The physician executive can help improve doctor-patient relationships.

An integral part of the physician executive's job, but one that is not relished, is confronting clinicians when they are doing something wrong. If the problem involves nedical skills, the confrontation cannot be delayed, but if it involves interpersonal relationships, individuals and organizations will sometimes let the issue slide too long. If physicians have good clinical skills but bad bedside and office manners, they will lose patients. As competition increases, organizations are increasingly realizing that they must address these problems and solve them quickly before patients take their business elsewhere.

Physicians who get and keep patients will have good communication skills as well as technical expertise. When patients, nurses, or colleagues see a physician yell, throw things, or slam the phone down in disgust, they get uneasy. They think they may be the next target of the physician's anger or that the bad mood will "get on them," much like a big truck racing through a mud puddle splashes dirty water on people on the curb. The physician executive is most likely the one who has to talk to the clinician about changing behavior when it becomes a problem for others.

Often patients want one thing, while the doctor wants another. The patient wants time. There may be a waiting room full of patients, and the doctor doesn't have the time to give. The patient wants to tell all the information he or she knows. The doctor wants to delve for only the pertinent facts. In any situation where people have different goals, there is the potential for communication problems.

Twenty years ago, physicians didn't have to be so concerned with communication skills. I grew up going to a family physician who took good care of my colds, flu, and a severely burned arm. He was gruff and grumpy and talked very little. I didn't like how he acted, but I revered him because my family did. I didn't think I had any choice in the matter. Now the public has found it has a choice. People are changing physicians because they don't like the way they act. A survey of more than 500 patients "...found that 85% either had changed their physician in the past five years or were thinking of doing so. The main reasons cited for changing physician were related to the style or personality of the physician.... The most consistent finding in the satisfaction literature is that characteristics of the provider or organization that make care more 'personal' are associated with higher levels of satisfaction. Good communication skills, empathy, and caring appear to be the strongest predictors of how patient will evaluate the care received." [1]

Patients' perceptions of the quality of care are different from physicians'. Physicians think about scientific matters--patients want to feel cared for first because they can more easily measure that. In another context, imagine you are on the runway in a airplane and the pilot begins to talk. He talks poorly, inexactly. "We'll be taking off some time here. Hope it won't be too long. I think the weather won't be too bad. I'm not sure when we'll get there." You're nervous right off. Then, later in the flight, you pull down the tray and find food on it. People think if airlines don't clean the trays, they don't maintain the engines properly. You hope you land safely, and then you swear never to fly that airline again. None of us are ever sure that the pilot knows what he is doing, so we look to little things for reassurance.

The same is true for physicians. Patients don't think about the degrees and fellowships hanging on the doctor's wall. Patients cannot be sure of physicians' technical competence, because they don't know what doctors know, so they concentrate on whether physicians are nice to them or not. If physicians don't look them in the eyes, if they don't lean forward a little when they talk to patients, if they use jargon that makes patients feel dumb, patients don't like them, even if they know what they are doing. In the doctor's office and in the hospital, people are closer to naked than they want to be. They are full of emotion. They are often cold and frightened. The big machines that clinicians use terrify them. They need to be reassured, listened to, and talked to gently.

Patients want more than they used to and are willing to shop around to get it. The physician executive is the one ultimately in charge of seeing that they get it. He or she can explain to clinicians what patients want and help them learn how to give it. The following is advice that a physician executive could give to physicians for whom they are responsible.

Patients want a doctor who:

* Shows warmth and concern.

* Gives them enough time to say what they want to say.

* Demonstrates that he or she understands what the patient has said.

* Speaks simply to them.

* Tells them what is wrong and what to do in an unhurried manner.

How do you show warmth and concern?

When you enter the examining room, smile, shake hands, say "Good morning, Ms. Jones, how are you today?" If the patient replies, "Not so good," say, "I'm sorry to hear that. Can you tell me about it?" Look them in the eyes. Don't stare at the chart and write the whole time.

* Try to discover and acknowledge their fears. When you do, they feel close to you and feel that you really care. If you guess at their feelings and you're wrong, they will tell you what they are feeling.

* Hand them a tissue if they cry. If you can just wait a few minutes while someone cries and not try to fix it immediately or stops it, you give them a special gift.

* Do not make derogatory remarks. If someone has heart problems and they are overweight, don't sarcastically say "Well, no wonder." Calmly say, "Among other things, you will need to lose weight to lessen your chances of a heart attack."

Warmth can also be conveyed by touching. Touch on the hand occasionally (especially in the hospital) if you can get comfortable with that. "In no other professional relationship is the requirement for the human touch greater than between physician and patient. Lest we forget, human touch is not the mere laying on of hands, but an ineffable presence of the physician: that presence must reach beyond the body to the patient's mind and very spirit." [2]

Because of potential charges of sexual harassment, physicians need to be careful with touch. Shaking hands is a safe way of touching. Decide to touch on the basis of how sick patients are or how bad they feel. If they feel bad, touch them. If it is a routine physical, a handshake will do. A light pat on the hand or arm shows you care. However, if patients are acting seductive in any way, don't touch them other than to examine them.

How do you give them enough time to say what they

want to say?

