Communication: the other half of medical care

Dr Paul Nisselle explores the evolution of communication in medicine and how mastering the art of doing it well could save your skin

The Flexner Report, published in 1910, crystallised a revolution in medical education.¹ The craft-based model of training through apprenticeship in the community became science-based university training, accompanied by bedside teaching in hospitals. Sir William Osler also commented at the time: “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”

Medicine became a biomechanical science. The bedside emphasis was on “find it and fix it” training – make a diagnosis; decide on the treatment. That is obviously of primary importance, but we now appreciate that the quality of the doctor–patient relationship also has an impact on the outcome of medical care.²

In 1984 an American analysis of 73 tape-recorded consultations in a primary care setting found that: 

• Only one quarter of the patients were allowed to finish their reply to their doctor’s open-ended initial question, eg, “And what brings you to see me today?”, without interruption
• The average time from when the doctor asked the open initial question to when he or she interrupted, usually with a closed (clarifying) question, was 18 seconds 
• Patients who were allowed to complete their opening statement without interruption usually did so in less than 60 seconds – none went longer than 150 seconds 
• Consultations with patients allowed to complete their opening statements of concern lasted only six seconds longer.³

A similar study of consultations in an emergency department showed that the average time before there was an interruption was just 12 seconds. Giving instructions on discharge took, on average, 76 seconds. Only 16% of patients were asked whether they had any questions.⁴

The “patient-centred” model of care is now the accepted paradigm

Thankfully things have improved. Medical schools and postgraduate training bodies have substantially increased the hours of teaching committed to communication training. The “patient-centred” model of care is now the accepted paradigm. We would like to think that medical paternalism – the Sir Lancelot Spratt or Dr Finlay model of medicine – is now fictional, a long time past. But is it? There are pockets of resistance.

The Harvard medical practice study showed, and a number of later studies remarkably consistently confirmed, that only around 3% of patients who had the grounds for a successful claim in negligence actually pursued one.⁵ What made them sue? Why did the other 97-98% not sue?

There is now good evidence to show that most complaints and claims brought against doctors, whilst precipitated by an adverse outcome, would not have been brought if the predisposing factor of a poor patient–doctor relationship was not present.⁶

Many believe that a good “bedside manner” is inherent, not acquired. That is not true

Many believe that a good “bedside manner” is inherent, not acquired. That is not true. Every doctor can improve his or her communication skills. If you can teach someone to take a blood pressure you can teach them how to communicate more effectively – provided that they are motivated to learn new skills and change established behaviours.

Communication is the “other half” of medical care. Obviously, clinical competence must come first. To use a tennis analogy, if clinical competence is the "forehand” of medicine, communication competence is the “backhand” – you’ll never be a great tennis player with just a good forehand. So why is this of concern to MPS?

MPS seeks to help members reduce their risk of complaints and claims. We now offer a number of risk management workshops focused on communication issues. The first is the “Mastering Your Risk” workshop. Come along and spend half a day learning what it is all about. Check the website for when and where they are being held; if there are none listed for your area, check the events pages for any further updates.

References

1. Flexner, A, Medical Education in the United States and Canada, Carnegie Foundation for Higher Education (1910)

2. White et al, Annotated Bibliography for Clinician Patient Communication to Enhance Health Outcomes Institute for Healthcare Communication, New Haven, CT 06511-5901, USA (November 2005)

3. Beckman HB, Frankel RM. The effect of physician behaviour on the collection of data, Ann Intern Med, (1984) 101: 692-6.

4. Levinson, Frankel, et al. Resuscitating the physician-patient relationship: Emergency department communication in an academic medical center, Annals of Emergency Medicine Vol 44 Issue 3 pp 262-267 (September 2004)

5. Brennan, Leape et al: Incidence of adverse events and negligence in hospitalized patients: Results of the Marvard Medical Practice Study, Qual Saf Health Care, 13: 145-152 (2004)

6. Bunting RF Jr, Benton J, Morgan WD. Practical Risk Management Principles for physicians, J Health Risk Manag, Fall;18 (4):29-53 (1998).