Communication affects all areas of medicine. The Joint Commission assessed sentinel events and found that 66% were related to communication mishaps. Communication failures that lead to errors are often complex—resulting from hierarchical difficulties, conflicting roles, ambiguity in responsibilities, and power struggles. As rheumatologists, we pride ourselves in being good communicators. How can we improve our communication and avoid poor communication and resultant risky situations? Here are a few suggestions:
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Explore This IssueJune 2012
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- Mind your “nonverbal.” Humans send and interpret signals subconsciously through nonverbal communication—posture, facial expression, eye movement, voice tone, gestures, touch, etc. Research suggests that we use nonverbal behavior to derive the meaning of an interaction 60% to 90% of the time. This is especially true in emotionally charged situations that are typical in medicine. Physicians should be paying close attention to their patient’s nonverbal clues. Perhaps even more important, physicians need to mind their own nonverbal behavior to ensure that their body language and tone accurately mirror the words they choose.
- Use open questions. Instead of asking, “How is your rheumatoid arthritis today?” consider, “How are you doing today?” Allow the patient to tell their whole story in response to an open question. This gives patients the sense you are listening and there for them. It also allows the patient to share his or her chief concern. One-third of the time, the chief concern (e.g., struggling at work and at home) is different than the chief complaint (rheumatoid arthritis [RA]). Understanding the difference can lead to a more successful interview.
- Communicate empathy. Patients often complain about not being heard or understood by their physicians. To be empathic, work to understand the feelings of the patient and convey that understanding. Pay careful attention to nonverbal communication, listen attentively, and stay with the patient through his or her story. Reflect or summarize what you heard. Reflective listening is a therapeutic technique that improves the patient’s experience and produces results. “So it sounds like your RA is worse today,” builds that bridge. The patient recognizes that you are listening.
- Pay attention to handoffs. A handoff occurs whenever the care of a patient transfers among providers. These may occur all day long in your office between you and your medical assistant. “Please set up the patient in Room 1 for a steroid shot.” Using a few identifiers can be helpful. Consider saying the patient’s name in case you have given the wrong room number to your assistant. Handoffs occur between doctors when requesting or providing a consult. They may also occur at the end of the day, on weekends, or when departing for vacation. Consider using a standard reflective statement at the end of the handoff. “So, doctor, you want me to setup Miss Jones for a steroid shot in Room 1?” This may reduce handoff errors.
- Begin with a briefing. The Joint Commission mandated taking timeouts prior to the performance of procedures. As outpatient physicians, these may seem unnecessary, but consider a brief team meeting at the start of the day. “Jane is coming in at noon; let’s get her MRI result before I see her.” Conduct these briefings with the entire office, using active communication and checklists to assist with the day. This will make staff feel valued and will promote safer care.
- Assess your answering service. Call your own office or answering service. Do you encounter a lengthy phone tree, resulting in a long wait time? Are physicians who call you given an early option that bypasses the greeting and transfers them to a live receptionist? In a world that relies on instant communication, it is becoming harder than ever to talk to a physician. Make it easier to contact you directly.
- Review all labs, X-rays, and pathology reports and let the patient know the results. This is a simple and logical suggestion but it is not always performed. One recent study showed that 7% of physicians did not follow up on abnormal tests.1 Structure a system that allows you to check test results in a nonchaotic environment. Care is enhanced when patients can access their results.
- Accurately communicate prescriptions. Medication errors are among the top five reasons for medical liability lawsuits. Remember the five “Rs”—right patient, right drug, right dose, right route, and right time. Always double-check your prescriptions. If you handwrite your scripts, make them legible and accurate—especially when using decimal points. Over time, we will be mandated to switch to a safer alternative, electronic prescribing, so this format should be encouraged.
- Carefully consider obtaining informed consent. In brief, some of the important elements for informed consent include: 1) the nature of the illness or medical condition; 2) the nature of the treatment; 3) alternatives, if any; and 4) substantial risks in undergoing the treatment. Giving informed consent should not be delegated but should always be done by the provider. Informed consent is always a process that includes a discussion and in some cases a written agreement. For example, written consent should be considered when you prescribe a chronic corticosteroid, a disease-modifying drug, or biologic therapy. Have the patient reflect back on what they just heard. “So you want me to try hydroxychloroquine and the risk may be the occasional eye problem?” Printed handouts describing the common side effects of the drug may be helpful, too.
- Value your support personnel and listen to them. Physicians cannot perform their jobs without the help of their teams—receptionists, medical assistants, registered nurses, and many others. Team members have different vantage points and often have more time to listen to patients. To create an open environment, be approachable, and let the support team be “the eyes and ears” of patient care. We all need to value and welcome the input of others, and the best way to accomplish this is to explicitly ask for input and to show respect for your coworkers by taking their comments seriously.
Dr. Boyle is associate professor of medicine and rheumatology at Denver Health Medical Center/University of Colorado Denver School of Medicine.