In the Journals

Researchers identify ways to improve physician-patient visits

Findings of a mixed methods study in JAMA identified five ways to improve patient-physician visits: prepare for a meaningful interaction, listen attentively and completely, agree on health goals, connect with the patient, and tune in to emotional hints.

“Human connection remains central to medicine but is in jeopardy in the current health care environment.,” Donna M. Zulman, MD, MS, of the primary care and population health division at Stanford University School of Medicine, and colleagues wrote. “In an era of increasing reliance on technology for health records, diagnosis, and treatment, recognizing and prioritizing the value of human connection and care are crucial.”

Researchers observed 27 primary care visits in three different settings to identify practices that promote clinician presence, focus and attention. They also conducted qualitative interviews with 10 physicians, 27 patients and 30 nonmedical professionals. These research activities and a systematic review of 73 studies ultimately yielded the five practice recommendations.

Prepare for meaningful interaction

Zulman and colleagues recommend practicing “personalized preparation,” during which the physician peruses the patient’s pre-visit surveys (if applicable) and reviews the patient’s medical conditions, life circumstances and back story. They also recommend taking a moment to pause and focus before or at the beginning of the visit through mindfulness exercises such as deep breathing and handwashing.

Zulman DM, et al. JAMA. 2020;doi:10.1001/jama.2019.19003.

“Although a mindfulness-oriented practice might not appeal to all clinicians, experts generally agreed that it requires minimal training, is easy to implement in varied and busy clinical settings and can be tailored per personal preference,” Zulman and colleagues wrote.

Listen attentively and completely

The researchers stated that the first part of this two-pronged recommendation — “listening with one’s whole body using open and receptive body language” — consists of sitting down while with a patient, leaning in towards the patient, arranging one’s body toward the patient, and keeping an open body position by using gestures that convey openness and respect. Examples of this include making eye contact with the patient and allowing him or her to view computer screens that contain their information.

In the second prong of the recommendation, the physician lets the patient speak without interrupting, uses silence as a productive tool and asks pointed questions.

“When physicians listen attentively and avoid interruptions during opening monologues, patients communicate more, provide more medical information and report greater satisfaction,” Zulman and colleagues wrote.

Listening without interruption reduces anxiety without substantially extending the duration of the visit, according to the researchers.

“Using silence can also reduce the incidence of ‘doorknob syndrome,’ i.e., when a patient raises new concerns at the very end of the visit,” they continued.

Researchers added that this component also requires minimal training and that physicians need to be aware of a patient’s language barriers and cultural preferences when implementing it.

Agree on health goals

Zulman and colleagues stated that physicians can easily implement this recommendation by asking a patient “What brings you here?” or “What is your main question or concern for today?” The patient’s answers should be apparent in subsequent discussions during the visit. Then, towards the end of the visit, the physician should ask “is there something else you want to address in the visit today?”

The researchers also wrote that, “understanding what matters to a patient is at the core of patient centered, humanistic care, and when achieved early in the visit, helps set the stage for meaningful encounters.”

They added that this recommendation lowers the number of concerns brought up at the appointment, improves patient satisfaction ratings and reduces patients’ pain and anxiety.

Connect with the patient

Connecting with patients by asking about their sociocultural backgrounds and personal circumstances has also shown to improve patient satisfaction ratings, according to Zulman and colleagues. In addition, this practice has been linked to lowered racial biases and improved quality of care, leading to fewer subsequent patient visits.

Physicians can also connect with patients by acknowledging their efforts in a genuine, positive manner and celebrating successes by using language that conveys approval, empathy, partnership and reassurance. These actions have been linked with positive patient health outcomes and higher numbers of patients involved in their own care, Zulman and colleagues stated, adding that there is mixed evidence on how easily this recommendation can be implemented in practice.

“While rigorous evaluations of this practice examined in-depth training for multiple communication behaviors, expert panelists thought that the use of positive framing and language could be adopted with minimal time and resource investment, and that this practice could contribute to the joy of practice,” they wrote.

Tune in to emotional hints

The last recommendation centers on exploring emotion by interpreting a patient’s verbal and nonverbal emotional cues, evoking patient emotions by asking questions such as “How are you doing?” or “How are you feeling about this?” and making comments that demonstrate understanding of a patient’s emotions such as “That sounds very difficult” or “I can see that this is affecting you deeply.”

Accurately perceiving emotional cues could require more training among clinicians. Therefore, researchers noted that this particular recommendation may need a greater resource investment than the others, and it could increase a patient’s office visit time. However, previous studies suggested these potential barriers are offset by the benefits of its implementation.

“A large body of evidence suggests that clinician interpersonal sensitivity, including the ability to perceive patient emotions, is associated with positive patient outcomes, including patient satisfaction, appointment adherence and learning of conveyed information,” Zulman and colleagues wrote. “While individuals’ emotional sensitivity may vary widely, research shows that patients appreciate physician attempts to elicit and identify their emotional cues, even when the clinician is mistaken.”

Related editorial

Lisa Sanders, MD, of Yale Internal Medicine at Yale New Haven Hospital, and colleagues wrote that these five practices are already well-known in the medical community, but their impact will be limited until “fundamental barriers” — such as the burden of electronic health records and heavy workloads — are addressed. It will also be difficult to implement these practices for patients with challenging conditions “no matter what is in a physician’s toolbox,” according to the authors.

Sanders and colleagues added that “physicians need to move beyond gestures and techniques to recreate a system that values the patient-physician interaction and recognizes that this relationship is one of the most powerful diagnostic and therapeutic tools in medicine.” They concluded that the missing link to achieving to this re-creation is a “system that supports and values this critically important relationship.” – by Janel Miller

Disclosures: Sanders and Zulman report no relevant financial disclosures. Please see the study and editorial for all other authors’ relevant financial disclosures.

