BLOG: ‘Hacking’ medicine through the betterment of communication skills
Recently, I have been reading the work of Tim Ferris, the author of The Four-Hour Workweek and others. His interests range from meditation and weight loss to investing and speed reading. The essence of his work is breaking down complex tasks into bare minimum steps, and he is fond of using medical terms such as “minimum effective dose.” Simply, he “hacks” the processes of acquiring difficult skills so they can be reproducible to the masses. His methods piqued my interest.
Similarly, Atul Gawande, MD, PhD, endocrine surgeon and accomplished writer, has written about hacking complex problems in medicine. His book, The Checklist Manifesto, chronicles the development of the WHO safe surgical checklist. It is an excellent book and something I would recommend to any provider, young or old. Gawande mentions how simple tasks in an operating room, such as introductions, can have exponentially large effects on patient safety, team work and even infection rates. He was solving complex problems with an emphasis on basic steps and mastering them. Like Mr. Ferris, he was hacking medicine.
This made me think about my strengths and weaknesses as a provider and how I have tried to hack them. Nothing I say is novel or ground breaking, nor is it intuitive. The things I say come from experience, trial and error, and the guidance of others. I would like to share them with you.
Communication: Ask the right question
Frequently, I examine patients and discuss treatments for their orthopedic maladies. After discussing the plan with them, I would ask, “Do you have any questions?” I observed many times patients had no questions. Was I that detailed? Were they not worried? Then I realized I was asking the wrong question. One of my mentors observed me in an interaction and said, “Try this: “What questions do you have?” I found this puzzling. How much of a difference could this make?
In subsequent patient interactions, I queried my patients in this new way. The result: a lot more questions. It was a revelation. What kind of prosthesis am I having? What do you mean by total knee replacement? What exactly is this injection I am getting? What is the difference between a total shoulder replacement and a reverse total shoulder replacement? How soon can I drive? When can I go back to work? I was now answering many questions as I was formulating a plan or examining the patient. I have no complaints. I was engaging patients in a new way and making them a part of the clinical decision-making process.
I asked my attending why this method was so effective. He said, “When you say, ‘What questions do you have?’ the implication is, ‘Of course, you must have questions.’ Alternatively, what people typically ask is, ‘Do you have any questions?’ The implication with that is that if you have any questions, it’s the patient’s fault for not understanding because, of course, you as the physician explained it perfectly.” It was a simple, yet effective strategy for communication.
There is much we need to improve on with effective patient communication, and this is nothing new to us. In a review by Ha and colleagues entitled, “Doctor-Patient Communication: A Review,” it was concluded that most patients complain about communication issues rather than clinical competency. According to a Wall Street Journal article in 2013 called, “The Talking Cure for Healthcare,” breakdowns in “physician and patient communication is cited in 40% or more of malpractice suits.” Patients also adhere to drug regimens better and outcomes for chronic health problems improve with good communication. Specifically for our field, in 2010, Tongue and colleagues showed orthopedic providers significantly overstate their communication skills. This ideas are not meant as criticisms. We all want what is best for our patients. What if we are just asking the right question in the wrong way?
In my first year of clinical practice, I would stand a distance away from the patient and cross my arms whenever I would interact with them. I would stand in attention and listen intently. I was serious, and I wanted to take the matter seriously and convey to the patient my seriousness (alliteration intended). The effect: “He’s so serious. Is he always this serious?” I loved talking to patients and I cared, desperately, for each of them, yet I was viewed in exactly the opposite way by the patients and my colleagues.
Confused, I asked my manager for guidance. Her answer: “You cross your arms too much.” Many people had remarked that I always stood and crossed my arms when speaking with patients. This was not a behavior that was engaging to the patient. The solution: I sat down and folded my hands on my lap or crossed my legs, or if I was standing, I would put my hands behind my back or in front but never crossed my arms.
The popular belief is that arms crossed signals defensiveness and resistance, says Karen Friedman, an international communications expert. This was hardly the effect I was intending.
However, according to body language expert, Janine Driver, this assertion is a myth, and crossing your arms initiates the creative and analytical portions of your brain. In fact, she states it is an effective strategy in a brain storming situation. She concedes, however, that most people still perceive this gesture negatively. So I stopped folding my arms across my chest, and the effects have been very dramatic; this is also evidenced by improvements in my patient scores.
I still regard myself as serious, but this small change, along with sitting down looking at the patient at eye level and smiling, has had a great benefit in my communication skills with patients.
I do not pretend to have the best communication skills, or that my interactions with patients are perfect. But just as I have not mastered my understanding of fracture care or evaluating MRIs, I am confident in saying my communication skills need just as much work. The good news is that, just as knowledge can be obtained by reading articles and books or revisiting lectures, communication skills can be learned and improved upon.
We are not born with excellent communication skills and training does help provider-patient communication. Ferris and Gawande have shown that small changes in very complex systems can have dramatic effects on abilities and outcomes. I hope these two hacks, and the related works of these authors, can improve your patient care and ability to communicate with patients.
Daniel J. Acevedo, PA-C, is a board-certified physician assistant who practices at the Orthopaedic Center of Central Virginia in Lynchburg, Va. His research interests include physician assistant education and precepting, osteoarthritis, and periprosthetic joint infections.
Disclosure: Acevedo reports no relevant financial disclosures.