Can you hear me now?

This past week I had the opportunity to orient a large group of incoming residents to our hospital, providing some background on our institution but also giving them "the benefit of my opinion" on many matters relating to healthcare and the profession of Medicine.

I asked for a show of hands.  How many of you treat every patient with courtesy and respect?  Listen carefully to your patients? Explain things in a way they can understand?  The good news is that all the hands went up.  I haven't conducted this survey with our attending staff, but I believe that except for some (understandable) eye-rolling, the honest answers would be the same.

The bad news is that our patients don't agree.  Or, at least one time out of five they don't.  What does this tell us?

Hospitals and health systems like ours are devoting more attention than ever to physician communication skills.  In fact, it was to audit a day-long medical communication program, soon to be rolled out to our doctors, that I spent a day recently in Northwell's own university, known as CLI, the Center for Learning and Innovation.   I was already convinced that this is something we need, and that the investment of time in an effective training program could be worthwhile.  What I came away with was a sense of how much there is to learn and practice, a reminder that we can all improve (no matter how good we think we are), and that this matters in a host of ways to the patients and families who seek our care.

If you ask most physicians of my generation what they were taught about communicating with patients - at least during formal training - they will tell you how they learned to "take a history."   This is a process that begins with a "chief complaint" (it would seem that patients are, by definition, "complainers") and includes a "history of the present illness" followed by the "past medical history" and so forth.  A moment's reflection reveals, however, that understanding the data set necessary to work toward a diagnosis - important as this may be - is not the same as knowing how to communicate effectively.

(When pressed, most of us can recite at least one pearl - that we ought to sit down when we speak with the patient "because this makes it seem like we're there twice as long." It seems to be true, by the way. But mastering a single knot does not an expert sailor make.)

How do we know we need to improve?  Simply put, because we ask our patients how we're doing every day.  The questions I asked our new residents are the same questions that patients receive as part of the federal survey known as HCAHPS.

For several reasons, communicating effectively with patients and families is harder now than it ever was before.  Consider that in the past, when patients experienced durable relationships with their primary physician, who then became the physician-of-record during times of hospital care, the dynamics were quite different.  The patient chose the physician, and if the relationship didn't work, the patient chose another physician.  A long-term relationship meant that the parties really knew one another.  There was a bond, and there was confidence both in the physician's skill and in his commitment to the patient's best interest.  Care was also less complex, with fewer interventions and fewer consultations.

The contemporary hospital-based physician faces a very different scene.  Emergency physicians, hospitalists and intensivists practice in teams.  There is no pre-existing relationship with the patient, and patients are passed from one provider to another. (I am reminded of the traumatized foster child, passed from one home to another, reluctant to trust or form relationships at all...).  Consistent messaging becomes increasingly difficult, as differing communication styles intersect with bona fide differences of opinion superimposed on the dynamics of acute illness where priorities change from day to day.

In this setting, its not that effective, empathic communication isn't possible.  To the contrary, it is more important than ever, exactly because it isn't easy.  In the framework of education, we could say that the requirements are threefold - knowledge, of what comprises effective communication; skills, which means practice; and attitudes, referring to the extent to which we recognize and value relationship-based care as a foundation to creating the outcomes we want for our patients.  For many of us, exceptional skill in this domain is also foundational to our sense of professional pride and accomplishment, to what we mean when we call ourselves "physicians."