Published 9/1/2009

Communication pitfalls and pearls

Dr. Amalgam is a 53-year-old orthopaedic surgeon and a partner in a mid-sized group practice. He has a simple model of clinical care: “find the problem and fix it.” But Dr. Amalgam also recognizes the need to improve his communication skills to enhance his practice and his status in the community.

Although he is confident in his technical skills, Dr. Amalgam realizes that he has lost some communication skills learned in residency and that he has not adopted new interviewing techniques to match changes in his patient base. He also recognizes that interviewing errors can compound, rather than resolve, patient confusion.

In attempting to “find and fix” his patients’ musculoskeletal problems, Dr. Amalgam realizes his patient interviews have become almost mechanical, without any expressions of empathy. His standard educational monologues didn’t always fit his patient’s immediate interests or needs, as shown in the following medical encounter:



Dr. Amalgam: “So, what brings you in today?”

Stern voice, standing posture, and looking at chart may intimidate patient.

Patient: “My knee has been bothering me.”

Patient expresses a concern, pauses, and is then interrupted by the next question…

Dr. Amalgam: “What kind of work do you do?”

Physician does not inquire further about patient’s concern and changes topic.

Patient: “Um, well, I was an administrative assistant as of the beginning of January, but I got laid off, so…”

Patient answers the question and expresses another concern.

Dr. Amalgam: “So, recently laid off.”

Physician stays on topic but does not give patient the chance to elaborate. Physician avoids eye contact, and offers no empathy.

Patient: “Yes.”

Monosyllabic answer suggests that the patient is in a passive mode in response to the interrogation style of this interview.

Dr. Amalgam: “OK. OK. When did you injure your knee?”

Physician changes topic and assumes an injury.

More importantly, Dr. Amalgam notices that patients he expected to do well sometimes failed to fully recuperate from their injuries or surgical procedures. He typically associated their slow recovery with complications, their need for added attention, or the fact that they never seemed to complete the therapy he recommended. He begins to wonder whether a new model of clinical care—one focused on better communications—would help both him and his patients.

Help for Dr. Amalgam
Dr. Amalgam’s model of clinical care, “find the problem and fix it,” represents only half of a complete clinical care model. Focusing only on the biomedical tasks ignores the communication tasks necessary to truly find the problem and fix it.

Dr. Amalgam recognized that when he “communicates” with patients, he does not always consider certain essential components of the medical encounter. He has read about the “4Es” educational model, which defines the critical communication tasks as Engage, Empathize, Educate, and Enlist the patient. These communication tasks are considered to be of equal importance to the “2Fs” of the biomedical tasks—Find the problem (diagnosis) and Fix it (treatment) (Fig. 1).

Engagement establishes an interpersonal connection that sets the stage for the patient-physician interaction, drawing the patient in.

Empathy demonstrates a physician’s understanding of and concern about the patient’s thoughts and feelings. The patient is seen, heard, and understood by the physician.

Education delivers information to the patient. The patient learns something.

Enlistment extends an offer to the patient to actively participate in decision-making. Enlistment acknowledges that the patient controls much of what can happen in his or her healthcare treatment plan.

Dr. Amalgam maps out a new, patient-centered structure for future patient interviews:



Dr. Amalgam: “How can I help you today?”

Sitting, smiling, making eye contact, and leaning forward demonstrate a caring attitude.

Patient: “My knee has been bothering me.”

Patient states a concern.

Dr. Amalgam: “Sorry to hear that. Before we go further, though, I'd like to find out if there is something else bothering you.”

Physician provides empathy (hears) and then defers further discussion pending other issues.

Patient: “Well, I was also wondering why my finger keeps snapping in the morning when I bend it back and forth.”

Patient states another concern.

Dr. Amalgam: “So, a finger that catches, especially in the morning. Is there something else?”

Physician avoids “oh, by the way” at the end of the interview

Patient: “No, not really.”

Patient is done with her agenda.

Dr. Amalgam: “So, which should we start with?”

Physician invites patient to prioritize concerns.

Patient: “Well, perhaps the knee pain, but I did want to make sure we have time for both.”

Physician’s chance to prioritize the second complaint, if needed to save time.

Dr. Amalgam: “OK, fair enough. You said your knee has been bothering you. Tell me about that.”

Physician explores concern with open-ended question, eye contact, smile, calm voice tone.