Communicating Health: Priorities
and Strategies for Progress

Objective 11-6. Healthcare Providers' Communication Skills

• Drafters

• Small Group Participants

• Text of Objective

• Scope

• Measurement

• Issues Pertaining to Measurement

• State of Knowledge About Issues Represented by the Objective

• Stakeholders and the Status of Their Activities

• Factors That Can Influence Change

• Strategies and Solutions

• Action Steps

• References

Drafters
Debra Roter, Dr.P.H., Johns Hopkins School of Public Health

Gregory Makoul, Ph.D., Feinberg School of Medicine, Northwestern University

Small Group Participants
Kaytura Felix Aaron, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services

Charmaine Cummings, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services

Mary Jo Deering, Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services

Barbara Sharf, Texas A&M; University

Robert Shochet, American Academy on Physician and Patient

Note taker: Laura Zauderer, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services

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Text of Objective
Increase the proportion of persons who report that their healthcare providers have satisfactory communication skills.

Scope
The objective is intended to represent an important aspect of provider-patient communication but cannot encompass all issues raised by and related to the subject. The objective means to serve the specific purpose of providing data on progress for select factors related to provider-patient communication and the general purpose of stimulating discussion about a wide range of provider-patient communication issues.

Measurement
The objective is measurable. It seeks to determine how patients evaluate their healthcare providers in terms of behaviors important to provider-patient communication. Data are collected as part of the Medical Expenditure Panel Survey (MEPS) administered by the Agency for Healthcare Research and Quality (AHRQ). The items from MEPS are

In the last 12 months,

• How often did doctors or other health providers listen carefully to you?

• How often did doctors or other health providers explain things in a way you could understand?

• How often did doctors or other health providers show respect for what you had to say?

• How often did doctors or other health providers spend enough time with you?

Response categories for each item are Never, Sometimes, Usually, Always, and "I had no visits in the last 12 months." Current data are reported in Table 4. Data from each item are reported separately rather than aggregated for a single number.

The explicit purpose of the objective is to ensure that patients have the opportunity to assess a key element of the healthcare encounter: communication with their care providers. The larger goal of the objective is to ensure steady improvement in the capacity of patients and providers to communicate with each other in support of better patient outcomes. It is recognized that provider-patient communication is a multidimensional phenomenon that impacts on all aspects of care and patient outcomes, which makes it difficult to assess with a single measure. The four MEPS items provide data on core dimensions of provider-patient communication but are certainly not exhaustive. Measures of additional dimensions would enhance our understanding of the dynamic between patients and providers, and the development of additional measures should be an important part of future activities in this area.

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Issues Pertaining to Measurement
As currently stated, the objective measures patients' assessment of providers' communication skills. Such an assessment may actually translate into a measure of satisfaction, which is less robust than other possible measures. An ideal measure would allow actual assessment of skills according to predefined criteria. The issue should be less one of satisfaction and more one of capacity- and skill-building, both for patients and providers. As patients and providers increase their abilities to communicate with each other, it is anticipated that a host of valued patient outcomes also will improve.

Source: Medical Expenditure Panel Survey, AHRQ, 2000

Similar to the objective on health literacy, issues of limited literacy, proficiency in English, and cultural and linguistic differences are critical considerations for the development of appropriate assessments of patients' and providers' communication skills as well as the design of interventions to improve communication skills. There is growing recognition that being able to comprehend health information and services is critical to all aspects of personal health management. There is also growing acceptance that a multicultural society that values health for all requires the healthcare system and providers to provide culturally and linguistically competent health care. Even if assessments of patient-provider communication are conducted in the appropriate languages for the patients and the providers, instruments that are not sufficiently sensitive to limited literacy skills and cultural and linguistic differences may mischaracterize both groups' ability to communicate with each other.

An additional consideration for assessment is that the items from MEPS are not specific enough in identifying which healthcare providers from which disciplines have which skill levels. Patients are likely to assess the communication skills of physicians differently from those of nurses, and differently among specialties. The current MEPS questions do not allow such distinctions. More precise data on disciplines and occupational categories would be important to allow the data to inform the design of effective interventions for skill-building for patients and providers from different disciplines and with distinct roles in healthcare processes.

