In this article ...
Examine five steps health care organizations can take to improve
physician communication skills.
With increasing stress and complexity in today's health care
environment, appropriate and effective physician communication is more
important than ever. This includes communication among physicians,
nurses, case managers, and other members of the health delivery team,
communication among physicians and administration, and communication
among physicians, the patients, and their families.
The good news is that strong communication leads to a great
potential for improving the patient experience in regard to
satisfaction, quality and safety. The bad news is that there are too
many communication gaps that lead to less-than-optimal outcomes of care.
The ugliness occurs with physicians (and others) who refuse to
abide by appropriate professional standards of care and often leads to
disruptive behaviors that can negatively impact patient care. What can
we do to make things better?
There needs to be a multidirectional approach to improving
communication. This starts by raising levels of awareness as to the
importance of communication in the care management process, looking at
obstacles that may get in the way, providing communication skills
training, developing a supportive organizational culture, and addressing
issues of non-compliance that may result in adverse events (see Table
The first step is to raise levels of awareness.
Physicians need to recognize the importance of effective
communication and how it impacts patient care. From a care management
perspective, communication plays an important role in three areas:
compliance, coordination and error prevention.
Taking the time and making the effort to communicate effectively
with patients and their families will promote a better understanding of
the medical condition and help frame appropriate expectations that will
improve patient compliance in following instructions and recommendations
In more complex medical cases where multiple care providers are
involved, more effective communication with other physicians, nurses,
care managers and support personnel will improve overall care
coordination that is particularly important as patients and their
families move through the various stages of transitional care.
Third and most important is the prevention of communication gaps
that may lead to the occurrence of preventable adverse events. The good
news is that there is a great opportunity to improve outcomes of care.
The bad news is that it isn't working the way it should. (1) The
ugly news is that the continued occurrence of adverse events often can
be traced back to gaps in communication flow. (2), (3)
After raising awareness, the next step is to get a better
understanding of underlying barriers that may impede the process. No one
intentionally starts out the day planning to be an ineffective
communicator. It's just that things seem to get in the way.
From a historical perspective, physicians are not trained to be
effective communicators. The training process starts out in an
environment of intimidation and insecurity, leading to feelings of low
self-esteem. Confidence and respect are gained by independent study
promoting knowledge acquisition and technical competency.
Little if any time is spent on developing personal or relationship
skills that may lead to a lowered sense of "emotional
intelligence," resulting in a diminished sensitivity to surrounding
events. (4), (5) These experiences often lead to an autocratic,
egocentric, domineering style of behavior that is the antithesis of team
collaboration and communication skills.
The good news is that many medical schools are now introducing
training courses to promote communication and collaboration skills. The
bad news is there remains a personal and organizational reluctance to
A second contributing factor is the growing stress and frustration
in today's health care environment. Increasing complexity, growing
external monitoring and intrusions affecting decisions about care
delivery, time demands, changing models of care, and significant
reductions in reimbursement have all led to increased levels of
physician stress, frustration, and career dissatisfaction. These, in
turn, may lead to increasing levels of burnout, depression and more
serious behavioral disorders. (6),(7)
The good news is that many of the situations can be addressed by
recognizing the importance of working with physicians and implementing
educational programs, wellness programs, and/or coaching services
designed to help them more effectively deal with environmental stresses.
The bad news is physician reluctance to admit that they can't
handle the stress or accept outside help or advice.
After raising awareness and addressing potential barriers, the next
step is to introduce communication skills for physicians. This is a
complex process that may be limited by physician values, beliefs,
interests and willingness to spend time in training.
Many organizations have approached this topic by implementing more
generalized system-wide communication enhancement programs that involve
Many organizations have had success with the
SBAR(Situation/Background/Assessment/ Recommendation) communication tool
that is designed to enhance efficiency in health care information
exchange by scripting out specific questions and responses that promote
an efficient interchange between two individuals responding to a
specific patient need. This tool has worked well, particularly in the
area of nurse/physician interactions.
Team collaboration training through models based on the airline
industry crew resource management programs have been of value in
improving team-based care, particularly in the areas of surgery,
perinatal, emergency care and intensive care services.
