Doctor/Patient Communication: Where Knowledge and Caring Meet make them every day. Whether investing extra time with your children to ensure a healthy relationship or investing in mutual funds to plan for retirement, every day you take a little extra time to work toward a brighter future for those you care about. And being a dedicated orthopedic surgeon, that extra investment surely includes your patients.

"Communicating clearly and thoroughly with patients has numerous proven advantages," states Dr. Terry Canale, an orthopedic surgeon with the Campbell Clinic in Germantown, Tennessee. "For several years I have worked with a number of colleagues through the American Academy of Orthopaedic Surgeons (AAOS) to advance the cause of improved doctor/patient communication. This effort began in 2000, when we surveyed the public to assess their level of knowledge of orthopedic surgeons and what we do. Unfortunately, we found that most people didn't know what orthopedic surgeons do, as compared to neurologists or podiatrists. Those who did know didn't think we were compassionate. When we surveyed our members about this particular issue, however, most orthopedic surgeons thought they were caring, listened well, and were accessible to their patients."

Continues Dr. Canale, "Concerned about this disconnect, AAOS has initiated a public relations effort to get the word out about what orthopedic surgeons do. Additionally, we hired sociologists and psychologists to lead courses for our members on doctor/patient communication. Because these folks come from a different training background than orthopedic surgeons, however, the two groups really weren't on the same page. We then formed a partnership with the Bayer Institute, long known for physician training, and sent orthopedic surgeons there for a week's worth of training on doctor/patient communication. The instructors at the Bayer Institute have taught over 40 Academy members to be mentors for the AAOS Communication Skills Mentoring Program. In the past seven years these mentors have taught more than 200 workshops to more than 4,000 orthopedic surgeons and residents."

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Dr. John Tongue, Chair of the AAOS Communication Skills Mentoring Program (CSMP), says "While we all like to think we're good communicators, our survey revealed that many members were less charitable about their colleagues" communication skills than their own. And the public's perception of us matched our opinions of our colleagues. What leaps to mind is the term 'high tech, low touch' a phrase AAOS Director of Marketing Lewis Jenkins uses to emphasize the gist of this important survey. In my era we were never formally trained in how to interview a patient. We simply observed staff and mentors and picked up what we could. The prevailing philosophy was, 'If you could speak English, and the patient could speak English, then you could take a history.' As it turns out, this falls pretty short of the mark, however. The truth is that we can all improve in this area."

To this end, the CSMP has partnered with the newly re-named Institute for Healthcare Communication (IHC) to develop and implement an educational program of interactive, orthopedic-specific workshops to improve patient/physician communication. Explains Dr. Tongue, "We applied the '4 E's' educational model that we learned from IHC, added orthopedic examples, and developed video vignettes of orthopedic cases. Our courses, which usually run four and a half hours, are focused presentations and discussions with no more than 30 people around a U-shaped table. Research clearly shows that interactive education results in longer retention of important information and concepts than didactic lectures. Also, we now understand, compliments of IHC, that adults learn best by comparing differences. This means that when I discuss an issue with colleagues who may have different perspectives of a form of treatment, I may choose to adopt some of their ideas. The goal is to consider several differing opinions and practices rather than just letting an expert tell other physicians they need to do things differently."

Traditional training for orthopedic surgeons includes rigid plates, rods and external fixators for fracture care. Nowadays, the leaders in doctor/patient communication have widened the scope to include other, less tangible points of learning. States Dr. Canale, "There is a huge difference between what we are taught in medical school and what this program is teaching. We use a framework of the four E's: engagement, empathy, education, and enlistment. Engagement involves the initial meeting with the patient. When you walk in the room you have only five seconds before he or she forms an opinion of you. Start out by knocking on the door, smiling, and addressing the patient professionally, in particular if that person is older. Dress professionally, maintain eye contact, sit down in order to be on the same level with the patient, and touch the patient briefly in order to connect. Don't say, 'Are you doing well?' because this person may feel like his leg is falling off. Just say, 'How can I help you today?'"

Continues Dr. Canale, "Empathy, while hard to define and teach, is the most important element of the interview. A rough definition would be 'how the patient perceives you thinking about him or her and whether or not you care.' Your goal here is to get the patient on your team. The most important part is your ability to listen to the patient. Research has shown that a typical orthopedic surgeon will interrupt a patient after 19 seconds. We have also found, however, that if you let patients talk until they can't talk anymore, they will finish up within two minutes. You want to tell them what you know and they want to tell you what they know. But remember, a patient doesn't care how much you know until he knows how much you care."