Findings of a mixed methods study in JAMA identified five ways to improve patient-physician visits: prepare for a meaningful interaction, listen attentively and completely, agree on health goals, connect with the patient, and tune in to emotional hints.

“Human connection remains central to medicine but is in jeopardy in the current health care environment.,” Donna M. Zulman, MD, MS, of the primary care and population health division at Stanford University School of Medicine, and colleagues wrote. “In an era of increasing reliance on technology for health records, diagnosis, and treatment, recognizing and prioritizing the value of human connection and care are crucial.”

Researchers observed 27 primary care visits in three different settings to identify practices that promote clinician presence, focus and attention. They also conducted qualitative interviews with 10 physicians, 27 patients and 30 nonmedical professionals. These research activities and a systematic review of 73 studies ultimately yielded the five practice recommendations.

Prepare for meaningful interaction

Zulman and colleagues recommend practicing “personalized preparation,” during which the physician peruses the patient’s pre-visit surveys (if applicable) and reviews the patient’s medical conditions, life circumstances and back story. They also recommend taking a moment to pause and focus before or at the beginning of the visit through mindfulness exercises such as deep breathing and handwashing.

Zulman DM, et al. JAMA. 2020;doi:10.1001/jama.2019.19003.

“Although a mindfulness-oriented practice might not appeal to all clinicians, experts generally agreed that it requires minimal training, is easy to implement in varied and busy clinical settings and can be tailored per personal preference,” Zulman and colleagues wrote.

Listen attentively and completely

The researchers stated that the first part of this two-pronged recommendation — “listening with one’s whole body using open and receptive body language” — consists of sitting down while with a patient, leaning in towards the patient, arranging one’s body toward the patient, and keeping an open body position by using gestures that convey openness and respect. Examples of this include making eye contact with the patient and allowing him or her to view computer screens that contain their information.

In the second prong of the recommendation, the physician lets the patient speak without interrupting, uses silence as a productive tool and asks pointed questions.

“When physicians listen attentively and avoid interruptions during opening monologues, patients communicate more, provide more medical information and report greater satisfaction,” Zulman and colleagues wrote.

Listening without interruption reduces anxiety without substantially extending the duration of the visit, according to the researchers.

“Using silence can also reduce the incidence of ‘doorknob syndrome,’ i.e., when a patient raises new concerns at the very end of the visit,” they continued.

Researchers added that this component also requires minimal training and that physicians need to be aware of a patient’s language barriers and cultural preferences when implementing it.

Agree on health goals

Zulman and colleagues stated that physicians can easily implement this recommendation by asking a patient “What brings you here?” or “What is your main question or concern for today?” The patient’s answers should be apparent in subsequent discussions during the visit. Then, towards the end of the visit, the physician should ask “is there something else you want to address in the visit today?”

The researchers also wrote that, “understanding what matters to a patient is at the core of patient centered, humanistic care, and when achieved early in the visit, helps set the stage for meaningful encounters.”

They added that this recommendation lowers the number of concerns brought up at the appointment, improves patient satisfaction ratings and reduces patients’ pain and anxiety.

Connect with the patient

Connecting with patients by asking about their sociocultural backgrounds and personal circumstances has also shown to improve patient satisfaction ratings, according to Zulman and colleagues. In addition, this practice has been linked to lowered racial biases and improved quality of care, leading to fewer subsequent patient visits.

Physicians can also connect with patients by acknowledging their efforts in a genuine, positive manner and celebrating successes by using language that conveys approval, empathy, partnership and reassurance. These actions have been linked with positive patient health outcomes and higher numbers of patients involved in their own care, Zulman and colleagues stated, adding that there is mixed evidence on how easily this recommendation can be implemented in practice.

“While rigorous evaluations of this practice examined in-depth training for multiple communication behaviors, expert panelists thought that the use of positive framing and language could be adopted with minimal time and resource investment, and that this practice could contribute to the joy of practice,” they wrote.

Tune in to emotional hints

The last recommendation centers on exploring emotion by interpreting a patient’s verbal and nonverbal emotional cues, evoking patient emotions by asking questions such as “How are you doing?” or “How are you feeling about this?” and making comments that demonstrate understanding of a patient’s emotions such as “That sounds very difficult” or “I can see that this is affecting you deeply.”

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Accurately perceiving emotional cues could require more training among clinicians. Therefore, researchers noted that this particular recommendation may need a greater resource investment than the others, and it could increase a patient’s office visit time. However, previous studies suggested these potential barriers are offset by the benefits of its implementation.

“A large body of evidence suggests that clinician interpersonal sensitivity, including the ability to perceive patient emotions, is associated with positive patient outcomes, including patient satisfaction, appointment adherence and learning of conveyed information,” Zulman and colleagues wrote. “While individuals’ emotional sensitivity may vary widely, research shows that patients appreciate physician attempts to elicit and identify their emotional cues, even when the clinician is mistaken.”

Related editorial

Lisa Sanders, MD, of Yale Internal Medicine at Yale New Haven Hospital, and colleagues wrote that these five practices are already well-known in the medical community, but their impact will be limited until “fundamental barriers” — such as the burden of electronic health records and heavy workloads — are addressed. It will also be difficult to implement these practices for patients with challenging conditions “no matter what is in a physician’s toolbox,” according to the authors.

Sanders and colleagues added that “physicians need to move beyond gestures and techniques to recreate a system that values the patient-physician interaction and recognizes that this relationship is one of the most powerful diagnostic and therapeutic tools in medicine.” They concluded that the missing link to achieving to this re-creation is a “system that supports and values this critically important relationship.” – by Janel Miller

Disclosures: Sanders and Zulman report no relevant financial disclosures. Please see the study and editorial for all other authors’ relevant financial disclosures.