Refocusing physician-patient communication

In a typical patient visit these days, there seem to be more interruptions than interaction.

Patients are battling illness or trying to convey a series of critical points to a physician who is either furiously typing and likely still reeling from previous patient visits or anxious to get through the rest of the day. It doesn’t make for the best collaboration, according to internist Danielle Ofri, MD, Ph.D.

In her newest book, “What Patients Say, What Doctors Hear,” Ofri, an associate professor of medicine at the New York University School of Medicine, examines the state of physician-patient communication and what can be done to reduce the distractions and get back to focusing on improving the patient’s health.Danielle Ofri, MD

Ofri recently spoke with Medical Economics about  her fifth book, what works with her own patients and to offer advice to peers who may be struggling to make meaningful connections with patients.

Medical Economics: What do you think are the most common barriers to good patient-physician communication?

Ofri: The first one is time. We all know that time is getting shorter and shorter for physicians, with more and more to do in that time. I think almost all doctors would agree that if they had an hour with each patient, they’d be excellent doctors. Unfortunately, no one is giving us that hour.

The other thing that has come along, of course, is the electronic health record (EHR), which has greatly impacted physician-patient communication. There are definitely some advantages: the chart doesn’t get stuck in dermatology clinic, or the X-ray is not in the surgeon’s back pocket. Those are great things that definitely enhance doctor-patient interaction, but the EHR has sort of sprouted like a disease, growing more parts and metastasizing to every part of the visit. You just can’t get through the visit without being glued to the screen. We end up mainly talking to our computers and the patient is wandering off into space.

Medical Economics:  You openly admit in the book that being a good listener as a doctor is difficult. What has helped you in your own patient interactions?

Ofri: We all know the data that physicians interrupt patients in eight to 10 seconds and how awful that is, so I tried an experiment where I let patients talk without interrupting them. We all worry that patients will talk forever, but I learned quickly that they don’t do this. Most patients, within a minute, get out what they need to say and then they are done and ready for questions from the physician.

Even patients who answer “all-of-the-above” for the entire review-of-systems only spoke for four minutes. And then our future visits are much more effective and efficient. So although it seems counter-intuitive, I find it very efficient, especially with my patients with multiple complaints, to give them a chance—even once—to talk it all out.

They feel like they are truly being listened to and cared for, and I feel like I’m not going to miss anything. If I’d cut them off at the chase after the first symptom—like I usually did—they might never get to that second thing they’d planned to say like, “I think I had a stroke last week.” I’d miss that and that would be terrible medicine.

Medical Economics: Does that help avoid the “doorknob” comment, where a patient says what often turns out to be the most important thing when the physician is exiting the room?

Ofri: That helps alleviate that, but I think it is also important to say at the end: “Is there anything else we missed?” Often that’s enough to reassure the patient that you are listening.

My other strategy is that I use the physical exam as my second chance for communication. Once we are away from the computer, patients are often more likely to reveal things that were a little hard to say across a desk—especially if the doctor is facing the computer, not the patient. The patient may remember the cough, now that I’m listening to her lungs, or he might feel more comfortable revealing the eating disorder, or sexual dysfunction that was too awkward to discuss before.

To address medication adherence, I’ll often say, “Lots of patients have trouble taking their medications sometimes. Tell me some times you’ve had trouble with yours.”

My other version is asking, “What is the hardest thing about having diabetes?” Patients will tell you right away where the money is: It might be the cost of medication or a side effect, like diarrhea or loss of sex drive, or I used to use drugs, so syringes are not the best thing for me. That makes it really efficient. The truth is that my patients already know the “broccoli talk,” they’ve heard it before and I’m wasting my time repeating it. Instead of reading the riot act, yet again, about amputations, blindness and dialysis, we can use those precious minutes on the things that really count.