Dr. Tongue couldn't agree more. "Empathy, or demonstrating to the patient that you understand how they feel, is often lacking in doctor/patient communication. Research finds that the average orthopedic surgeon might offer one empathic statement during a new patient interview—often they use none. Yet the most valued concern from the patient's perspective is that we connect with them. Sympathy often masquerades as connecting, but it is a poor substitute and often comes across as patronizing. In our CSMP workshops we use role-playing to get doctors accustomed to using some of these techniques. The doctor playing the role of the patient often admits to feeling better about the communication when the person in the doctor role expresses empathy. This role-playing reinforces the importance of empathy. It seems to be incredibly difficult for some doctors to simply say something like, 'This must be frustrating (frightening, difficult, overwhelming) for you.' My theory is that doctors might be afraid they'll be seen as a Dr. Marcus Welby who is willing to spend the rest of the day chatting with this patient!"

"Research confirms that if we do not connect with our patients and address their concerns, the time required to care for them will actually increase due to repeated references to those concerns not being addressed, phone calls to staff and to you, and family members expressing their uncertainty regarding the patient's care" states Dr. Tongue. "We tell workshop participants that if they ask an open-ended question, patients expect to be interrupted, so try saying, 'Tell me more,' and letting the silence work for you to encourage the patient to tell their story. Within two minutes you will get 80% of what you need. While the content may be jumbled-up, and you have to listen closely, the patient's explanation will help you evaluate his or her reasoning power and ability to be descriptive. Today in America, listening is often defined as waiting to speak! The bottom line is that listening to our patients demonstrates our respect for them."

As for the third 'E,' education, it's more familiar to physicians. "Educating patients is what we do best," says Dr. Canale. "In the Communication Skills Mentoring Program workshops, we let people know that it's easy to overwhelm a patient with a lot of medical terms. It's important to use plain, clear language to ensure that the person understands what you are saying. And you also want to understand patients' preconceived notions, as many times they come in with a predetermined diagnosis, such as cancer. Patients should be checked throughout the educational phase of the interview to assess their understanding of what is being discussed. Patient questions should be encouraged now, not just at the end of the interview. We instruct physicians to say, 'This is what I think is going on with you. How does that fit with what you think?' They will feel like you are working from a position of shared decision-making. This paves the way for the fourth 'E,' enlistment. If you have laid all of the groundwork, it should be easier to enlist patients into the treatment plan."

Adds Dr. Tongue, "Enlistment techniques include summarizing your salient points before you leave the room, writing out your instructions, and not leaving the room without ensuring that the patient understands everything you have said. Say something like, 'Mrs. Jones, let's make sure you and I are on the same page. Can you tell me what exactly you will tell Mr. Jones about what I said today?' That way, the patient feels like you care, and you know you won't have to spend extra time reviewing information at a later appointment."

With the volume of orthopedic information expanding daily, not to mention the challenges of managing a practice, doctors might think that taking extra time to ensure good doctor/patient communication is just too much to deal with. Not so, says Dr. Tongue. "Four thousand orthopedic surgeons and residents have participated in more than 200 AAOS CSMP workshops over the past seven years. They describe many communication-related frustrations because of gaps and miscommunication often related to patients'; hidden issues. They truly enjoy and appreciate learning research-based techniques to help close those gaps, allowing them to practice better medicine. Our courses are carefully evaluated, and they are consistently rated highly. Doctors are learning that these techniques make them more efficient and productive. Adopting selected communication techniques reduces their liability exposure, improves their work satisfaction, and creates happier patients. Significantly, they will also reduce the time they will have to spend on callbacks or for a family conference because mom never understood or could not recall important information from the first appointment."

What are some of these pearls of wisdom? Says Dr. Tongue, "Doctors are often a bit undone when patients come in with two or three complaints. To help them triage, so to speak, we suggest that instead of saying, 'I understand you are having problems with your left shoulder,' we say, 'How can I help you today?' When they say, 'My left shoulder hurts,' we reply, 'Is there anything else?' to which they might respond, 'My left knee is killing me and I have a bad bunion.' You can then explain that because the shoulder is chronic and can wait, and the knee problem is most important to the patient, it ought to be addressed immediately. You can save time by letting the patient know that you'll discuss the knee problem now and that the shoulder problem can be rescheduled; you might also offer to make an appointment with your partner for the bunion. If you don't get everything out in the open at the beginning, you will have gone through the whole shoulder issue, and as you're leaving, the patient will say, 'Oh, by the way doc...' and bring up the knee and bunion problems when you have your hand on the door! In their eyes it seems you are shorting them if you have not negotiated the patient's agenda up front. Early negotiation allows you to explain the limits of your time with the patient in the context of their best interests and shows respect for all their concerns."

