When psychologist Dominick Frosch first moved to Palo Alto several years ago, one of his first priorities was to establish himself with a new primary care physician. Frosch has Type 1 diabetes, and having a rapport with a doctor to help manage his chronic condition was crucial. But when Frosch walked out of the exam room, he realized he hadn’t really met a new provider at all—at least, not in the way he’d imagined it.
“He had his back turned to me the entire time,” Frosch says. “That was the last time I saw that particular doctor.”
What Frosch experienced is not uncommon. As tablets begin to take the place of charts and a physician’s attention is diverted to screens, patients are beginning to feel like a third wheel. The time they do have to express their concerns is growing increasingly compressed, making them feel rushed or judged when they come armed with questions.
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For Frosch, the shaky stake of patient-physician communications is more than just a personal gripe. A senior scientist with the Palo Alto Medical Foundation Research Institute, he’s led studies on the problems caregivers encounter in establishing a patient dialogue and how to fix them.
“There’s growing evidence communications is the central factor in producing beneficial outcomes,” Frosch says. “And more needs to be done.”
For decades, medical school curriculums put patient communications at low priority. It was a skill that physicians were expected to develop independently and on the job. The problem? “It’s not something they naturally know out of the box,” Frosch says. “Formalized training is really valuable.”
While some schools have increased their attention on communications strategies—sometimes called “doctoring programs”—it’s not every institution, and consequently a number of physicians are released into the wild every year without learning proven techniques on how to both talk and listen. Electronic records have put up another barrier, with physicians busy typing and reviewing data on a screen instead of being attentive to the patient on the exam table.
For patients, the experience is magnified: feeling doctors are rushed for time, they hesitate to ask too many questions. If the challenge a doctor’s findings, they might be fearful they’ll be labeled a “difficult” patient and receive lower-quality care in the future. With both sides feeling compromised before the appointment even begins, it’s little wonder that crucial information can be left out.
Harlan Krumholz, M.D., a cardiologist and health care researcher at Yale University, believes that the first step to improving the dialogue is to approach the patient with the idea that the physician is here to help resolve a problem. “Getting to know the individual and learning what their preferences are will help guide you to the most appropriate method of communicating,” he says. “It’s not a one-size-fits-all approach.”
Some patients, Krumholz says, may have poured over internet research about a given condition and can have a productive conversation without being spoon-fed details; others may have only a passing understanding and need further explanation. “You need to meet the patient where they are,” he says. “You can’t just assume they’ll know what it is you’re talking about.”
That belief can stem from “Doctor Google” concept, where it’s imagined that every patient comes in armed with a base understanding of things. “There is the notion of a more empowered, activated patient, but you can make a mistake buying into that model,” Frosch says.
Once you’ve gauged how much information a patient has and how much he or she needs, making the most of the allotted time is key. Research has shown that pulling up a chair to a bed—if a patient is hospitalized—can make visits seem longer because the physician seems more engaged. Looking at patients and reacting to their expressions and body language is also key to increased satisfaction with a visit. No one wants to feel like their digital record is of more value to a doctor than actually being in the room.
But a productive visit isn’t solely in the hands of the physician. According to Frosch, a physician looking to improve their patient dialogue will let them know how they can do their part. “It’s up to both sides to make the most of the limited time they have,” he says. “The patient needs to think about why they’re there, what concerns they have, and what they want to talk about prior to the appointment.”
Letting patients know not to be afraid to voice concerns is also key. “Part of the job is to engender trust,” Krumholz says. Physicians might want to think of it as a kind of intervention—stepping in and letting patients know they have a safe space to discuss their concerns without fear of being labeled or cut off due to time. For patients with more complex conditions, booking more of the latter can be a huge benefit. “To have a long appointment to check up on someone with hypertension might be unnecessary. But someone grappling with a complex condition is going to need more time.”
Part of Frosch’s work is keeping an eye on the future of communications. In addition to more training at the student level, the next generation of exam rooms might help provide a more welcoming environment for two-way conversations.
“Putting a tablet in the center of a room between the doctor and the patient provides a straight view of the patient,” he says, eliminating the notorious turned-back phenomenon. Technology like Google Glass might also help keep a physician focused on the patient while assisting data is retrieved.
Most importantly, having a “second” in the room to transcribe can make a substantial difference. “That person can do the work of documentation while the physician is doing the work of being a physician,” Frosch says.
The byzantine world of health care financing might curb some of these ambitions. But it costs nothing for a physician to empower a patient with a voice. “Creating an open environment,” Frosch says, “is letting them know it’s safe.”