Get quiet and listen. If you sit down and look at them, they think you are giving them more time than if you stand, write in the chart, and never look at them. Have some small talk in the beginning to break the ice. "Orlando cardiologist H. E. Gross said, "I always make an effort to sit at the bedside rather than stand at the end of the bed with one foot out the door.... You sit at the bedside and look 'em in the eye and ask them about their life and job. You find out where they were born and raised and ask them about their families. Then you really get to know them rather than diving right in and asking them about their chest pains.'" [3]

At the beginning of sessions, let them talk for at least a minute. (By the way, they will tell you more if they have their clothes on.) The following is an example of a patient complaint that I will use in the rest of the article to illustrate how to respond to it. "I had the flu about a month ago. I had sore throat, coughing, and my usual sinus infection. I can't stop coughing. I tried Tussionex, Delsyn cough syrup, and a series of cortisone that seemed to make it worse. My allergist suggested the cortisone. No cough drops work. Every time I eat, it's worse, and I have a coughing fit. My career is over if you can't fix this. I make my living standing up talking to people. I can't do that if I'm going hack hack hack."

I've talked to a few physicians who said they let the patient talk five minutes or until they want to stop, but a study at Case Western Reserve said that the average doctor interrupts the patient after 18 seconds. The patient may want to ramble on about something that happened in 1946, their best year, so let him or her talk about it a little. If this is difficult for you, put a clock where you can see it and watch it without being obvious. Nod your head, move your eyebrows up and down, say "uh huh" to let the patient know you are listening.

Then you can take control of the interview.

* Ask open-ended questions to get more information. They start with who, what, wherem when, why, and how. What would you like for dinner? is open-ended. Do you want fish for dinner? is closed. Closed questions invite a simple yes or no. You can train someone to be passive in the first five minutes of a conversation by asking closed questions. He or she will just say yes and no and not give you more information.

If you are in the emergency department and must ask questions quickly, try saying to the patient, "I need to ask you about 15 questions to find out how to help you. I'll move quickly and write some, but I'll be listening carefully to you on one question, I'll stop you and ask you to go to the next one." People respond better if you tell them what you are going to do before you do it. They are prepared and feel they have some control.

* Search for the emotional part of the illness. Ask, "How are you feeling about this?" If they say, "Scared," validate the feeling. Say, "I can see why you would be." When patients acknowledge their fears, some of the fear is lessened.

* Give a verbal signal that time is limited. Patients often are afraid to tell you something, and they put it off till the last minute. To let them know the end is coming so they can get this information out, say, "I've enjoyed seeing you. Before we end here, I want to review how to take these medications."

How do you demonstrate that you

under what the patient has said?

Restate or summarize what the patient has said to you. Example: So you are has said to you. Example: So you are coughing all the time. It's worse when you eat. Tussionex and cough syrup didn't help, and cortisone seems to make it worse." You can then ask, "Do I have it right?" or "Is this what you meant?"

How do you speak to them simply?

* Assume that most medical terms are unfamiliar to the patient. Many people do not know what you mean when you say anterior, posterior, asymptomatic, etc. Explain these words without implying that the patient is not bright. Example: "I think you have a hiatal hernia with esophageal reflux. That means there is a weakness in the muscle at the bottom of your esophagus that allows the gastric acid from you stomach to go up into the esophagus. This irritates the tissue in the esophagus and the back of the throat, which sends a message to your brain to cough.

* Be careful about the tone of your voice. Don't talk in a monotone. Do not sound sarcastic. If you don't know whether you do these things or not, ask someone or look at yourself on videotape.

* Speak slowly--not too loudly or softly.

* Have one piece of information in each sentence and then pause.

How do you tell them what is wrong and what to do in

an unhurried manner?

* Slowly tell the patient what is wrong. Example: We'll need to take some x-rays to be sure. It will be an upper GI series, which means you will drinks a chalky substance that doesn't taste too bad. As it goes down your throat and esophagus, we will take pictures to see if a hiatal hernia is present and if acid from your stomach is going into your esophagus.

"I'm giving you two drugs--reglan and pepcid. They usually help this condition fairly quickly. Pepcid reduces the acid produced in your stomach, and reglan tightens the muscle at the base of the esophagus. Take them at night before you go to bed. These flareups will usually settle down in a couple of months."

* Plan to repeat difficult instructions. After you tell someone bad news, they don't hear anything else. If you say the word "cancer," patients are overcome with fear, and many minutes may pass before they hear your words again.

* Write down instructions and give them to patients to take home. Do this in addition to telling them--not in place of.

* Ask the patient, "Will it be difficult for you to follow this treatment plan? This gives them a chance to let you know if they plan to follow your directions. You may be able to suggest ways they can overcome perceived difficulties.

You want to be sure the patient understands what you say. Don't imply that they may be too ignorant to understand what you have said. Take the burden on yourself and imply that you may not have been clear. Example: "I want to be sure that I have explained things clearly. Would you tell me your understanding of what we talked about."

"Many people believe physicians see their patients as, say, only 'a lung cancer' or 'an Ml,' rather than as people." [4] Making the effort to use good communication skills and show warmth lets them know you see them as human beings you care about. They'll keep coming back, and they are much less likely to sue.

References

[1] Clearly, P., and McNeil, B. "Patient Satisfaction as an Indicator of Quality Care." Inquiry 25:25-36, Spring 1988.

[2] Furlow, T. "Clinical Etiquette: A Critical Primer." JAMA 260(17):2559, Nov 4, 1988.

[3] Barbieri, S. "Why Doctor-Patient Rapport is Ailing." The Orlando Sentinel Section E, p.1., Aug. 15, 1991.

[4] Moseley, R., and Cheong, J. "A Breakdown of Trust." The Orlando Sentinel Section G, p.1, Aug. 18, 1991.

Barbara J. Linney is Director of Career Development, American College of Physician Executives, Tampa, Fla.