AAOS Now

Published 5/1/2011
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Mark C. Gebhardt, MD

Communication matters

From reducing litigation to improving patient care, communication is key

One of the two premises of the Communications Skills Mentoring Program (CSMP), a 4-hour seminar developed by the Academy under the guidance of John R. Tongue, MD, and S. Terry Canale, MD, is that communication matters. The other premise is that communication techniques can be learned.

Why does communication matter? Certainly communication skills are critical for an orthopaedic surgeon to be able to obtain accurate patient histories, establish correct diagnoses, and explain treatment plans to patients in a manner that they can comprehend and to which they will “adhere.” This is challenging enough when patients and physicians share a common culture and language, but it becomes even more challenging when they have different cultures and languages.

Communication and litigation
But there are other important reasons communication matters. One important reason is that effective communication with a patient can keep the physician out of the courtroom. It is well known that most litigation cases are not due to actual malpractice or “bad surgeons,” but rather because patients felt that they were not treated fairly as individuals or they didn’t understand the treatment recommendation. When procedures don’t turn out the way patients think they should have, the patients are angry and hurt. Patients tend not to sue doctors they like and with whom they feel rapport; they sue doctors who never took the effort to get to know them and understand their beliefs and desires or who treated them without respect.

One of the studies that impressed me was by Wendy Levinson, MD, which was summarized in the book Blink: The Power of Thinking without Thinking by Malcolm Gladwell. She and her group studied conversations between physicians and their patients; some of the physicians had been sued and others had not. By listening to the interviews, she could accurately predict which physicians had been sued and which had not. Doctors who had not been sued spent more time with their patients (a mere 3 minutes more!) and they oriented the patients regarding what to expect during the visit. They used humor and “active listening” techniques, yet each group collected essentially the same information from the patient.

Nalini Ambady, PhD, took this even farther by listening to short snippets of conversations between surgeons and patients and filtering out the high frequencies so that the content could not be heard, just the intonation and rhythm of speech. By listening “blindly” to the conversations, she could accurately predict which surgeons had been sued—not by what they said, but by the tone of voice they used. Surgeons who sounded dominant were likely to be in the sued group; surgeons who sounded less dominant and more concerned tended to be in the group that wasn’t sued.

Finally, a 1994 study looked at lessons learned from plaintiff depositions. When asked why they sued, plaintiffs listed relationship issues: patients or families feeling devalued, poor delivery of information by the doctor, the doctor’s failure to understand the patient and/or family perspective.

Communication and decision-making
Establishing rapport and involving the patient in the decision-making process is another important aspect of effective communication. Physicians, who have the medical knowledge, must be able to transmit that information to patients in a way that patients can understand, repeat, and incorporate when carrying out recommendations. The patient’s understanding of the potential risks of a given procedure, the next steps if a complication occurs, and the alternatives to a recommended procedure will help him or her in making the decision to have surgery or not. It will also lessen the devastation if a complication occurs. Knowing the possible outcomes of a procedure prepares the patient for the unexpected and makes it less frightening if the outcome is less than expected.

When an untoward event does happen in the operating room or the clinic, good communication skills are critical. The physician must be willing to help patients understand what happened and deal with the outcome. Patients need to know that they are not being abandoned. But too often, physicians fear that an apology is an admission of guilt and are uncomfortable discussing these situations with patients.

Communication in action
A few years ago, a wrong-side surgical error occurred at my institution. The lengths to which the surgeon, the surgical team, and the hospital reached out to the patient were astounding. After recovering from the initial operation, the patient ultimately let the same surgeon perform the procedure on the correct side.

First of all, the surgeon and patient had an immediate discussion. The surgeon explained what happened and apologized. The patient was not abandoned or shunned, which sometimes happens when people don’t want to confront a difficult situation. Arrangements were made for admission to the hospital and subsequent home care, the surgeon made house calls to check on the patient, and the patient-relations department of the hospital (including the CEO) reached out to help.

The surgical team received counseling, starting with an immediate debriefing and root cause analysis. All members of the team, including the resident and attending surgeon, were first-rate, experienced personnel, but obviously very distressed by this untoward event. Getting them involved early in determining what went wrong was an important step in designing strategies to ensure that an event like this would never happen again.

One result of this incident was the institution of quarterly grand rounds with anesthesia, surgery, and nursing staff to collectively discuss safety issues in the operating room (OR) and to educate each other on multiple aspects of team training. We redesigned and demonstrated proper “time-out” procedures using actual OR staff and surgeons. We subsequently redesigned the sign-in and sign-out procedures recommended by the World Health Organization; recently the Joint Commission visited our hospital and declared these procedures as “best practices” to be disseminated nationally. Crucial to all of this was communication between the caretakers and the patient and among the caretakers to develop and promulgate better practices.

Next steps
Courses like the CSMP can help physicians improve their ability to interact with patients and, in so doing, enhance the satisfaction of both physicians and patients. Medical liability insurance carriers are recognizing the importance of physician-patient communication and some, like ProMutual in Massachusetts, offer premium discounts to surgeons who take steps to improve their communication skills. Programs that help surgeons communicate effectively with patients when an undesired event occurs are also being developed.

One area that still needs attention is the interactions between physicians of differing specialties and between surgeons and the surgical team. Orthopaedists tend to work in isolation, but occasionally rely on consultants to help with patients who have difficult medical problems during the perioperative period. This is often viewed as an adversarial interaction, and that attitude can be transmitted to trainees. “Don’t consult an infectious disease specialist because he or she will just advise taking out the implant” is a commonly heard comment.

As medical care becomes more complex, orthopaedists have to be able to communicate not only with patients but also with colleagues so the patient receives the proper expertise for difficult problems at the right time. House staff duty hours also make this critical. When residents and physicians change shifts, communication is essential so that key information about a patient’s hospital course is not lost.

This is most evident in the OR, where working as a team is essential to improving the culture of safety. Because these teams are composed of members from differing cultural, educational, and specialty backgrounds, unprofessional and disruptive behavior in the OR cannot be tolerated. All members of the team are dedicated to helping the surgeon get through the operation safely and avoid preventable errors.

Culturally competent communication
Communication is important in ensuring that all patients get the treatment they deserve. Physicians must recognize the potential impact of unconscious bias on interactions and recommendations for patients of different cultures or gender. For example, African Americans, Hispanics, and women are less likely to be offered a total joint replacement than white men, despite seemingly identical indications. Recognizing these unconscious biases and learning to deliver culturally competent care will help orthopaedists ensure that all patients get the treatment they deserve.

Mark C. Gebhardt, MD, is a mentor in the AAOS Communications Skills Mentoring Program. He can be reached at mgebhardt@bidmc.harvard.edu

Additional References:

  1. Gladwell, Martin: Blink: The Power of Thinking Without Thinking. Back Bay Books. Little, Brown and Company, Publishers. 2005
  2. Levinson, W, ROter, DL, Mullooly, JP, Frankel, RM: Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA: 277)7), 553-559, 1997
  3. Ambady, N, Laplante, D, Nguyen, T, Rosenthal, R, Chaumeton, N, Levinson, W. Surgeons’ Tone of Voice: A Clue to Malpractice History. Surgery, 132 (1), 5-9, 2002
  4. Beckman, HB, Markakis, KM, Suchman, AL, Frankel, RM: The Doctor-Patient Relationship and Malpractive. Lessons from Plaintiff Depositions. Arch Int Medicine. 154(`12), 1365-`370, 1994