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Opinion |
1 Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr., RI 1053, Indianapolis, IN 46202-5200.
Received December 8, 2000;
accepted after revision January 17, 2001.
Address correspondence to R. B. Gunderman.
Introduction
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What we've got here is a failure to communicate.Donn Pearce and Frank R. Pierson
Cool Hand Luke (screenplay)
The standards by which residents will be evaluated in the future are changing. The American Board of Medical Specialties has adopted six general competencies for all physicians [1]. These include medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice. Radiology educators need to take a close look at these competencies and determine what their implications may be for the future of radiology. To that end, this article focuses on the third of the six general competencies, interpersonal and communication skills. We spend huge amounts of time training residents to detect lesions, offer appropriate differential diagnoses, and perform procedures, but little or no time teaching them how to communicate with patients. How can we prepare residents to be more effective communicators throughout their careers as practicing radiologists?
There are important reasons for all physicians to be effective communicators. First, a clear correlation exists between the quality of communication and the level of patient satisfaction [2]. Most patients assume that they are receiving technically competent care; the quality of the patient—physician relationship is the major determinant of their satisfaction. Moreover, communication has been proven to affect patient outcomes [3]. For example, patients who highly rate the quality of communication they have with their physicians tend to require less analgesia and enjoy higher functional status [4]. Communication is also a major factor in medical malpractice suits: Low-quality communication is a higher predictor of litigation than adverse outcomes [5], and 70% of depositions show evidence of faulty communication [6]. Finally, high-quality communication with patients is associated with higher levels of career satisfaction among physicians, indicating that efforts to improve patient—physician communication can benefit not only patients but also physicians themselves [7].
Radiology residents must be given opportunities to improve their communication skills. Physician develop habits or styles of interacting with patients, and those habits can be positively influenced by appropriate educational experiences during their formative years. By helping residents adopt effective habits of patient communication early in their training, residency programs can improve patient care, enhance career satisfaction, and enrich the future of radiology itself. What follows is a discussion of six key characteristics of effective communicators—traits training programs should aim to foster—and a list of 10 practical techniques that radiology residents can be encouraged to implement as they interact on a daily basis with patients.
Traits of Effective Communicators
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It is imperative that all physicians interacting with patients and families manifest a high degree of sensitivity to their needs and vulnerabilities. Radiologic tests and procedures are routine for the radiologist, but they are usually new experiences for patients and families and may provoke a considerable degree of anxiety. Patients often regard imaging examinations as potential threats, insofar as they may reveal life-threatening diseases or injuries. Moreover, providing patients with the information they need to give informed consent brings to their attention additional risks of the procedures themselves. Physicians can not simply neglect to mention the unpleasant aspects of imaging, nor should they "sugar coat" the risks in an effort to make things easier for patients. On the other hand, such discussions can be handled in a gentle and compassionate way, and residents should endeavor to interact with families with the same degree of sensitivity they would hope other physicians would show their family members.
Courtesy
A busy attending radiologist and a resident entered a patient examination
room. Without a word to the patient, they began to discuss the patient's
condition and the appropriate technique for the examination. A minute later,
they both left the room, without ever saying hello to her or introducing
themselves. The patient later reported that she wasn't sure they realized that
she had been in the room.
Patients are human beings too, and deserve to be treated with an appropriate level of respect and civility. It can be extremely disconcerting and even humiliating to be talked to or about without having first been introduced. The health care enterprise is a complex one, especially from the patient's point of view, and patients may come into contact with a bewildering variety of health care workers during a single visit. A physician would never start an examination on a patient without first verifying the patient's identity, and patients have the same interest in knowing who is caring for them. No matter how pressed for time or overworked residents may be, even forgiving patients are likely to perceive the residents as rude if they fail to introduce themselves.
Compassion
During a prolonged interventional procedure performed under local
anesthesia, the radiologists present discussed the similarities and
differences between this patient's condition and others they had seen in the
recent past. In part because they never took time to explain to the patient
what they were doing or why, the patient later complained that the experience
left her feeling "like a piece of meat under a microscope."
Patients need to know that those caring for them view them not merely as an assemblage of organs or tissues, but as persons. This principle is succinctly embodied in the comment of another patient, who complained, "I am a human being, not a laboratory rat." Because the radiologist's expertise is based so thoroughly on images, restricting the professional gaze to the anatomic interior of the patient is an ever-present occupational liability. Yet from the patient's point of view, what the radiologist says is every bit as significant as what the radiologist does. Radiologists need not take time out to give a lecture to each patient, but nearly every patient encounter is an important opportunity for education. Taking a minute or two to educate patients relieves a good bit of their anxiety about the unknown. Moreover, administering even minidoses of teaching automatically invites the physician to look at the health care encounter from the patient's point of view (Does he or she understand what I am doing and saying?), and gives the patient the sense of being treated as a person.
Appropriateness
Because of time constraints, a team of medical students came into the
radiology department to interview a father awaiting the completion of his
son's imaging examination. He later complained, "They were rude and
asked the most ridiculous questions they could think of: whether I am married
to the child's mother, and whether I have ever been arrested for child abuse.
For God's sake, my son had a heart murmur picked up at a routine
check-up."
No template for the patient—physician encounter works well in all cases. Radiologists must be attuned to the situation at hand and adapt their approach accordingly. Even a single inappropriate comment or question can seriously undermine the relationship between a patient and a physician. Everything the radiologist says to the patient is an opportunity to assess the patient's response and to adapt the discussion accordingly, not simply a one-way transfer of information. A key to effective communication is good listening, including the ability to tune in to nonverbal clues to the patient's state of mind.