Patients often come with a list of questions—which is generally a good thing—but I caution them to be realistic. If you make a list, I tell them, prioritize the top two or three things. Don’t expect that we’ll get to them all, otherwise we’ll end up doing a superficial job, which can even make things worse.

Medical Economics: You note the tug-of-war between keeping patients happy for the benefit of a better patient satisfaction score versus telling them uncomfortable truths. (One example is using the term “obesity” versus just saying that they are “overweight.”) In your opinion, have these scores hurt medicine more than helped?

Ofri: Patient satisfaction scores have the potential for both helping and harming. The obvious upside is listening to the patient’s voice, which has rarely been heard by those making the decisions in the healthcare system. So philosophically, I’m in agreement that we should address patient satisfaction. Unfortunately, the response is often window dressing—like valet parking or a nicer coffee machine in the waiting room.

We need to help the patients focus on what matters: Were things explained to you adequately? Were there enough nurses on the ward? Did the doctors answer your questions?

It’s hard enough to for patients to understand what’s going on in the medical world, and if we doctors haven’t explained that well enough, that’s important to know. We tend to think that our having stated the information is enough, but when a patient is scared, confused, in pain or constipated beyond belief, it can be hard to absorb the information.

Medical Economics: You also note that unlike the Dutch, U.S. doctors don’t get paid to listen. Could you envision a scenario where we could in the future, via a CPT code?

Ofri: If I sit and talk with the patient, Medicare will reimburse me $49. But if while I’m talking I insert a tube in one of a patient’s orifices—and you can choose any orifice you want—the reimbursement increases 10- or 20-fold. And if I happen to run a CT scanner across the patient at the same time, that’s thousands more dollars.

So right there you can see that our medical system values procedure over the doctor-patient conversation. But if you think about the diagnoses that can be made, the analyses that can be elaborated and the treatments that can be rendered, the doctor-patient conversation is the single most powerful tool that we have in medicine.

I don’t need to code differently for listening, but the doctor-patient conversation—without the tube or the CT scanner—should be valued and reimbursed at a much higher level that reflects its central importance in the practice of medicine.

Medical Economics: There is a lot of research in the book that involved audio and video recording of patients and doctors for later analysis. Today’s docs get a lot of requests to record a visit via smartphone, but are often hesitant to permit it. Should they comply more with this request and use this as a learning opportunity?

Ofri: I actually haven’t been asked directly, but I feel I’d have to honor that request. A full medical visit can be a lot to digest by the patient and so I can see why the patient would want to review it later. Maybe it would make us doctors think more about how we come off. If we see in a video we’re staring at our screens the entire time, it could be a bit embarrassing. Maybe it would push us to look up for a minute!

The patients really own the time—at least that’s the way I look at it. So if they want to tape it or film it, it’s their prerogative. We doctors should stand behind anything we do in the office.

Medical Economics: At the end of the book, you advise your peers to “shut up,” even just a bit, in their typical visits. Given the myriad issues doctors face, how can they balance more active listening while overwhelmed with so much?

Ofri: I try to think of the times when I’ve accompanied a parent or a child to a doctor’s visit—I wanted the physician to be 100% there for me. The patient you are seeing now may be one of 20 for you, but remember that you are the only one to them. You are the one doctor they are seeing after waiting hours in the waiting room and maybe weeks or months for the appointment. Try to keep that in mind, that they are desperate for your focus and attention. Amidst the chaos and minutiae of the day, that’s how I try to clear my mind to be there for my patient.

Peer review: Useful communication tips from page to practice

“What Patients Say, What Doctors Hear,” by Danielle Ofri, MD, provides valuable tips to improve communication between patients and doctors. I have already put them to use to improve my practice.

I was not previously familiar with her work, but a quick search will find references to quite a number of her articles and works and she is clearly an expert in the field. Her suggestions, supported by a wealth of data, can be experimented with and implemented in a practice immediately with easy-to see, though not easily quantifiable, results.

