Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients

Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients

 

Tom Janisse, MD, MBA; Karen Tallman, PhD

Perm J 2017;21:16-097 [Full Citation]

https://doi.org/10.7812/TPP/16-097
E-pub: 03/10/2017

Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients

ABSTRACT

Introduction: The top predictors of patient satisfaction with clinical visits are the quality of the physician-patient relationship and the communications contributing to their relationship. How do physicians improve their communication, and what effect does it have on them? This article presents the verbatim stories of seven high-performing physicians describing their transformative change in the areas of communication, connection, and well-being.
Methods: Data for this study are based on interviews from a previous study in which a 6-question set was posed, in semistructured 60-minute interviews, to 77 of the highest-performing Permanente Medical Group physicians in 4 Regions on the “Art of Medicine” patient survey. Transformation stories emerged spontaneously during the interviews, and so it was an incidental finding when some physicians identified that they were not always high performing in their communication with patients.
Results: Seven different modes of transformation in communication were described by these physicians: a listening tool, an awareness course, finding new meaning in clinical practice, a technologic tool, a sudden insight, a mentor observation, and a physician-as-patient experience.
Discussion: These stories illustrate how communication skills can be learned through various activities and experiences that transform physicians into those who are highly successful communicators. All modes result in a change of state—a new way of seeing, of being—and are not just a new tool or a new practice, but a change in state of mind. This state resulted in a marked change of behavior, and a substantial improvement of communication and relationship.

INTRODUCTION

The top predictors of patient satisfaction with interaction with health care practitioners are quality of the physician-patient relationship and the communications contributing to their relationship.1-4 There is limited understanding whether physicians can transform their communication and relationship behaviors, and how they can accomplish that. The purpose of this study was to find and share physician experiences of change, in their own words.

Although effective communication may be more natural for some, this article seeks to demonstrate, through physician stories, that highly effective communication with patients can be learned through insight or experiences and a change in state—of mind, of being, of purpose—that results in markedly different communication behavior. This can be acquired through a variety of different activities or experiences.                

Phase 1 of our previous study identified the top practices that discriminate between high-, medium-, and low-group physicians on the basis of panel-level patient satisfaction ratings. The top practices were “Focus on the Patient’s Agenda” and “Draw Out the Story”5 (Figure 1).

Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients

Communication

A patient’s satisfaction derives from, is based in, relationship with his/her physician. A high level of physician communication skill builds and enhances patient relationship. A patient may be satisfied that the right test is ordered—a successful cognitive act—but not with the conversation about it—both cognitive and subjective. Strengthening communication skills can improve this, as in the practice of “explanation to achieve understanding” (which follows). In addition, connection is also required to build and maintain relationship (addressed after this).

“Explanation to achieve understanding” was the most commonly cited activity, among these high-performing physicians, in answer to interview Questions 4 and 5 (see Sidebar: Interview Questions for High-Satisfying Physicians).

Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients

Representative physician verbatim comments, reported in a previous article,6 included the following:

  • “If you want to identify the medicine they got today—it’s as if they walked out with knowledge they did not have before, a level of understanding that they did not have before, and insight into the problem that they may not have had before.”
  • “I explain their situation as I see it with a medical or surgical point of view in terms they can understand. And usually with drawings. For me a picture of something helps. I develop the drawings as I’m talking. It’s like a storybook, I guess.”
  • “I think our job is pivotal in giving them the expertise, letting them have the knowledge that they need, to make the right decision with us.”

Connection

Connection between two people is a subjective experience. In response to Question 2, in a previous article by the first author (TJ),7 several physicians described connection as

  • “I think you don’t feel it with your rational mind: you feel it with your emotional mind.”
  • “If you don’t have a relationship with your patient, then you don’t really have an effective treatment protocol.”
  • “A sense of belonging in community with the patient, of myself as a whole person in the room with them.”
  • “There is nothing really that separates me from them; the humanity of it all is clear to me in our connection.”

Well-Being

Another previous article by the first author,8 which answers Question 3, addresses in part questions about improved patient experience that include: Is there benefit for physicians who have made changes in their practice? Can this be an antidote to burnout?

Following is a summary statement from that article, in which 23 physicians described (in verbatim comments) 5 components that integrate to enhance their well-being: 1) they derive something from patient interactions, 2) they are aware of their state of well-being, 3) they have both a personal and professional sense of self, 4) they practice self-care, and 5) their personal well-being has an effect on patient interactions.

