Communication Skills Improve Empathy,Mindfulness,and Doctor–Patient Relationship

Kathy Cole-Kelly, an expert in communication in medicine, professionalism, and the medical humanities, has had years of experience in teaching medical students and clinicians how to communicate better with patients. Being present and empathic are key ingredients to interacting with patients, as Ms. Cole-Kelly shares in this column.

Q: Effective communication, compassion, and empathy can sometimes go under the radar in the doctor–patient encounter. When did you first become interested in the need for specific medical school curricula addressing these issues?

Kathy Cole-Kelly: Early on in my medical career, I was eager to forge forward with new medical school curricula addressing sensitive and important communication topics, which were not often addressed in other areas of medical students' education. As a result, a group of national colleagues and I became very interested in the topic of doctor–patient communication. This came out of our awareness at that time of the great dissatisfaction that many patients were experiencing when they were encountering physicians. My colleagues and I got involved in thinking about how we could do more work around the topic of doctor–patient communication. Many people were starting to do research in this area. However, 25 years ago, one would have found only a handful of articles on this topic. Now, there is an overwhelming number of articles because of the clear evidence that it makes an enormous difference to have effective communication between the doctor and the patient. ^1,2

When I started doing this work three decades ago, we really were at the cutting edge, and people were saying it was intuitively a good thing to do. However, as the research became more robust, and it was very clear that including such curriculum was not just a choice but a requirement, the National Board of Medical Examiners actually developed an exam for all medical students, which tests their communication skills. Every medical student who now graduates—most schools make it a requirement of graduation—has to pass this exam, and the students are evaluated regarding their interactions with a standardized patient, usually covering about 12 different scenarios.

Case Western Reserve University (CWRU) School of Medicine in Cleveland, Ohio, has had a long tradition of being very patient- and relationship-centered and having their students be innovators. My work now is simply one way that this continues.

Q: What are some of the topics that you focus on when teaching medical students communication skills?

Ms. Cole-Kelly: At the very beginning, it is simply teaching the students how to take a patient history and gather information about their health or illness. Then we have the students learn how to present medical information to a patient and how to educate them about an illness or a treatment plan. Later, we teach them how to do motivational interviewing, and we also teach a wide range of screening communication skills, such as screening for addiction, domestic violence, and many other topics.

In the second year, they start learning how to talk to a patient about grief and loss. They also learn how to go through what we call the process of shared and informed decision making because there is greater awareness of the importance of including the patient in any decision about their health. This increases adherence and increases satisfaction when the patient's perspective is included in the decision-making process. The physician shares the information needed to make a decision, and together the patient and the physician make the decision that is best for the patient in terms of his/her needs, expectations, and beliefs.

In the third year, we move to more advanced training skills, such as giving bad news or very bad news. We also have students learn skills of talking or interacting with an angry patient, how to go through shared decision making when there is a very emotionally charged situation, how to conduct a family interview, and how to manage multiple members of the family who might have different agendas.

Q: You mentioned earlier that the evidence has been gathered and affirmed that teaching medical students such communication skills is very effective. What are some of the measures that you are speaking about specifically?

Ms. Cole-Kelly: Specifically, there is research that demonstrates that when a physician demonstrates good empathic communication skills—that means demonstrating to the patient that they are trying to understand the patient's perspective and acknowledging the patient's feelings—there is an increase in patient satisfaction in the doctor–patient encounter. There is also a reduction of malpractice suits, regardless of the outcome of what has been happening. ³ There is an increase in physician satisfaction with their work as a physician as well.

Research has also shown that there has definitely been a significant measure of improvement in adherence related to outcomes such as diabetic control, hypertension control, or any type of health behavior change that a physician is recommending. ⁴ Adherence is very important, and for physicians who are relationship-centered and skillful in motivational interviewing, that is going to be impacted very beneficially.

Q: Tell us about your specific role at CWRU School of Medicine, and how does your curriculum teach medical students to communicate more effectively with their patients?

Ms. Cole-Kelly: When the medical students begin in the summer of their first year, I spend three weeks teaching the basics of the medical interview. I present a highly interactive lecture calling upon their own experiences with physicians for them to think about, and after that portion of the experience, they gather in small groups for further discussion. The students also work with standardized patients—these are actors trained to a specific patient scenario—and the students practice their interviewing skills and receive feedback. They are observed by their peers and a fourth-year medical student who has a skills checklist, and then they do some self-assessment as well. Another very important component is that the students are videotaped, and they have an opportunity to watch their videos because there is nothing like seeing yourself doing something to help you improve what you are doing. Throughout the next two years of medical school training, the students have a series of sessions introducing them to more robust communication skills. Each of these sessions is a part of the Foundations of Clinical Medicine curriculum.

