to do what the physician
desires but to understand the patient’s concerns and to
make decisions acceptable to both the patient and the physician1.
As we move to a consumer-driven health-care system in which patients
expect to understand their medical problems, their treatment options,
and the relevant outcomes data as well as to participate in decisions
about their care, we must be ready to answer their questions. We
must be prepared to provide both information and judgment about new
technologies, alternative treatments, interpretation of medical
data, new pharmaceutical products, and the impact of genomics on
their conditions and treatment options. We must communicate effectively.
Managed care and information technology have altered our practice
of medicine and the management of our offices. We must constantly
reassess the impact of these changes on our ability to communicate with
and to establish relationships with our patients and to carry out
the duties of our profession. Adherence to the core elements of
professionalism—that is, altruism, accountability, excellence,
duty, honor, integrity, and respect for others—is not possible
in the absence of effective communication between physicians and
patients and between physicians and their colleagues.
Not surprisingly, observations about the inability of physicians to
listen carefully and to communicate effectively with patients can
be found throughout the medical literature. In his Presidential
Address to the American Orthopaedic Association in 1987, Goldner
noted that communication was one aspect of the art of medicine that
required improvement4. He described marketing studies that showed that
patients were impressed by the tone of voice, body movement, and
actions of the physician as well as by factual information. He suggested
that the physician should "look in the mirror occasionally" and
carefully review his or her habits and mannerisms. He went on to
state that our time is "our most valuable asset," recommending
that we learn to use our time efficiently without sacrificing our ability
to listen carefully, think logically, and respond with compassion
and reasonable actions. In order to cope adequately
with patients and their problems, he recommended that we "don’t talk
down to the patient; don’t use complex terminology for explanation;
don’t coax the patient to have a procedure; don’t
exaggerate the severity of the musculoskeletal problem; don’t
belittle the patient who is already frustrated, anxious, or indecisive;
and don’t become exasperated with questions . . . don’t
ignore telephone calls; don’t perform cursory examinations;
and don’t let the patient’s personality affect
you adversely. Remember the patient is sick, not you." Dr.
Goldner emphasized that "finances should not be primary
in establishing the attitude of the physician toward the patient." Referring
to the Hippocratic oath, which, written over 2600 years ago, described the
physician’s obligations to his patients, he challenged
us to think about the orthopaedist’s behavior and he asked: "Where are
the courses, the update information, the dogma, and the emphasis
concerning attitude and behavior and interpersonal relationships?"
Despite Dr. Goldner’s insights and admonitions, there
appears to have been little, if any, formal response to these issues
in current residency training or in the continuing medical education
of orthopaedic surgeons. Managed care is putting new pressures on physician-patient
communication and on the role of information in that relationship.
For these reasons, the importance of effective communication by orthopaedic
surgeons and the strategies for achieving it is a renewed concern
for the leadership of the American Academy of Orthopaedic Surgeons
and other national organizations involved in the education of new surgeons
and the continuing education of practicing surgeons.
As a profession, we are reacting to many highly publicized issues that
damage the public’s trust, including fraud and abuse, conflict
of interest, inadequate informed consent by patients, perverse financial
incentives, fierce market competition, and, in extreme cases, criminal behavior.
The Institute of Medicine’s report entitled "To
Err is Human" notes many unnecessary deaths resulting from
medical care5. Part of the solution to deficiencies in the patient-physician
relationship, not to mention in medical care, is attention to the
problems with the system as well as to the core elements of professionalism.
Wynia et al., who addressed this issue in a recent editorial, stated
that a physician’s behavior could be understood with respect
to three areas: (1) devotion to medical service, (2) public profession
of values, and (3) negotiation of social priorities that balance
with medical professional values6.
With regard to devotion to medical service, they noted that physicians
should place the goals of individuals and public health ahead
of other goals. They must be devoted to the work of providing
care and must remain motivated to work hard even when financial
rewards for such work are not great. With regard to public profession
of values, they noted that the word "profession" means "speaking
forth." Physicians should speak out about their values,
which we have been lax in doing. We must also accept responsibility
for our individual professional actions as well as the shared standards
of our profession. Finally, with regard to negotiation of social priorities
that balance with medical professional values, they observed that professionalism means
that there is a social contract between physicians and
the public. The challenge for physicians is to maintain their continued accountability
to the public and its changing values while protecting core health-care
values.
In recognition of the long-term consequences of an eroding public
trust, there is considerable interest among physician
leaders in reinvigorating medical professionalism. Physicians are
noted for their technical expertise, which is exceptional,
but our attempts at self-regulation are replete with failures.
Rothman7, ix a recent editorial,
noted several ways to promote and implement professionalism:
· Relationships between pharmaceutical companies and
physicians and professional organizations should be publicly disclosed.