About the first component, the first author wrote the following8:

… though requiring energy, focus, and tolerance is nourishing, energizing, and brings fulfillment and meaning. It prevents burn-out, which appears to grow out of mechanized work, often menial, squeezed of human emotion, meaningful moments, and personal conversation. Rather than draining your energy—as physicians, including me, were taught in medical school, and re-enforced by a medical culture rooted in this unexamined belief—physicians find nourishment in their patient interactions. It is often a simultaneously therapeutic moment for both physicians and patients. Without these interactions, physicians struggle to sustain themselves when acting totally objective and tending solely to the task at hand, rather than to the person they are with.

METHODS

In Phase 2 of the video-visit study,5 a standardized, 6-question set was posed, in semistructured, 60-minute, 1-on-1, confidential interviews, to 77 of the highest-performing Permanente Medical Group physicians in 4 Regions on the “Art of Medicine” patient survey. Of the participants, 20 physicians practiced in Los Angeles, CA, and Honolulu, HI; 42 in Portland, OR; and 15 in Oakland, CA. These interviews were audiotaped with permission, transcribed, and coded for patterns. The Los Angeles and Honolulu physicians practiced internal medicine and family medicine. The Portland and Oakland physicians represented 16 disciplines—cardiology, family medicine, general surgery, infectious disease, internal medicine, immunology, nephrology, obstetrics/gynecology, oncology, orthopedics, ophthalmology, otolaryngology, pediatrics, pulmonary medicine, psychiatry, and urology.

Stories that included a transformation experience emerged spontaneously during the interviews; thus, it was an incidental finding when some physicians identified that they were not always high performing (based on overall rating) in their communication with patients. Also, because transformation was not part of the coding set for the reviewers, each transcript was later reviewed by the first author in search of different kinds of stories of transformation.

The importance from our previous study5 of drawing out the patient’s story is paralleled here by our drawing out the physicians’ story of communication transformation.

RESULTS

Among those physicians who experienced a transformation, seven different modes of transformation were identified, as expressions of their change in attitude and practice.9

In verbatim stories about their transformative activity or experience, we hear from the physicians how the change came about, or what led them to it, and how it advanced their interaction and experience with their patients. They also express what it meant for them, and what it means for them now.

Of note, rather than these stories necessarily describing the point of the physicians’ transformation, they are stories of noticing their transformation, however sudden or gradual.

1. Listening for Story

“Using a listening technique allowed me to hear the patient’s story.”

The Story: “Listening didn’t come naturally to me, and that’s why one of those physician communication sessions was so important to me: to use a technique that didn’t come naturally. Using a listening technique allowed me to hear the patient’s story. I think sometimes patients understand you’re using a technique—for example, if you really have to struggle to use a technique—so I frequently had to step back from my natural thing: getting the information. I still find myself, when I do patient care, having to remember that technique of listening to their story. The patient story is the most important thing. When I talk to young physicians, I say it seems fraudulent and not yourself, whereas if in your heart you realize that the goal is to share mutual stories, then that really resonates with people. Oh, yeah, I can do that. That’s not a technique, that’s what I want to do. And the question is how do you get there? Why did you go into medicine? Some aspect of helping other people. How can you help them if you don’t know their story? That is so powerful, so that is what allows me to very frequently step back from the technique of listening to what am I in medicine for. Meeting people, at their level, at their pace, what they want out of the encounter, because their life story is what brought them here. So, I think that’s the most powerful thing that’s happened in medicine: we can move from being the scientist to being the healer. The technique was definitely knowing that if you let the majority of patients talk, in 2 minutes or so they will tell you the story in their own words. Then they’ll stop and allow you to go to the areas that you really need to know. They may not begin with it, but by the time you leave, you have to know some piece of information. But if you let them wind up and wind down, they will feel affirmed; you will get the real important aspect, which is the story.”

2. Using the Dialogue Box

“I started to write down personal patient notes and over time noticed I was sharing these personal moments and stories with my patients.”

The Story: “As a leader in information technology—I work part time in the clinic as an internist, and part time managing the IT system—I am always trying out something else in this electronic health record system that we haven’t officially used or trialed in practice yet. So, I found this dialogue box—a permanent fixture of the chart, ie, it always stays with the patient record—that you could put little pieces of information in. Those who have found it and use it characteristically put in the patient’s telephone number, for example. Well, I was talking to this patient one day, and the patient said he was looking forward to this vacation trip to go see his cousin he hadn’t seen in ten years and go fishing. So, I wrote that in the box. When I next saw the patient a couple of months later, before I went in the room, I opened this box and remembered about his fishing trip. I felt uneasy about mentioning it because I wouldn’t have just remembered this, and I didn’t want to be manipulating, but I asked him about his trip anyway. He was really excited to tell me, and it actually was an enjoyable visit for me. So, I started to write down personal notes in this dialogue box, and over time I noticed that I looked forward to going to the clinic again because I was sharing these personal moments and stories with my patients. My Art of Medicine scores were okay, not great, and so I wondered if my new activity had any effect on my scores. I tracked it for a year or more, and my scores went way up—it was a significant increase. And I hadn’t changed anything else in my practice, and I hadn’t introduced any other communication techniques. Having these personal exchanges with my patients transformed my experience in the clinic for the better and was obviously better for my patients because their satisfaction scores—their rating of me—improved also. So, using a technology tool actually prompted a change in my practice behavior.“

3. Physician as Patient Experience

“I learned how frustrating it can be as a patient to not know how much your doctor knows about you in the moment.”