For physician-specific communication training, the easiest way to
introduce a program is through a series of one-hour educational seminars
that start with developing the business case of why effective
communication is important to patient care and then following up with a
series of different lectures on sensitivity training, diversity
training, conflict management, anger management and other topics
relevant to organizational needs.
More comprehensive workshops and training sessions can get into
more depth on communication mechanics, personality styles, and role-play
scenarios. Looking at the typical physician/patient encounters,
important skills to emphasize include listening, not interrupting,
seeking input, taking time to discuss, being sensitive to other
people's needs and levels of understanding, and maintaining focus
on a collaborative effort to accomplish the desired goals.
Some physicians may need additional training to help with
"difficult conversations" in an effort to enable them to more
effectively present critical information about the seriousness of a
disease and alternative treatment plans in an objective and empathetic
manner. The more time the physicians and other members of the health
care team spend on group discussions and role-play interactions, the
greater the chance for success.
Crucial to the success of any communication training program is the
underlying culture and leadership commitment to make it all happen.
Having clinical and administrative leaders committed to the importance
of culture, trust, respect and collaboration, and championing the cause
around promoting quality and patient safety sets the stage for success.
At our organization we have implemented the Just Culture Program,
SBAR training, and the Team Steps Training Program, and are currently
working our way toward Magnet designation. (8)
Appropriate and timely intervention reinforces effect. As mentioned
previously most physicians are not aware that they are not effective
communicators, and hopefully education and training focusing on the
benefits to care management and overall satisfaction will increase their
sensitivity to the importance of learning and adopting effective
In many cases where communication lapses are brought to the
attention of the physician, raising their awareness and making positive
suggestions as to how to more effectively handle the situation will
often do the trick. Success is dependent on the individual circumstance,
the skill set of the individual doing the intervention and the
receptiveness of the physician to have this type of discussion.
More chronic and severe cases will require more formal
interventions that may lead to more structured recommendations for
coaching, training or counseling. In severe cases, particularly around
disruptive behaviors, holding physicians directly accountable for their
actions may be the only recourse, with noncompliant physicians being
subject to sanctions or loss of privileges.
Improving communication leads to better outcomes of care. As
leaders of a multidisciplinary health care team, physicians need to
recognize the importance of their role in being able to lead, direct,
coordinate, and follow through on care decisions and treatment
recommendations that require efficient communication flow and task
accountabilities for all participants in the process.
Physicians have their own individual pressures, priorities and
constraints, and we need to be sensitive to these issues as we ask them
to become involved in projects outside their traditional views on care.
(1.) O'Malley, A., Reschovsky, J. "Referral and
Consultation Communication Between Primary Care and Specialist
Physicians: Finding Common Ground." Archives Internal Medicine.
171(0: 56-65, Jan. 2o11.
(2.) Joint Commission Sentinel event Alert #4o July 9, zoo8
(3.) Rosenstein, A., O'Daniel, M. "A Survey of the Impact
of Disruptive Behaviors and Communication Defects on Patient
Safety." Joint Commission Journal on Quality and Patient Safety.
34(8):464-71. Aug. 2oo8.
(4.) Krasner MS, Epstein RM, Beckman H, et al. "Association of
an Educational Program in Mindful Communication with Burnout, Empathy,
and Attitudes Among Primary Care Physicians." Journal of the
American Medical Association 302(12):12.84-93, Sept. 23, zoo9.
(5.) Arond-Thomas, M. "Understanding Emotional Intelligence
Can Help Alter Problem Behavior." The Physician Executive 3o
(5):36-9, Sept.-Oct. 2004.
(6.) Shanafelt, T., Balch, M., Bechamps, G., Russell, T.
"Burnout and Career Satisfaction Among American Surgeons."
Annals of Surgery 25o(3):463-71, Sept. 2009.
Rosenstein, A., Mudge-Riley, M. "The Impact of Stress and
Burnout on Physician Satisfaction and Behaviors." The Physician
Executive Journal 36(6):16-23, Nov.-Dec. 2010.
8. Bashaw, E. Rosenstein, A., Lounsbury, K. "Culture Trifecta:
Building the Infrastructure for Magnet and Just Culture at a Community
Hospital," Publication pending, American Nurse Today.
By Alan H. Rosenstein, MD, MBA
Alan H. Rosenstein, MD, MBA, is medical director of clinical
efficiency and care management at ValleyCare Health System in