Bedside Manner for the Modern World

You might say Dr. Peter Barnett is a persuasive man. After all, he was able to convince a patient with hemophilia, who is also a Jehovah's Witness, to undergo a life-saving blood transfusion, which is generally forbidden by the religion's teachings.

Barnett, an internist and assistant professor at the University of New Mexico, says the 18-year-old patient, who was used to being hospitalized about four times a year for severe bleeding, just didn't believe what the hematologists were telling him about the severity of his condition.

"He'd never been transfused and was always told he was about to die. His experience was the doctors were always wrong and he was always right," Barnett recalls. "I asked him if he could imagine a situation where he could take blood. I was trying to understand how black and white his beliefs were. And he said, 'It would depend on whether I thought I was going to die.' "

In fact, the patient's condition was grave, so Barnett sat down and explained the whole transfusion process. "I didn't push him," Barnett says. "Three days later he changed his mind."

This wasn't a matter of the clinician forcing his own agenda on the patient. Barnett, a faculty member of the American Academy on Physician and Patient (AAPP) - an organization that promotes "relationship-based healthcare" and provides communication skills training to physicians - was simply exercising "accurate empathy," what he considers one of the cornerstones of good physician communication. It means eliciting a clear picture of the patient's values, beliefs, feelings, and preferences to set the foundation for the medical visit.

Barnett and others are embodying this modern twist on the old concept of "bedside manner," and using strategies to enhance their dialogue with patients to ultimately provide them with better care.

Before you decide you just don't have time to talk to your patients about their feelings, consider that "the time you spend up-front frequently saves time later [in the form of] phone calls, questions, and complaints," according to Barnett. Other physicians agree.

Jenni Levy is an internist who's also a course director for the AAPP, and trains residents at St. Luke's Hospital in Bethlehem, Pa. When she suggests to her charges that they just let patients talk about what's on their minds, their response is: "I'll be there forever."

Wrong, Levy insists. "The literature is really clear about this. For the vast majority of patients, if you ask them, 'What brings you in today?' and let them go until [they] run out of steam, the most it's going to cost you is 90 seconds."

Granted, "What brings you in?" is a little different from Blood Transfusion 101. But the underlying premise is the same: Get agreement with the patient from the outset about what you're going to accomplish and how, and you'll save time, reduce frustration, and likely have a happier and more compliant patient.

Set the agenda

You may assume you know what the patient's problem is and what he wants you to do about it, but until you ask, don't be so sure.

"Take a minute on the front end and elicit all of the patient's agenda, without [focusing] on that first or second complaint. Then negotiate that agenda based on what's realistic," says Barry Egener, MD, medical director for the Northwest Center for Physician-Patient Communication in Portland, Ore. "It takes two or three minutes at most, then you have a common ground to get the work done. The alternative is not to develop a specific agenda. Then you may be surprised by an agenda item at the end of the visit." Most physicians recognize this as the dreaded "Oh, by the way ..." moment that often occurs just as your hand is on the doorknob.

The approach works, especially with difficult or needy patients. Levy cites the example of one upset patient with multiple medical problems and plenty of hard-to-address symptoms, who had been recently hospitalized for a blood clot.

"At the beginning of the visit, I said, 'I want you to tell me everything. Let's get a list and figure out what we're going to deal with.' A couple of things we put aside because we weren't going to have time and they really weren't as important to her.

"At the end, she said, 'You've given me a lot of information and I feel much better about what's going on.' I did nothing from a medical standpoint to alleviate any of her symptoms, many of which I can't. But because she feels like I really listened and I addressed her concerns, that made it OK."

This kind of interaction helps Levy manage her time during individual appointments and throughout the day.

"My patients will tell you I spend a lot of time with them," she says. "I generally don't spend more than the typical 15 minutes, but it feels like more because they get to say what they need to say and I respond in a way that tells them I'm listening. The time we use is much more valuable to them."

Suppose the patient brings in a laundry list of problems to address. "Prioritize the list," says Barnett. Schedule another appointment if necessary.

"You're actually asking [the patient] to share with you the burden of managing the time," Barnett adds. "Most patients will respect this."