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State of Knowledge About Issues Represented by the Objective
The growing body of literature linking communication skills to a host of valued patient outcomes, including satisfaction, adherence, and positive health indicators, is drawing increasing attention to the centrality of the interpersonal skills of healthcare providers to the delivery of quality medical care. As a result, communication skills are increasingly regarded on a par with other technical areas of medical practice for which proficiency is expected (Lipkin et al., 1995). Within this context, "patient-centeredness" in medical communication curricula has become the shorthand reference to the constellation of skills most often regarded as a critical element in the delivery of quality interpersonal care (Lipkin et al., 1995; Mead and Bower, 2000; Tressolini and Pew-Fetzer Task Force, 1994). Patient-centered skills are those that are responsive to patients' values, needs, and preferences and commonly include data-gathering skills (e.g., use of open-ended questions, particularly in the psychosocial domain), relationship skills (e.g., use of empathy, reassurance, support, and emotional responsiveness), partnering skills (e.g., paraphrasing, asking for patient opinion, negotiation, and joint problemsolving), and counseling skills (e.g., informativeness, persuasion) (Lazare et al., 1995; Roter, 2000).

Although the specification of patient-centered skills has its origin in the medical literature (Engel, 1977; McWhinney, 1989), the skills are equally relevant and applicable to all healthcare providers, including those representing the full spectrum of allied health fields. Furthermore, patients have a role in improving the quality of their medical and dental interactions by increasing their own communication skills.

Physician and patient training in communication skills. A limitation of the empirical literature evaluating the acquisition of communication skills, or the link between these skills and patient outcomes, has been the literature's primary reference to physicians or physicians in training. Much of what has been learned, however, is likely to apply to other healthcare providers as well.

Many commentators have noted the ironic fact that physicians perform thousands of medical interviews during their career with only minimal formal training in communication skills. Fortunately, evidence supports that training in the area is effective and long-lasting, with at least one study demonstrating that skills were maintained as long as 5 years after training was complete (Maguire et al., 1986). Whereas communication and interpersonal skills training is now considered an essential component of medical school criteria by the Liaison Committee on Medical Education, implementation of such training remains highly variable (Association of American Medical Colleges [AAMC], 1999). Communication and interpersonal skills have also been deemed one of the required competencies for resident physicians (Accreditation Council for Graduate Medical Education [ACGME]) and practicing physicians (American Board of Medical Specialties [ABMS]), a development that will extend teaching and assessment programs across the continuum of medical education and practice. Medical students, residents, and practicing physicians will likely benefit from attention to a framework that highlights essential communication tasks (Makoul, 2001).

The length and format of communication training programs vary a great deal, with some training programs offering as few as 4 hours of instruction and others with a developed curriculum of 40 hours or more. Although very short programs have failed to demonstrate a successful training effect in the past (Levinson and Roter, 1993), more recent use of interactive CD-ROM technology to tailor direct feedback to residents on interviewing performance are very promising and time-efficient (Roter and Larson, 2002).

In contrast to the existence of many programs aimed at physicians and many published evaluations of such programs, relatively little research has tried to intervene with patients to improve the communication process. The earliest of these experimental intervention studies was a waiting-room intervention designed to increase the number of questions patients ask (Roter, 1977). This proved successful in doubling the number of questions patients asked and led to a significant increase in study patients' level of internal locus of control and improvements in appointment-keeping over a 6-month period.

A related, but more elaborate, waiting-room intervention was developed by Greenfield and colleagues (1988) that not only influenced patients' communication behaviors (experimental patients elicited more information from physicians, talked more, and were more assertive) but had significant effects on health outcomes, including reduced blood sugar, reduced blood pressure, reduced patients' reports of functional limitations (mobility, role functions, physical activities), and improved patients' perceptions of their overall health (Greenfield et al., 1988; Kaplan et al., 1989).

Adherence with therapeutic recommendations. Not surprisingly, research has found correlations between physician-patient communication and adherence. Patients are more adherent when their physicians deliver more information, ask more questions about adherence (but fewer questions overall), and engage in more positive talk (Hall et al., 1988). Patients of physicians who were more sensitive to nonverbal cues (as measured with a standardized test) were more likely to keep their scheduled appointments than were patients of less sensitive physicians (DiMatteo et al., 1986).

Clinical outcomes and quality of life. The amount of information that physicians provide to patients, partnership building, and emotional rapport and support are related to a range of health outcomes, such as improvements in emotional health, symptom resolution, physical functioning and quality of life assessments, physiological indicators of disease management (e.g., blood pressure, blood sugar), and pain control (Stewart, 1996). For example, blood pressure control improved more if patients were allowed to tell their whole story to their doctor and the doctor provided more information to the patient (Orth et al., 1987), and emotional health status improved more over time when the physician's communication style included more psychosocial counseling (Roter et al., 1995). Reductions in emotional distress and measures of depression, as well as improvement in coping, also have been associated with patient-centered communication (Stewart, 1996).

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Stakeholders and the Status of Their Activities
Eight broad groups of stakeholders directly share interests in the improvement of clinical communication, as described below.