Honesty
During an imaging procedure, the radiology nurse recommended that the
resident use a particular piece of equipment. The resident informed the nurse
that her suggestion was inappropriate. Later, when the attending radiologist
entered to room to observe, he asked the resident why he hadn't used that
piece of equipment. To the patient's surprise, the resident took no
responsibility and instead blamed the nurse, who had since left the room.
Few things are more corrosive to the trust on which good patient—physician relationships depend than dishonesty. Even apparently innocuous instances of deception, the "white lies" a physician might be tempted to tell in order to provide reassurance to a patient, ultimately do more harm than good by undermining trust [8]. Because patients need to be able to entrust physicians with their lives, physicians have a duty to deal honestly with patients at all times. Patients need to know that they can confide in their doctor, that their doctor is operating not from pecuniary self-interest but out of a commitment to their welfare, and that their doctor will be there for them in times of need. When a patient perceives that a physician has acted dishonestly, word of mouth can damage the regard of many friends and family members for the whole profession of medicine. The career of every physician has been enriched by the high standard of conduct observed by professional forebears, and it is incumbent on each physician to preserve that trust for generations of physicians yet to come. If something unfortunate has happened, it is better to acknowledge and express regret about it than to attempt to cover it up.
Openness
A patient sat silently as two radiologists discussed his case. After they
left the room, the patient commented, "They never let me in on what they
were thinking. I would have liked to know why they were saying all those
things, but instead I just felt like an idiot."
Patients should be regarded not as passive recipients of medical ministrations, but as active participants in their own care. Keeping the patient "in the dark" merely breeds uncertainty and anxiety, as well as a sense of impotence that is antithetical to a strong patient—physician alliance. By getting patients actively involved in their own care, physicians can improve both the technical outcomes of care, through improved patient compliance, and patients' overall satisfaction with the care they have received [9]. Moreover, keeping patients informed and involved bespeaks a high level of physician respect that helps to preserve and promote patients' sense of their own vigor and dignity. Many of the procedures through which we put patients can seem awkward and even dehumanizing, but explanations of what will happen and why go a long way toward putting them at ease.
One of the best ways to make the experience less discomfiting is to give patients opportunities to pose questions and take the time to answer them appropriately. Many experiences in the health care arena are so new that patients may have difficulty formulating questions. In such cases, it can be helpful for the physician to offer, "Some of the patients undergoing this procedure wonder about...." Such openness helps patients feel that the radiologist understands where they are and cares enough to help them understand what is going on.
Practical Tips
These traits of effective communicators provide a theoretical underpinning
for the development of daily habits of effective communication. However, the
translation of theory into practice is not always a straightforward matter. To
show how these traits manifest themselves practically in interactions between
radiologists and patients, I list 10 simple habits of communication that all
physicians can make use of in the first few minutes of every patient
encounter. It is important that radiologists not view the first minute or two
of a patient encounter as a mere formality, an essentially meaningless
exchange of pleasantries, but that they treat it as a crucial stage in
building a healthy patient—physician relationship.
Introduce yourself, shake hands with the patient and every family member or friend in the room, and find out their names and relationship. You do not want to mistakenly refer to the patient's mother as "grandma" during the examination.
Whenever addressing the patient and family members, refer to them by name, generally using Mr., Mrs., or Ms. Make sure you have understood everyone's name correctly; if necessary, ask them to spell it.
Make eye contact with the person to whom you are speaking. It is disconcerting to be spoken to by someone who never looks you in the eye, because it creates the impression that they are avoiding something.
Touch the patient. No words can substitute.
Find out routinely how long the patient has been waiting, and acknowledge it. When the wait has been especially long, consider offering some explanation. It is possible to express regret without accepting unwarranted blame.
Convey an understanding of the patient's history. Such a demonstration provides reassurance that the radiologist "has done his homework," and gives the patient a chance to expand or clarify any important points.
Briefly explain any tests or procedures in language that the patient and family can understand. A key part of any explanation is the rationale, why the examination is being performed in the first place.
Ask if the patient has any questions. Take time to answer them, including, when appropriate, the admission, "We don't know."
Listen, giving the patient your undivided attention. It is acceptable to jot down notes as the patient talks, but those notes should pertain to what the patient is actually saying.
Look for opportunities to express respect and admiration. Telling patients and families that they are doing a good job frequently means more to them than physicians would ever suppose and enhances their ability to cope with bad news, should the need arise.
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In discussing useful techniques of communication, the teaching physician should stress that high-quality patient—physician interaction is not merely a tool to be used for some other end. Radiology residents must not be left with the impression that the techniques of effective communication deserve attention merely because they provide a means of manipulating patients to achieve more important goals, such as higher customer satisfaction ratings or reduced medical—legal liability. Rather, effective communication and the enrichment of the patient—physician relationship are worthy ends in themselves and deserve to be pursued for their own sake, regardless what other benefits they produce. They lie at the core of what it means to be a good doctor, something to which all good radiologists intrinsically aspire.
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  L. Berlin Communicating Results of All Radiologic Examinations Directly to Patients: Has the Time Come? Am. J. Roentgenol., December 1, 2007; 189(6): 1275 - 1282. [Full Text] [PDF]
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L. Berlin Communicating Findings of Radiologic Examinations: Whither Goest the Radiologist's Duty? Am. J. Roentgenol., April 1, 2002; 178(4): 809 - 815. [Full Text] [PDF]
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