Teachable Communication Skills
- Hannah Todd
- Apr 3, 2022
- 5 min read
In my last post, I talked about findings from the Clinicians of the Future report stating that patients want to be “heard, understood, and involved in decisions”. They cite this as a change in patient expectations, but they give no guidance on how to accomplish compassion (or empathy, the term they use in the report) in practice to make patients feel this way. They even go so far as to say that empathy cannot be taught. There is considerable discussion in the literature about whether compassion/empathy skills can be taught, and actually there is evidence that these are evolutionary traits which can be promoted, coached, and encouraged. Of course people do have different strengths and weaknesses, and while some people are more compassionate than others at baseline, there are behaviors that we can teach to upcoming medical professionals (and current providers) that are perceived as being compassionate by patients, and that serve to improve the therapeutic alliance.
As a prime example for actionable change, one study[1] found that, after asking a patient about their chief complaint, the provider then interrupts the patient after just 11 seconds of listening. Not only is this rude, but it conveys to the patient that their story and lived experience are unimportant. Additionally, it leads to loss of potentially relevant information for correct diagnosis. In school, we learn that at least 80% of the information required to make an accurate diagnosis is provided during the patient interview. Imagine what kind of diagnostic accuracy we could have if we allowed patients to tell their story without interruption. On average, a patient only takes 37 seconds to tell their entire story. All patients in the study were finished talking after 2 minutes. Listening for 40 seconds could eliminate 5 minutes of follow up questions, as well as making the patient feel heard and understood.
Time is tight in the medical world, but I think we all have at the very max 2 minutes to spend listening without interruption. This would create trust, build therapeutic alliance, and lead to more accurate diagnoses. Furthermore, a different study illustrated that providers miss up to 79% of opportunities for compassionate connection via acknowledging and validating a patient’s emotions during the initial patient interview [2]. If you, as a provider, are waiting for the best time to interrupt to further your own agenda for the conversation, you will definitely miss bids for connection. By allowing the patient to speak freely for an average of 37 seconds, we could give patients respect, listen for opportunities to demonstrate compassion (like saying “wow that sounds really hard” or raising eyebrows or shaking your head in commiseration or making eye contact or, or, or…), in addition to getting the full picture for diagnostic accuracy. These are teachable behaviors that we definitely have enough time to build into our busy schedules as providers. Let me illustrate this with an example.
I had a patient recently who has had neck problems for 50 years. He was in a horrific car accident in his 20s, but that was a long time ago, and he has no idea what his initial injuries were because imaging and health care priorities were so vastly different. He pursued treatment for his neck issues several years ago, but his providers did not listen to him about his body, they pushed him too far too fast, and he stopped going to physical therapy after 2 visits. He started to become alarmed when he recently lost strength quickly and had decline in function in both arms, especially his hands, as well as excruciating shoulder pain that prevented him from sleeping. Prior to arriving at my therapy clinic, this patient went to an orthopedist, who gave him cortisone injections for possible carpal tunnel and sent him to therapy for potential rotator cuff pathology.
When I started treating him, he did not share any of this information about his neck. All the rotator cuff special tests were negative, and he definitely did not have carpal tunnel, but he clearly had bilateral weakness. He mentioned quietly that he might stop driving because he couldn’t turn his neck at all. I attempted to ask him about neck symptoms/history, but he gave a vague non-answer and we moved on. He had about 5 degrees of cervical spine motion in any direction upon examination. He didn’t share any of his neck history with me until our 4th one on one, hour long visit, when he experienced some strange sensory changes outside of a typical referral pattern. He got scared, and because we had a foundation of trust and consent for treatment, he finally told me the whole story. After taking two additional visits to convince him to undergo spinal imaging to clear any type of spinal cord impingement (thankfully imaging was negative), it took a whole 3 more visits to convince him to allow me to add some gentle neck exercises to his routine.
This patient is now finished with therapy. His upper extremity symptoms were caused by his latent neck pathology. He increased his neck range of motion by over 400% in each direction. He can reach all the shelves in his house, carry groceries, and he can play guitar again. He can sleep through the night comfortably most nights. In a physician’s office with a 10 minute visit, it would be impossible to make this patient feel safe enough to disclose his entire medical history, to answer his questions/address his concerns, and to educate him about his possible treatments and treatment outcomes. This is probably why his orthopedist incorrectly diagnosed him with carpal tunnel and rotator cuff pathology. These conversations also wouldn’t happen in an over-scheduled therapy clinic, with one therapist covering 3-4 patients at a time. They definitely wouldn’t have happened if I had interrupted him in the first 11 seconds, since he would have stopped coming back to therapy as he did with his first therapy attempt.
In the age of empowered patients, where paternalistic care isn't cutting it, our treatment times should be increasing, not decreasing. We should be given ample time to build relationships, listen to our patients, and have real conversations to provide real patient education. These skills ARE teachable, and by writing them off as just personality characteristics instead of recognizing them as integral medical skills, we devalue them to the point where only 18% of medical providers think that empathy is a crucial skill. And we fail to teach them adequately in medical training programs. Patients are suffering. We aren’t letting them tell their stories, and when they are speaking, we are planning our next interruption rather than actually listening and processing.
Imagine if schools trained providers by saying, “One intervention that you can perform immediately, to double adherence to treatment protocols, decrease pain levels, and speed healing time, would be to listen without interrupting when you ask your patient what’s wrong. During the 1-2 minutes that they spend telling you the history of their chief complaint, make at least 2 nonverbal acknowledgements of the patient’s distress/suffering.” And then, what if we tested health care students on these skills during practical examinations, which they already undergo for other aspects of patient care. It could be transformational to the entire health care system.
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