Talking with patients cannot be delegated


Published 9/1/2016
Terry Stanton

Mastering Communication Skills

In an Annual Meeting symposium focusing on core competencies for orthopaedic residents, AAOS Second Vice-President David A. Halsey, MD, of the University of Vermont, underscored the importance of communication skills training.

"The first premise is that communication matters," said Dr. Halsey. "You as a physician cannot fully delegate this task. Patients need to hear answers from you. For this reason, communication skills training is fundamentally important."

He noted that 70 percent of variance in patient satisfaction scores can be explained by the variance in communication skills among physicians. Additionally, the top reason that a patient switches physicians or hospitals is poor communication skills.

Patients want the answers to three questions, said Dr. Halsey. The "Ask Me 3"are: What is the problem? What do I need to do? Why is doing this important?

During patient interactions, Dr. Halsey said, physicians "need to know what patients want to get out of the encounter. They are interested in what you, as a physician, can do about their problem, but research shows that patients really want to know what they can do about it. Why is important. Life is all about choices."

Dr. Halsey advised residents to approach learning how to communicate with patients in the same way they would learn any surgical procedure. "We know from evidence that these skills can be taught, learned, and assessed," he said. "Communicating is like any skill. Your skills improve, and the time goes down, due to repetition. The number of encounters and interviews with patients dwarfs the surgical volume of even a very productive surgeon."

E4 communications tasks
Dr. Halsey described the "E4" communications tasks that have "come out of 3 years of work with the Institute for Healthcare Communication and 15 years of collaboration with the Academy with the idea of bringing together biomedical and communications tasks. The coming together of sensitivity, compassion, awareness, and cultural humility and cultural competency is what we need to help our patients."

The first E is engage, which "means connect with a patient as a person before you connect about their disease," Dr. Halsey said. "This is the most important thing you can do to start off the encounter. Without it, you don't have trust. Without trust, understanding goes, and adherence falls off. Engaging with a patient gives you a tool to summarize the agenda. Don't be afraid to ask, 'Is there anything else you want to cover today?' and to keep repeating that question."

Dr. Halsey pointed out that a physician's fear that the patient "will talk for 45 minutes" is unfounded. The evidence is that the patient stops talking after about 90 to 120 seconds. At that point, he noted, the physician can "summarize the agenda, and cement what you are going to cover now."

The second E is empathy. "Empathy is not sympathy, but trying to understand the patient's feelings about the issue," Dr. Halsey said. "With a brief moment of empathy, you will really help cement the relationship. With appropriate communication—not just verbal but appropriate touch and eye contact, the patient knows that you have seen and heard him or her, understood and accepted.

"In certain cultures, this is absolutely essential," he continued. "In any encounter, you will have a more powerful relationship if you have a moment of empathy. Before I took communications skills training, I would lean back when the patient started to talk. But when the emotions start coming out, that's the time to lean forward—just as you would with friends and family."

Engagement and empathy will improve outcomes, Dr. Halsey said. "Diagnostic accuracy goes up, and anxiety goes down. We send a message of partnership."

Education is the third E. "Patients don't need to know every little detail of their anterior cruciate ligament procedure or carpal tunnel problem," Dr. Halsey said. "They need to know 'what's wrong with me, what can I do about it, and how important is it?'"

He suggested using the educational tool "Ask-Tell-Ask." "In the middle of the encounter, you want to ask the patient what he or she already knows about the problem. Then you can tell—customize the final message. Finally, you circle back and close the loop by seeing whether the patient can summarize in their own words what you've said before."

The final E is enlistment, which is an invitation to the patient "to collaborate in shared decision making that is evidence-based and takes into account the patient's values and preferences."

The feedback loop
Another core competency in communications is feedback, which for residents can involve a communication loop with faculty and colleagues.

Among the goals of feedback, Dr. Halsey said, are the following: to lead to a change in thinking, behavior, and performance; to encourage recipients to self-reflect and think of how they might improve; and to narrow the gap between actual and desired performance. Feedback "is intended to change behavior rather than being an estimate of the person's worth," Dr. Halsey said.

A guideline for providing feedback follows a progression, such as "Positive/Positive, Negative/Negative." This means that the subject of the feedback (the resident) speaks first with a positive message; then the provider of the feedback (faculty or colleague) gives a positive message or characterizations. Finally, each offers areas for improvement.

This method is effective because allowing the person being evaluated to speak first gives him or her a feeling of control, and positive comments given first lessen anxiety. Also the subject and the provider "often identify the exact same issues," Dr. Halsey said. Conversely, if the subject has no insight, outside perspective can be constructive.

When negative feedback is provided, the goal is improvement—"always!" Dr. Halsey said. The environment should be relaxed, and suggestions for improvement should be specific. The focus should be on the work, not the person, and the learner should be allowed to self-evaluate first. Dr. Halsey noted that learners are often their own harshest critics. "You'd be surprised how critical they can get about themselves," he said.

In providing feedback, he noted, four things should be avoided: forming opinions based on things heard; making comparisons to other students or peers; focusing only on the negative; and being sarcastic.

The key skills in feedback, Dr. Halsey said, are to listen and to ask—not to tell and provide solutions. Most important, he concluded, "Always be sensitive and be nice!"

Terry Stanton is a senior science writer for AAOS Now. He can be reached at