The Story: “Here’s some background to frame what I’m going to say. I have been through a transformation in the last few years, so I find myself thinking: Is this the person who I am now vs before? This has to do with a lot of things—the most salient is that 2½ years ago I was diagnosed with breast cancer during pregnancy. So I had a crash course on what it’s like to be a sick patient. I went from a running vegetarian cardiologist with a clear shot to 90 to having to live with a monkey on my back in terms of mortality. My crash course included being a really sick patient who had almost a year and a half of treatment—chemo and surgeries and radiation. I’m still trying to reconcile what happened to me. Am I a new normal person today, and who I was before? I kind of miss that person—the healthy person from before—and sometimes I have a hard time remembering exactly who she was, and what she did. So, when you ask that question, I’m trying to think of myself as an integrative person, so I’m just going to talk about recent as opposed to before. Before I was considered someone who had a warm and fuzzy way of being, and I had high patient satisfaction scores then, but … what those words mean to me now are different. On a practical note, about courtesy and regard, one thing that I consciously changed when I got back from medical leave last year was how I walk into the room. Before, I’d shake their hand and say, “Hi, I’m Dr Smith.” I would tell them what question their referring doctor wanted us to answer today and, of course, I would answer their questions. Now, what I do by way of introduction is say, “Hi, I’m Dr Smith, I’m your cardiologist.” I also say, “I just want you to know that I’ve reviewed your medical records, and I’m planning on dictating a really great note so that that information will be on the computer by tomorrow. How does that plan sound to you? Is that okay with you? What do you think?” And they say, “Yeah, great.” So, right off the bat, I show them regard, about how I’m going to use this information, what’s going to happen with it, what’s in it for me. And I mention I’m doing that so that all of their doctors will be on the same page. This tells them what it’s going to mean to them. I also mention my own experience of being a really sick patient. I learned how frustrating it can be as a patient to not know how much your doctor knows about you in the moment, and whether they’ve reviewed your records or not, and that your anxiety level is way up here.”

4. Patients as Complete Human Beings

“Ten years ago, I would have said it’s all about making a good diagnosis, but now I see my patients as complete human beings.”

The Story: “Had you asked me that question ten years ago, I would have said, no, those things don’t really matter, it is all about making a good diagnosis using good technical skills when you remove a suspicious-looking mole, prescribing the right medicine to cure the proper diagnosed disease. But now ten years later I am starting to see that my role as a technician, as a professional scientific technical doctor, is probably far less important to my patients than what I used to believe because I see my patients as complete human beings. I do believe that I have a personal effect on the progression of the disease or the illness. And once again making this comparison ten years ago vs now, I would have thought ten years ago that simply having them take a drug that makes a laboratory test look better would make them feel good about themselves; it satisfies me as a scientist, but that accomplishment is a pretty small component in the overall wellness of the person. So now, I am much more able to recognize lifestyle modification—namely exercise and stopping smoking—and my demonstration of that in my own life by relating personal stories to the patients, which I never used to do and now I do. I talk about my own family, my own dietary habits and occasional indiscretions. I think it is important, and it’s helpful to show the human side of the physician and use it as an attempt to modify the way patients take care of themselves. I think that is a very powerful way of interacting and making a difference in people’s lives.”

5. It’s Not about Me

“My experience that it’s not about me, it’s about them, was a real shift in the way I saw myself.”

The Story: “I often wonder why I like what I do so much. It seems like there are people doing exactly what I’m doing, and they are not enjoying what they’re doing. I think it has nothing to do with the circumstances; it has everything to do with what you bring to the job. I don’t know how you teach that. How do you teach somebody to love what they are doing?