· Explicit guidelines are needed to implement and enforce
professional standards in our training programs and in our professional societies;
standards of behavior including service to all patients (i.e., free
care) should be required, not recommended.
· Professional associations should form alliances with
consumer groups to improve quality of care, implement professional standards,
and provide care to underserved populations.
· Medical schools and training programs should teach
skills that promote professionalism.
· Medicine as a profession must encourage and protect
whistleblowers so that it is not dependent on outsiders to identify
and publicize problems.
· Professional organizations need to expand their agenda
on lobbying and advocacy so that they do not conform only to the
members’ special interests.
· Professional societies, medical schools, and teaching
hospitals should have policies to minimize the influence of pharmaceutical companies.
By adhering to these principles, physicians would begin to restore
the public’s trust in our profession.
The Internet is providing health-care consumers with unprecedented
anytime and anyplace access to the full range of health-care information—i.e.,
new technologies, clinical trials, physicians’ training,
and quality measures. This access to information is effectively
converting the health-care system from one that is physician-driven
to one that is consumer-driven. As of 2000, there were over 17,000 health-care
web sites, and twenty-five billion transactions occurred annually
on these sites8. While the information
available on the Internet offers many new opportunities for patients
to participate more effectively in choices about their providers
and treatment options, it also creates many new challenges for physicians
with respect to the way that they communicate with their patients.
No longer are patients relying solely on the information provided
by their physicians. Physicians must anticipate patients’ concerns
and be prepared to explain and reconcile information presented by
the patient.
Power, in a keynote address to the Academic Practice Assembly of
the Medical Group Management Association in 2000, described a power
shift to the people, voters, and consumers8.
With new sources of information, consumers are becoming increasingly
educated and able to "go around the system" to
find what they want. Figure 1 shows the type of health-related information
currently being sought online. Interestingly, patients/consumers
are most likely to seek information about specific diseases and
treatment options—information that has been traditionally
provided by physicians. What seems clear is that consumers are increasingly prepared
to demand what they want, where they want it, and when they want
it. Power noted that patients (enrollees) or consumers are more
demanding, with 78% wanting a say in their treatment decisions
and 72% feeling uncomfortable when a physician leaves them
out of medical care decisions that affect them. Both of these emerging patient
requirements can be addressed through effective physician-patient
communication.
Power went on to state that the implication of these developments
is that the future of the health-care industry is unknown; the
information revolution will certainly result in substantial change.
Consumer-driven health-care is inevitable, and he stated that those
who resist change demanded by consumers will not survive8. Power
made the following recommendations: (1) increase personal attention
to each patient, (2) better integrate the voice of the patient,
(3) build quality into the process—a true consumer orientation
is not reactive, (4) survey patients, and (5) reduce waiting
time in the office for appointments and between office and surgery.
In this new era of health care, physicians will have
to adapt to the consumer-driven requirement of performance
accountability in communication. Consumer choice is going
to minimize the employer’s role, especially with the development
of voucher systems and defined-contribution health programs, which
give consumers more responsibility while requiring them to bear more
of the cost for their care. Historically, consumers have always
been intolerant of poor quality, bad service, high costs, and inadequate
communication. Coulter stated his belief that consumers are potentially
more interested in the physician practices than health plans have
ever been9. He also stated his
belief that, in the future, physicians will have a broad role in
the health-care organizations, but they will be required to pay
attention to quality as well as to service, consistency,
and better organization. In a recent Institute of Medicine report
on the future of health-care systems, it was noted that today professionals
control care but, in the future, the patient will ultimately control
care10. The current system is
built around the physician’s time, but the future system
will be built around the patient’s time—not only
when and where but how much patients demand from physicians—i.e., "24/7/365." Physicians
will need to organize their clinical practices in such a way that
sufficient time is provided for effective communication, and, where
possible, they will need to make patient education materials available
to provide additional information and to reinforce their instructions.
A second impact of information technology and the Internet on health
care is the availability of new opportunities for creating and providing
efficiencies that promote access and "customer" satisfaction
as described by Power8. Physicians
who are able to give patients easy access to information and retain
personalization will get and retain their business. Currently, few
physicians use the Internet to communicate with their patients.
However, over time, e-mail correspondence may supplant
traditional telephone messages and provide a means of direct
contact with patients. The Internet, however, poses a threat to
the physician-patient relationship because it tears down traditional
market boundaries. The physician is no longer the sole repository
of knowledge as patients are able to access multiple sources of
information.
Managed care presents some unique challenges with regard to the
physician-patient relationship and communication as well as professionalism.
Levinson et al. stated that it is essential for the physician to
believe that he or she is on ethically firm ground when recommending
a course of action to the patient11.