Another tip from Dr. Tongue: "Instead of providing a well-rehearsed monologue of the patient's condition and recommended treatment, I advise using a 'speak-check-speak-check' technique, where we say 50 or 100 words and then check to see if the patient has understood what we have said. You can say, 'Is this making sense?' and then get them to respond with more than a nod of the head. If we talk at length, whether using the patient's own words or using a lot of technical jargon, respectful or shy patients will often shake their heads as in, 'Yes, I understand,' when they really don't."

As in many life situations, it's how you phrase things that makes a difference. Says Dr. Tongue, "A great technique at the end of an interview is to improve how we elicit questions. Instead of, 'Do you have any questions?' we suggest the best thing to say is, 'What questions do you have?' with an uplifting tone of voice that suggests that questions are expected. When asked, 'Do you have any questions,' patients will often say 'no' because they believe you should have covered everything, and they want to be respectful. Unlike cardiac surgeons, we must do long-term follow-up on our patients, and we must be concerned with adherence to the treatment plan. Otherwise the outcomes will not be what everyone expected."

Continues Dr. Tongue, "In our CSMP workshops we maintain an atmosphere in which we are all learners. Two mentors facilitate each highly interactive session with between six and thirty participants. We present the premises and research, including the educational model of the '4E's,' and mix in orthopedic-specific video vignettes with mini-breakout sessions. We ask participants to list their frustrations about patient interviews and then offer techniques during the remaining workshop to help close the gaps in communication that led to their frustrations. Every workshop is different. We have now completed workshops for more than 2,000 practicing members of AAOS and half the residency programs in the U.S. We return to each residency every two to three years. The feedback from the workshops is fantastic. If it's a mandatory part of a residency program on a beautiful Saturday morning, residents might come up to us and say, 'I didn't want to be here, but this was terrific! I want to try out these techniques.'"

Perhaps if a surgeon reflects on a time when he or she was the one sitting on the exam table, new ideas about communication will crop up. States Dr. Tongue, "I notice that patients are often reluctant to inquire about a surgeon's level of experience with a procedure, perhaps because to pose such a question could seem disrespectful. I volunteer that information so that patients are more comfortable. We also need to take into account someone's lifestyle. I recently did a shoulder reconstruction on a barber, who regularly needs to raise his elbow away from his chest. While in post-op, I made a point of reviewing his work issues with him, which gave him confidence that we were on the same team. It's also sometimes a good idea to ask the patient to tell you the most important concern they have at that moment because the answer can be valuable and ultimately save you time. Another time-saver, before discussing your initial assessment of the patient's diagnosis and treatment, is to ask the patient, 'What have you been thinking of doing about this problem?' Such a statement is respectful and is a true reflection of patient-centered care. The more you get the patient to open up, the less chance there is of patients going elsewhere for their care, or someone saying after a procedure, 'Why didn't you tell me about this?' As a rule, my patients are well prepared and educated, so there are few surprises, frustrations, or angry words toward yours truly. And don't forget to pull out your sense of humor from time to time when it's appropriate, remembering that being self-deprecating will never offend your patient."

Dr. Tongue notes, "The AAOS Communication Skills Mentoring Program offers many resources, including outreach. With more than 40 trained mentors across the country, we can travel to orthopedic departments, practice groups, specialty meetings, or state organizations to present these highly rated educational programs, while providing Category 1 CME credits."

Dr. Canale's final comment: "This concentration on patient communication is paying off. The topic is now being considered as one of the areas of competency by the residency review committee. Our goal is to reach all 16,000 members of the Academy, who all could benefit from this training. Aside from the previously mentioned benefits, many insurance companies offer discounts for physicians who have attended our training. That's yet another incentive to learn and implement this new skill set."

Dr. Tongue adds, "When you have a deep well of goodwill with a patient and that person knows you're both 'in this together,' he or she will be less upset if something goes wrong. Developing that goodwill is something we can all improve."

The most important incentive? Mrs. Jones in 6E. She's scared, intimidated, and hesitant. But in the hands of a surgeon who understands and commands the nuances and techniques of patient-centered communication, her anxieties will decrease and she will have a sense of confidence about her medical situation.

Written by Elizabeth Hofheinz, MEd, MPH