About six years ago, I went through a period when I was feeling frustrated with my practice because I felt like I was not able to make the difference I wanted to make with certain patients. Where I was feeling stuck, as a pediatrician, was when a kid would come in with something that I could see the parent was responsible for, like a behavior problem that had a lot to do with parenting. I was very uncomfortable with being straight with the parents and saying, “Hey, you have to get your act together. We’ve got to send you to a parenting class or to counseling. You are part of the problem here.” I really disliked what I was doing, and thinking, “Gee, did I do the right thing?” At that time I took a self-awareness course, and it shifted the way I saw my job. I suddenly understood that I have nothing to do with why they are there to see me besides that I am there to serve them. The whole thing was I didn’t want to be rude to these parents, but they wanted an answer to their problem; they couldn’t care less whether I was rude or not. For me to be able to see, not just intellectually but experientially that it had nothing to do with me, that whatever I was going through was irrelevant to the outcome, was a moment of illumination to me. Since then, I love what I do, and I’m able to take that into the room. In other words, it’s not about me, it’s about them. That for me was a real shift in the way I saw myself, and it has stayed with me. I am able to bring that to my job and feel like I am more effective now. I have no problem now being straight with people and just calling things the way they are. I’m not rude, but I’m not concerned at all about being straight with people. So this three-day course about how you see and approach your life was an experience rather than an intellectual exercise. I learned that I had too much significance attached to everything—that it’s all about me—like, “Oh my gosh, how am I going to look?” and “Am I going to do the right thing?” That basically has nothing to do with doing the job. It was really a fundamental shift in the way you see yourself and the way you relate to people.”

6. Getting Nourished through Emotional Engagement

“Being emotionally engaged with your patients doesn’t have to burn you out; it can be nourishing.”

The Story: “I have much more of a sense of well-being from interactions with my patients than I used to. I’ve been trained since I was in medical school that all this connection is just draining your energy—right? It’s burning me out. And so I assumed that was happening and was why I had energy issues—and thought I’m not going to have the energy to deal with my kids tonight. So, once a mentor definitively changed my frame of mind about that—that it could be satisfying—then I was able to notice, yeah, there is something that’s draining about connection with patients—it does require energy—but there’s also something that’s nourishing about it. And now I have so much more satisfaction. I love seeing patients now. I did before, but now it’s just something special. It really is. It is nourishing.”

7. Something Positive for My Patients

“What made the difference for me was a conscious decision that I wanted to be there to try and do something positive for my patients.”

The Story: “I think that probably the most interesting thing about me in this regard was when I first came to this organization. They had just started the Art of Medicine scoring. It was about ten years ago. I did not do particularly well on the Art of Medicine scores when they were first done. I was probably ranked below average in many of the areas. I took it quite personally and made a conscious effort to improve in the areas where patients made comments where they thought I was deficient. It was remarkable that I saw absolutely no improvement in my scores by trying to consciously focus on those areas. Years went by, and I stopped paying attention. I came to believe that they weren’t very useful, at least as a route to self-improvement. You go to seminars, you hear people talk about how to do it right, what are patients looking for, and you learn techniques and tools. But, in the end, what made the difference for me was a conscious decision that I wanted to be there to do something positive for my patients. Going into a meeting with a patient and thinking that the important thing was for me to be right was not what was critical for the patient. What was critical for them was that I found something to do that was acceptable to them that would help them, whatever their issue was. When I started looking at it from that perspective, I started connecting better with patients and seeing a more positive response.”

Synthesis

As a synthesis, and to look for patterns, these experiences were characterized in physicians’ words and categorized into two themes—story and connection (see Sidebar: Themes: Story and Connection).

Can All Doctors Be Like This? Seven Stories of Communication Transformation Told by Physicians Rated Highest by Patients

DISCUSSION

These stories exemplify that improvement in communication skills and relationship can be learned through various activities and experiences that transform physicians into those rated highly by their patients. Ultimately, their transformation was through their own insight and behavior change.

All described modes resulted in a change of state-–a new way of seeing, of being, of purpose—acquired through a listening tool, an awareness course, finding new meaning in clinical practice, a technologic tool, a sudden insight, a mentor observation, a physician-as-patient experience. This change of state is not just a new tool or a new practice, but a change in state of mind. This state resulted in a marked change of behavior and improvement of communication and relationship.

In communicating with their patients, these physicians listened for story, connected cognitively and emotionally, and developed and maintained relationships with people who visited them as patients and rated them highly on creating a satisfying visit experience.

The authors hope that health care leaders’ expectations optimize and emphasize the essential value for physicians of subjective empathetic activities and experiences in creating the highest patient satisfaction. We recommend that leaders offer training sessions for physicians to learn how to listen effectively and enhance relationship with patients.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgements

This project was supported in part by a grant from the Garfield Memorial Fund.

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Janisse T, Tallman K. Can all doctors be like this? Seven stories of communication transformation told by physicians rated highest by patients. Perm J 2017;21:16-097. DOI: https://doi.org/10.7812/TPP/16-097.

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