A physician must decide whether he or she can deliver high-quality
care in a particular health-care plan, and, if not, he or she should
not participate. The communication skills required in this environment include
an understanding of the patient’s worries and concerns, coupled
with the ability to express empathy to the patient, to encourage
the patient to take an active role in the discussion of the options
of care, and to negotiate differences of opinion when necessary.
Levinson et al. described ways to resolve any disagreements that
develop between the patient and physician11.
As a result of managed care, patients worry about how financial
incentives provided by health plans and other arrangements that
physicians have with their health plans might influence the care
that they provide and recommend. Suggestions to physicians by Levinson
et al.11 include empathizing with
the patient’s concern about a conflict of interest and
expressing a firm commitment to the care of the patient. The physician
must discuss any financial arrangements in enough detail for the
patient to fully understand them. The physician also must provide
options for the patient so that he or she does not feel helpless.
Finally, at the end of the appointment, the physician must address
any unanswered questions. In some health plans, changes in resource allocation
are forcing patients to switch physicians. In such situations, the
physician should empathize with the patient about how he or she
feels about such a switch, while at the same time expressing a commitment
to the patient’s best interests. The physician should offer
options to the patient so that the patient does not feel coerced.
Levinson et al. recommended that, when the patient must
see a nurse specialist rather than the physician, the physician
acknowledge the patient’s frustration, educate
the patient about the team concept, and affirm a commitment
to work out any snags in the system to meet the
patient’s needs. In every instance, thoughtful and careful
communication will minimize the risks of less-than-adequate
decision-making and misunderstandings among patients, physicians,
and administrators of health-care systems. Minogue provided
additional insight into strengthening communication when he asserted
that "physicians have two fundamental duties:
they must balance the interests and wishes of the patient
with the welfare of the health care system in which they practice."12
In the same manner that we incorporate new knowledge about biological
processes into our treatment of patients, we must incorporate new
knowledge about the health-care utilization and experiences of all
of our patients, across all races and ages. In a study by Cooper-Patrick
et al., race and gender were found to be especially important in
the physician-patient partnership13.
They noted that black patients rated their visits to white physicians
as less participatory than did white patients who were seen by white
physicians. Recommendations for addressing ethnic diversity included
improving cross-cultural communication and providing patients
with more diverse physician groups.
Historically, diversity has meant inclusion of racial, ethnic,
and gender differences. However, Kennedy recently added a new meaning
to diversity, which includes the classic differences but also age-related
group differences concerning workplace values, lifestyle values, social values,
motivation, and communication styles14.
These communication differences are presented in Table I.
For these reasons, it is extremely important for today’s
and tomorrow’s physicians to understand not only the impact
of the age of their patients on how they communicate but also the
impact of their own age on how they communicate with their patients. Without
question, our age influences our expectations and patterns
of communication. Only by paying close attention to these age-related
differences can effective and meaningful communication occur between
two different age-groups with different communication
styles.
Preserving and strengthening the physician-patient
relationship in light of managed care and the other challenges discussed
above is essential to improving physician-patient communication. Effective
communication cannot exist in the absence of a solid, trusting
physician-patient relationship; the two are inextricably linked.
Fostering the kind of physician-patient relationship that will facilitate
effective communication can be helped by paying attention to the "Six
Cs" outlined by Emanuel and Dubler15,
which include:
· Choice—physicians and treatment options.
· Competence—expected of doctors by patients.
· Communication—physicians must listen, understand
the patient’s pain or problem, and communicate.
· Compassion—patients want technical proficiency
but also empathy.
· Continuity—the patient-physician
relationship should endure over time.
· (No) Conflict of Interest—the physician’s
primary concern must be for his or her patient—the patient’s
well-being must take precedence over the physician’s
own personal interest.
"Trust is the culmination of realizing these
six C’s, [and] not an independent element."15 Bulger incorporated these characteristics
in his definition of the physician in the new world of medicine16. Bulger described the modern, mature,
science-based clinician-healer as being both scientifically and
ethically competent and one who is calm, understands suffering,
comes to terms with death and dying, has knowledge of the placebo
effect and its role in scientific health-care practice,
is able to communicate and especially to listen, and, finally, understands
his or her own expanding and changing professional role16.
Guidance for strengthening physician-patient communication
also comes from reframing the role of the physician in caring for
patients. Historically (until the late 1960s), the traditional role
of the physician was to secure the medical welfare of his or her
patient. Minogue stated that the new, modern notion is that "the
physician’s stewardship extends not only to the medical welfare
but also to the wishes of the patient . . . the individual has a
legitimate claim to define what is best for himself or herself
even if the doctor disagrees."12 A
recent study by Braddock et al., in which 1057 patient visits with
fifty-nine primary-care doctors and sixty-five general
orthopaedic surgeons were recorded on audiotape, showed that only 9% of
the medical decisions met the criteria for complete informed consent17. These criteria included the patient’s
awareness of his or her role in the decision, the nature of the
treatment and alternative treatments available, the patient’s
understanding of the decision, and the patient’s preference.