Ofri describes numerous fascinating interactions between doctors and patients and it is surprising how each party can view the encounter in such a different manner. I can certainly be accused of “forcing” what I think is helpful patient education during encounters. However, if frequently repeated, patients don’t feel it to be helpful at all. They describe it as “being read the riot act” over and over and being constantly “nagged and harangued.” I was just trying to help.

Prior to reading this book, I did not realize that patients and doctors frequently have competing goals during an office visit. A patient has a story to tell. The doctor is listening for a chief complaint before proceeding with his or her part-time job as data-entry technician and striving to meet the quality metrics documentation for the alphabet soup bean-counter program forced upon doctors this particular year.

Ofri believes doctors need to concede some control of the interview to allow the patient to state what they want to say. Asking them what they feel is the biggest barrier to managing their particular condition can elicit unexpected responses that could significantly change our approach.

She also cites studies showing that allowing patients to talk without interruption after being prompted to “begin their story” takes far less time than we would anticipate (92 seconds on average), even when dealing with patients with whom we may be terrified to take this approach. I have not found the courage to try this with some of my patients. “Grounding,” using cues like nodding your head or saying “mm-hmmm” while the patient is speaking, improves communication and satisfaction for the patient, knowing that they are being listened to.

One particular insight that I find useful on a daily basis is recognizing how valuable the few minutes on the exam table can be. This window is where we can just listen to what the patient has to say, free of staring at and typing into a thoroughly unsatisfying computer medical record. It “is the first and only place to talk directly, without the impedance of technology,” she says.

Ofri presents applications of the research she cites in real-world scenarios with outcomes demonstrating that these concepts are not necessarily panaceas. They are, however, helpful tools that improve the doctor-patient bond and should enhance both patient and doctor satisfaction. Her book is well worth the three- to four-hour time investment it takes to read.

Douglas A. Perry, MD, specializes in internal medicine and is a partner in SouthCoast Health, a physician-owned multi-specialty medical group based in Savannah, Georgia.

Peer review: Peer suggestions, not pontificating, the strength of Ofri’s work

Allow me to begin by saying that I feel a strong professional kinship with Danielle Ofri, MD, as I read her words. She is at her best when she paints a mental picture of her interactions with patients.

Once a physician has practiced medicine for the better part of a lifetime, he or she recognizes the patients in the vignettes that Ofri so masterfully creates. I can, in my mind, see myself struggling to connect on a deeper, more meaningful level with the human being before me. This person has invested their trust and their vulnerability in their physician; it is incumbent upon him or her to respond with the sincerest and most intimate, albeit professional, bonding.

It is to Ofri’s credit that she carefully avoids pontificating on the “right way” for physicians to listen to patients. She freely confesses to her own ongoing and untamed shortcomings in her professional exchanges with her patients.

In a way, Ofri overstates her case to a certain extent starting at “The Language of Medicine” chapter, regarding the role of medical jargon in obscuring conversations with patients. It is true that all physicians can too easily bewilder patients when allowing purely medical terms to roll off the tongue with unjustified aplomb. But I suspect the vast majority of the lay public would understand “decompensate” in an appropriately sculpted sentence.

Ofri has framed her interesting tales of patient-doctor miscommunication within a much larger story. It is one which I have confronted (or run from) on only a handful of occasions in 40 years of practice.

The story of patient Morgan Amanda and her physician, Juliet Mavromatis, MD, is qualitatively different from the rest of the tales. In this case, there is a difference in each person’s understanding of the patient’s disease process and the road to treatment. For Morgan Amanda and her doctor, they must come to a point of compromise between their two disparate views of how to proceed. In the end, sadly, they are unable to do so.

I must say that this truly valuable book can be categorized neither as “for patients” nor “for doctors” exclusively. Patients may find some of the jargon confusing and distracting, while physicians may bristle at some of the sermonizing of the later chapters.

Arthur C. Sgalia, MD, practices internal medicine in Hopedale, Massachusetts.