During the students' third year—this is where CWRU School of Medicine has been an innovator in the field—we also have advanced communication skills. In 1998, CWRU School of Medicine was fortunate to receive a grant from the Josiah Macy Foundation, along with New York University School of Medicine and University of Massachusetts Medical School, to increase the teaching of advanced communication skills in the third year of medical school. Historically, what happens is that students learn good communication skills in the first two years, and then often those skills atrophy in the third year. This is in part because they have had a variety of role models that they have seen, and their skills can go a little astray from the gold standard that they had been learning. So, in many of the third-year clerkships, we have communication skills embedded in those as well.

Q: What are some of your personal observations regarding this work contributing to physicians' communication skills?

Ms. Cole-Kelly: The physicians who have come through this rigorous training process are more likely to demonstrate better communication skills. However, it is not a foolproof process by any means. I still have physicians referred to me from hospitals who need remediation in these areas. There are programs for communication skills and professionalism training for physicians already in practice. Another colleague and I run a CME course through CWRU School of Medicine for physicians in practice who have been mandated by their state boards of health or their hospital systems to remediate those skills.

When physicians have to recertify their boards on a regular basis, I believe that they should also have to recertify their communication skills. Whenever I ride on an airplane and someone says, “What do you do?” and I say, “I teach communication skills to physicians,” I have never had anyone say to me, “Oh, you do not need to do that. They are all wonderful.” I hear everyone say, “Oh, thank goodness you are doing that,” and then they will tell you their story. I believe that there is no question about how much we need this on an ongoing basis and how much it needs to be reinforced.

Q: What are some of the obstacles in the medical system that can interfere with optimal doctor–patient communication?

Ms. Cole-Kelly: In the United States, the emphasis on physicians being highly productive and the pressure in the healthcare system often means that they have less time with patients, and they have more tasks. The electronic health record has definite benefits, but it also has a lot of disadvantages both during the encounter and then afterwards. It often takes a lot of time, to dictate notes and to navigate the electronic health record. So, that is simply something that has been seen as a deterrent to optimal doctor–patient communication.

In our teaching curricula, we conduct a session, for example, on the doctor–patient–electronic health record relationship or the doctor–patient–computer relationship, and we try to encourage students to be mindful of the obstacles. As clinicians become busier and busier and they experience more pressure, they tend to start looking more at their screen and less at the patients. That is a very difficult problem. So, we teach students mindfulness in the patient–physician encounter and have our students read articles and attend workshops on mindfulness in order to stay as present as they can in the encounter.

Sometimes, the specialty can also affect the degree of communication with the patient. Specialties such as internal medicine or family practice usually have more continuity with their patients compared with some of the subspecialties, and there are often greater numbers of proponents for communication skills training in primary care. I believe that it is important for every specialty, however, to value the importance of these skills.

To Contact Kathy Cole-Kelly

Kathy Cole-Kelly, MS, MSW

Professor and Director of Communication and Medicine Programs

Co-Director, Foundations of Clinical Medicine Seminars

Case Western Reserve University School of Medicine, Cleveland, OH

E-mail: kathy.cole-kelly@case.edu

Q: After your many years of experience, what do you know for sure in terms of what clinicians should keep top of mind when interacting with their patients? Please share three or four aspects of what you know can make a difference in doctor–patient communication.

Ms. Cole-Kelly: Eye contact and attentiveness would be the first things. Also, we need to value the ability not simply to state empathic statements, but also to be present and mindful with the patient when demonstrating empathy. If a clinician is making an empathic statement, he or she is saying words such as, “I think I understand how hard this must be” or “That sounds really difficult.” Being present, however, is the whole gestalt of the clinician being there with the patient in the room and, for example, not making empathic statements as one is turning to go out the door of the exam room.

The other is to be highly vigilant about avoiding or defining medical jargon, so that patients have no idea what the clinician is talking about, and then getting stuck there. It is so important for clinicians to be sensitive to using language that patients are familiar with or understand. Clinicians should also strive to demonstrate warmth and a sense of genuineness in the presence of a patient.

There is also the importance of asking open-ended questions. I was reviewing some student videos today and thinking that not only is the open-ended question so important when a clinician starts the interview—one cannot do an entire interview of open-ended questions because they would get nowhere fast—but following up the first open-ended question, “Tell me what brings you here today,” with “Can you tell me more?” What happens so often in the interview is that the student, who has been accepted to medical school for their intelligent, bright, quick, searching mind, then wants to find the answer very quickly if they hear the problem. They need to be reminded to slow down and say to the patient, “Tell me more.” There is very likely more to the story than just that opening, “Well, I am having headaches.” If the clinician says, “Tell me more,” they will often hear a lot about the patient's life that may be contributing to the presenting problem. If one dives prematurely into “When did this start?” really important parts of that story may be lost.

Q: Is there any other advice that you would like to share with clinicians or people in charge of medical curriculum?

Ms. Cole-Kelly: We all need to remember that we too will be, or have been on the patient side, so as educators we want the students we are teaching to be as proficient in communicating as possible. For clinicians in practice, it is important to try to slow down and reflect.   ■