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Featured Guest Blogger:James I. Merlino, MD

James Merlino, MD James Merlino, MD

Every day, physicians and other healthcare professionals around the globe spend hours and hours learning how to keep up with the latest and best medical information. Being a life-long learner is part of the deal that comes with the sacred trust and commitment necessary to care for patients. When we sign up for this profession, we accept that part of the responsibility requires us to ensure that we know the most relevant and up-to-date medical information.

What is often ignored in this learning process is paying attention to developing the tools that let us improve the actual art of the “practice” of medicine. How do we interact with patients? How do we manage the clinic or bedside encounter? How do we organize information? How do we communicate? These are very important tools, but often they are not part of the normal teaching program for physicians in training, and certainly not regularly covered in continuing medical education for physicians in practice. Any discussion of these tools is often relegated to the generic heap of the physician’s “bedside manner.” And, the proverbial “bedside manner” is often learned by observation of mentors and teachers while physicians train – sometimes not the best role models. When new doctors set out to begin practices on their own, they are often forced to rapidly adapt based on what they assume to be observed best practices.

But these tools are much more important. They are not only an essential and necessary component of every encounter with patients at every stage of the patient journey; they also mine the patient data that is necessary for medical decision-making, enabling physicians and other providers to effectively do their jobs. Just like learning how to apply medical knowledge, these tactics can be learned, monitored, refined and improved. And, just as surgeons should think about how to make operations more efficient and effective, healthcare providers should spend time thinking about how to make their interactions with patients more productive and meaningful for both the provider and patient.

Studies of physician-patient communication demonstrate that only 37% of patients are able to complete their chief complaint before they are interrupted by a physician who is ready to unleash a barrage of questions necessary to “get to the diagnosis.” This interruption occurs, on average, within 23 seconds of starting the encounter. What is a really incredible fact is that, on average, allowing the patient to finish their chief complaint only requires six more seconds! Because of this interruption, patients often feel they are not being heard or listened to – they fall back into a submissive role, relegated to an inferior position relative to the more “esteemed” and “all-knowing” doctor.

Another frequent error physicians make is utilizing a “door knob” question. Often the last question or statement from the provider before leaving the patient is, “Is there anything else I can do for you?” or, “Do you have any other questions for me?” Invariably, if the patient feels dissatisfied with the overall encounter or if they were not able to be completely air their concerns and feel liberated, this “door knob” question is the patient’s opportunity to strike back. When this happens, the encounter gets longer, it becomes less efficient because it often re-opens a discussion around the purpose of the visit, and physicians become frustrated as they settle in for a potentially extended conversation that they had recently believed was closed.

"Studies of physician-patient communication demonstrate that only 37% of patients are able to complete their chief complaint before they are interrupted by a physician who is ready to unleash a barrage of questions necessary to “get to the diagnosis.” This interruption occurs, on average, within 23 seconds of starting the encounter. "

Now imagine if the office encounter occurred like this: The physician walks in and introduces themselves to the patient and their family and immediately starts a quick conversation about something non-medical (rapport building). Having established a personal connection, the doctor asks the patient to describe in their own words what they are concerned about most and what brought them into the office (allowing the patient to set the agenda). After agenda-setting by the patient, the physician works through the problem and comes up with a diagnosis. Finally, together with participation and interactions from the patient, a treatment plan addressing what the patient came in for, and shaped by additional information obtained by the physician closes the encounter (shared decision making). At the end of the encounter, instead of asking, “Is there anything else?” the physician reaffirms that they are here for the patient and will do everything they can to help them. Then, the physician thanks them for their time and the encounter is closed – everyone walks away happy.

Is this the current reality in offices around the country? No! Should it be? Yes!

This simple approach seems intuitive, but it is not. This example and additional pieces are part of a carefully choreographed exercise designed to make the patient feel more connected and satisfied, to help physicians better organize their time, improve efficiency of the encounter time and impact physician satisfaction. This case vignette is modeled after the Four Habits communication model developed by busy, practicing physicians at Kaiser Permanente of Southern California to help their physician colleagues improve their interactions with patients. There are many communication models and tips for improving the physician-patient interaction, but the point is that we often do not use these resources to help us get better at the “practice” of medicine.

Teaching communication skills is not just right for patients; it helps providers be more effective in their jobs. It helps bring empathy, improve satisfaction, and can bring efficiency to a physician’s practice that is burdened by the demands of seeing more patients in less time. It can also protect physicians from potential liability claims. The most common reason physicians get sued is because they did not communicate well.

If we, as providers, are going to transform and improve the way we communicate with patients, we have to agree that the skills that make up the foundation of our interactions with patients need to be taught, reinforced and exercised. Improving our skills with proven tactics like communication models will ensure that other tools, such as shared-decision models are used appropriately and more effectively.

About the Author:

James Merlino, MD, is the Chief Experience Officer of the Cleveland Clinic health system, and is a practicing staff colorectal surgeon in the Digestive Disease Institute. He is also the founder and current president of the Association for Patient Experience. As a member of the Clinic’s executive team, he leads initiatives to improve the patient experience across the Cleveland Clinic Health System. In addition to his work in patient experience, he also leads efforts to improve physician-patient communication, and referring physician relations. Partnering with key members of the Clinic leadership team, he helps to improve communication with physicians and employees, and to drive employee engagement strategies. Along with the Clinic CEO, he is co-chairperson of the Cleveland Clinic Diversity Council, and also sits on the professional affairs committee. He is a recognized world leader in the emerging field of patient experience. Dr. Merlino’s wife, Amy, is a maternal-fetal medicine specialist at Cleveland Clinic.