• Consumer and patient advocacy organizations. Consumer and patient advocacy groups have long recognized the significance of communication in the delivery of quality care and directly benefit from improved communication practices. Indeed, consumer demand for interpersonal competence can act as a catalyst for other stakeholder organizations to value, reward, and adopt higher standards of communication skills for providers. These groups can also be important sources of information on the relevant literacy, cultural, and linguistic considerations for different populations that should be part of assessments and interventions.

• Professional societies. Professional societies are responsible for the communication of professional values and the establishment of normative practice. They also provide vision and future direction to the profession through continuing education and advocacy services. Members of these organizations often hold influential positions in training, policy, and service delivery organizations. Many professional societies have an interest in patient-provider communication. Two professional groups that are particularly noteworthy in their primary dedication to education and research related to medical communication are the American Association of Patients and Providers (AAPP) and Advancing Communication Skills in Oncology through Research and Education (ACORE). AAPP has developed a train-the-trainers approach to the teaching of medical communication and conducts national and regional training retreats. ACORE is a newly formed organization designed to address the particular training and research issues relevant to communication between healthcare providers and cancer patients and their families.

• Academic training programs. Professional training programs (e.g., medical, dental and pharmacy schools, residency programs, nursing schools) set and monitor performance standards for programs and institutions; both AAMC and ACGME have highlighted the importance of teaching and assessing interpersonal and communication skills. These programs implement and develop curricula based on performance standards and are responsible for certifying that individuals have met an acceptable standard of competency throughout the training period. The National Board of Medical Examiners (NBME) and the Federation of State Medical Boards have approved the inclusion of a clinical skills exam, which includes communication with patients, in the U.S. Medical Licensing Examination, beginning in 2004. The Educational Commission for Foreign Medical Graduates currently administers a clinical skills test, one component of which addresses key dimensions of doctor-patient communication (AAMC, 1999).

• Accreditation organizations, governing bodies, and boards. A variety of organizations are responsible for credentialing in areas relevant to communication skills. These include bodies that credential schools (Liaison Committee on Medical Education) and hospitals (Joint Commission on Accreditation of Healthcare Organizations) and those that directly credential providers (specialty boards). Each of these bodies reviews and accredits programs and providers on a regular basis in accordance with explicit standards. The American Board of Internal Medicine (ABIM) is an influential body and a leader in setting standards for practitioners. This is just one of more than 20 different specialty boards encompassed by the American Board of Medical Specialties (ABMS), which are now committed to focusing on communication and interpersonal skills as a required competency for practicing physicians.

• Research and education conducted by foundations, universities, and Government agencies. These institutions set priorities for the research agenda and drive new initiatives. They are likely to establish and evaluate performance standards that will be implemented by training and credentialing bodies and adopted by health delivery organizations. Among notable activities, NCI has spearheaded research in health communication with the establishment of its Health Communication and Informatics Research Branch. The Branch has issued numerous program announcements and supported funding mechanisms dedicated to health communication, including the recent Consumer/Provider Communication Research Symposium (held in January 2002). The Robert Wood Johnson Foundation similarly has developed program announcements and has made commitments to fund research on enhancing patient activation and health communication. The Pew-Fetzer Task Force on Advancing Psychosocial Health Education produced an important report in the specification of relationship-centered care (Tressolini and Pew-Fetzer Task Force, 1994).

• Policymakers. Legislative and regulatory bodies on both the State and national level are influential in funding research, encouraging translational research, and speeding the adoption of good practices. Legislative work regarding the Patient Bill of Rights is indicative of interest in this arena.

• Training industry. University and private-sector efforts are already devoted to meeting basic and continuing educational needs of health providers. The industry has historically responded to changing educational needs of students, particularly in response to changes in licensure and certification exams.

• Healthcare delivery organizations, health plans, and purchasers such as employers and unions. Quality of care is highly valued in purchasing decisions. Communication skills are increasingly recognized as a quality indicator with substantial links to patient satisfaction, adherence, and positive health outcomes.

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Factors That Can Influence Change
Barriers. Increasing pressures to deliver more services in less visit time and competition for the delivery of more technical services (the "one more thing" syndrome) may diminish providers' responsiveness to continuing medical education (CME) programs to improve communication (Mechanic et al., 2001). This is particularly so as skill acquisition takes time (usually time away from clinical practice) and money associated with the provision of trained faculty and expertise. Additional barriers may include providers' lack of appreciation or awareness of multicultural relevant aspects of communication or specific needs of low-literacy patients. The lack of health information and services appropriate to the literacy, cultural, and linguistic needs of different populations is a major barrier to progress.