Physicians need to develop skills that enhance the patient’s
knowledge in these areas. As part of a similar study, Levinson and
Chaumeton reported that good communication is not necessarily more
time-consuming1.
Bridget Houlihan, a former orthopaedic patient, addressed the
entering class of the American Academy of Orthopaedic Surgeons in
2000 regarding her perspective as a patient: "Of course,
the most important part of an orthopaedic surgeon’s job is
based strictly on skill and medical know-how . . .The general public
seeks and relies on your expertise. But I think there is more to
being a good orthopaedic surgeon than having the ability to perform
medical procedures . . . I want my orthopaedic surgeon to act with
the highest level of professional competency and to stay on the
cutting edge of the field. At the same time, I want my surgeon to
admit to me if he or she doesn’t know the answer to one
of my questions, and then I want him or her to take the initiative
to find the answer . . . Listening has been a key part of the medical
profession . . . I encourage you not to let technology get in the
way of your listening skills. As a patient, I can tell you that
it is very comforting to know that I am being heard."18
It is important that attention to the physician-patient relationship,
communication, and professionalism be an essential
part of medical education, including graduate medical education.
The Accreditation Council of Graduate Medical Education has identified
several major developments that will have an impact on graduate
medical education19.
These include emergence of a global environment for medicine, disclosure
of the human genome, continued growth in scientific knowledge, the
effect of computers on all aspects of health care and education, growth
in information available to patients about their diagnosis and disease,
economic strategies that dominate academic settings, and the demands
of a multicultural society and an aging population. Excellent communication skills
are essential in this new health-care environment. Specifically
with regard to the physician-patient relationship, the Accreditation
Council of Graduate Medical Education recommended the following
broad areas of competency necessary for resident accreditation: patient care,
medical knowledge, interpersonal and communication skills, professionalism,
practice-based learning and improvement, and systems-based practice19.
Of the six requirements, two—communication and professionalism—specifically
deal with interpersonal skills. Interestingly, such requirements
were found indirectly in Flexner’s original report: "Specific
preparation . . . requires insight and sympathy . . . varied cultural experience
. . . ethical responsibility."20
In addition to the many suggestions for improving the physician-patient
relationship and communication in the present paper, the following
recommendations were made by a recent task force of the American
Academy of Orthopaedic Surgeons (AAOS) to the Council on Education
and the Board of Directors to help orthopaedic surgeons to enhance
their communication skills21.
They included programs and activities that can be done locally in
individual departments and practices as well as those that can be
organized on a national or regional level:
· Produce an AAOS advisory statement on physician-patient communication.
· Publish regularly featured articles on the
physician-patient relationship, including communication,
in the AAOS Bulletin.
· Develop an instructional lecture series similar to
those started this year to be presented at the annual meeting.
· Produce videotaped subspecialty-based training programs demonstrating
proper and effective communication as well as inappropriate or ineffective
communication.
· Provide lunchtime speakers at continuing medical-education courses,
including those at the Learning Center, in addition to the videotaped
programs.
· Establish a mentoring program in which fellows skilled
in communications could help those who are not.
· Provide an AAOS web site on physician-patient communications
for members.
· Provide an AAOS web site section for the public with
information on how patients can communicate more effectively with
their orthopaedic surgeon.
· Produce an article for the Journal of the American
Academy of Orthopaedic Surgeons on issues associated with physician-patient communication,
such as improved outcomes, increased office efficiency, ways to
reduce the prevalence of malpractice suits, and overall increased patient
satisfaction.
· The AAOS should develop a patient-satisfaction survey,
maintain a national database, and provide a mechanism for data analysis
that would allow fellows to compare themselves with their colleagues
in order to identify any differences and possible problems in communication styles.
In addition, such a program should offer fellows access to opportunities
for improving communication skills.
In summary, dynamic forces are changing the physician-patient relationship
and a new emphasis on physician-patient communication is necessary
to ensure that medicine remains a respected profession in our developing consumer-oriented
society. We can all improve our communication skills. We suggest
that all orthopaedic surgeons survey their patients on a regular
basis and evaluate their office staff as well as themselves. Essential components
of professionalism are continuing education, continuing self-evaluation,
and continuing improvement. Patients interact with the health-care
system one physician at a time. Our communication skill in terms
of collecting and sharing information, decision-making, and empathy
is the single greatest factor influencing each encounter. As a profession,
we need to ensure that this experience is as effective and positive
as possible.
Note: The authors thank Wendy Levinson, MD, for her contributions
during the preparation of this manuscript.
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