Leverage. Improved communication may afford some protection in regard to malpractice. Evidence shows that patients and families are more likely to sue a physician when faced with a bad outcome if they feel that the physician failed to communicate in a timely and open manner or was uncaring or indifferent (Beckman et al., 1994). One study documented differences in routine communication associated with a history of malpractice litigation. This study found that doctors who had never been sued had longer visits, engaged in more laughter, were more likely to orient the patient to what to expect in regard to the flow of the visit, and used more partnership-type exchanges (e.g., asking for the patient's opinion, enhancing patient's understanding of what was said and expectations for the visit, showing interest in patient disclosures, paraphrasing and interpreting what the patient said) than physicians who had been sued (Levinson et al., 1997).

Moreover, improved medical communication is associated with valued patient outcomes, including disease control (Stewart, 1996) and reductions in healthcare delivery costs, particularly those associated with disenrollment (Kaplan et al., 1996).

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Strategies and Solutions

• Broaden Objective 11-6 to reflect capacity-building and skill assessment rather than patient satisfaction with communication skills.

• Increase attention to skill development during medical training; support the inclusion of communication skills by accrediting bodies; develop CME programs, particularly Web-based, interactive formats that can maximize access and individualized tailoring.

• Mobilize activities across the nine stakeholder groups and develop crosscutting efforts where possible.

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Action Steps
Consumer and Patient Advocacy Organizations

• Build a broad consortium of advocacy groups that share a commitment to the improvement of providers' interpersonal skills.

• Encourage advocacy organizations to focus on credentialing of healthcare providers; educate them to the fact that requirements exist for medical, dental, and pharmacy students, and residency programs as well as for certification of practicing healthcare providers.

• Promote the development of patients' communication skills with their healthcare providers.

• Promote the inclusion of relevant literacy, cultural, and linguistic considerations in communication assessments and interventions for patients and providers.

Professional Societies

• Encourage and support the provision of CME programs that address providers' interpersonal skills.

• Emphasize training providers to address literacy, cultural, and linguistic factors, particularly for high-risk, vulnerable populations with the poorest health status and access to information and services.

• Promote the inclusion of relevant literacy, cultural, and linguistic considerations in communication assessments and interventions for patients and providers.

Academic Training Programs

• Encourage AAMC to periodically monitor and report on the status of communication skills education in medical schools.

• Encourage ACGME to periodically monitor and report on the status of communication skills education in residency programs.

• Support NBME's implementation of a standardized patient exam, which will motivate medical schools to enhance communication skills training for their students.

• Support ABMS efforts to have medical specialty boards assess interpersonal and communication skills as a core competency.

• Emphasize training providers to address literacy, cultural, and linguistic factors, particularly for high-risk, vulnerable populations with the poorest health status and access to information and services.

• Promote the inclusion of relevant literacy, cultural, and linguistic considerations in communication assessments and interventions for patients and providers.

Accreditation Organizations, Governing Bodies, and Boards

• Provide CME credits for communication training to providers through a variety of professional venues.

• Encourage State boards to include communication as a requirement for recertification. The American Medical Association has the list of all current State requirements.

• Emphasize training providers to address literacy, cultural, and linguistic factors, particularly for high-risk, vulnerable populations with the poorest health status and access to information and services.

Research and Education: Foundations, Universities, and Government Agencies

• Build research and programmatic collaborations across organizations.

• Evaluate existing programs for gaps and opportunities to support research and education to improve communication, particularly related to the role of literacy, culture, and language in patient-provider communication.

Policymakers: Legislative and Regulatory Bodies

• Work with professional societies and consumer and patient advocacy groups to support health policy and financing initiatives to adequately reimburse clinicians for time devoted to patient counseling and education (e.g., Medicare standards and reimbursement for patient-provider telephone or e-mail consultations).

Training Industry

• Work with the training industry and university programs to provide appropriate CME vehicles to disseminate good practices.

• Develop materials appropriate across the training spectrum.

• Emphasize training providers to address literacy, cultural, and linguistic factors, particularly for high-risk, vulnerable populations with the poorest health status and access to information and services.

Healthcare Delivery Organizations, Health Plans, and Purchasers Such as Employers and Unions

• Work through large group purchasers (e.g., unions, corporations) to assess quality performance in communication skills.

• Work with delivery organizations to identify and provide incentives to employees for good communication practices.

• Work with delivery organizations to conduct research to test the impact of improved communication on patient and provider satisfaction.

• Work with delivery organizations to include relevant literacy, cultural, and linguistic considerations in assessments of system and provider performance.

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References
Association of American Medical Colleges. Report III: Contemporary issues in medicine: communication in medicine. Medical School Objectives Project. Washington, DC: Association of American Medical Colleges, 1999.

Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice: lessons from plaintiff depositions. Arch Int Med 1994;154(12):1365-70.

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Tressolini CP, Pew-Fetzer Task Force. Health professions education and relationship-centered care. San Francisco: Pew Health Professions Commission, 1994.

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