When emotions run high

The weepy patient. The patient who just doesn't get it. The agitated patient who, you think, is about to throw your schedule hopelessly off-track. Every physician's experienced this type of situation.

"Ignoring it is not going to make it go away," says Levy. "It's going to subvert everything else you'll try to do in the interview. And it's going to drive repeat visits."

Instead, face that patient head-on. "I'm very direct about this. I'll say to the patient, 'It really feels like you and I are not seeing this the same way. What's your understanding of what's going on here?' and the patient will have some completely different impression of what I've said or what I understand," says Levy.

To respond to a patient's emotions in an effective way, she recommends trying what she calls the NURS technique:

NAME the emotion: "It looks to me as if you are sad/angry."

Make a statement of UNDERSTANDING: "I can see why someone in your situation would be upset."

Make a statement of RESPECT: Find something about how the patient has managed the situation that you can appreciate. "I think it's great that you've tried to start exercising."

Make a statement of SUPPORT: "I'd really like to work with you to make this better."

Once you've acknowledged the patient's feelings, it's important to stop and pause. "Frequently we won't stop there," Egener points out. "If we stopped, we would be leaving an uncomfortable silence during which the patient would elaborate: 'You're darn right I'm upset.' But that's what we want them to do. We as physicians need to tolerate that."

What's the real problem?

Those repeat visits that Levy describes are a real drag on a physician's time. The patient who comes back time and again with uncontrolled blood pressure or chronic pain is frustrating. And medical noncompliance, by some estimates, costs some $100 million in hospitalizations and nursing home admissions.

It's tempting, perhaps, to put the blame on patients who keep coming back but are not improving. After all, you've told them what they need to do to get better. But does what you've said make sense for that individual patient?

Levy suggests, "If people aren't doing what you ask, find out why. I can tell [patients] 4,000 times what they need to do, and if ... they don't have their own internal motivation to do it, it ain't gonna happen. Am I asking someone who doesn't have a car to do something that involves driving? Am I asking someone who can't read English to follow the instructions on a pill bottle?"

To facilitate the discussion, Levy recommends following a concept called Ask Tell Ask. "It's basically asking, 'What's your understanding about this?' Listen. Then, 'Here's what I think,' (giving a small bit of information), 'What do you think about that?' Listen," she says.

Keep in mind that there may be generational or cultural differences in the way patients prefer to interact with their physician. For many, the physician is an authority figure and the patient's role is to do as they're told. "The easiest thing to do is to ask people: 'When you see a doctor, do you prefer they make the decisions for you, or do you like to have a lot of input?' Most people will tell you. The problems come from making assumptions," says Barnett.

Adds Egener, "If the patient says, 'You're the doc, you tell me,' then being patient-centered in that situation means being paternalistic. You need to be flexible."

Go ahead, it's good for you

Barnett says research shows patients expect a lesser level of personal interaction with certain specialists. "Patients don't expect surgeons and some specialists, like cardiologists, the interventionalist types, to talk a lot about feelings. They have a much higher expectation for primary-care people - peds, OB, family practitioners - to be more concerned with their feelings."

Levy, a primary-care physician, is OK with that. She says some of the techniques she uses to address patients also help her deal with her own emotions, especially during difficult interviews.

"I find it energy-giving rather than energy-draining ... . I can respond in a thoughtful way rather than getting carried along on the tide of emotions."

Another benefit to practicing good communication skills is a reduced risk of being sued.

"Relationship-building skills clearly reduce malpractice risk. It's clear to me and to anyone who looks at the literature that what you do from a cognitive standpoint is not what puts you at risk for malpractice," Levy says.

Egener adds, "We know that [poor] communication is a factor in about 80 percent of lawsuits."

"Most physicians who are sued get sued multiple times. And that does not correlate with any indicator of quality of care at all," Levy says. "So it's not the kind of medicine that people are practicing that's the issue. It's how they're relating to their patients."

Indeed, veteran communication researcher Wendy Levinson found there were significant differences in the communication behaviors of primary-care physicians with claims against them and those without.

No-claims primary-care physicians used more statements of orientation (educating patients about what to expect and the flow of a visit), laughed and used humor more, and used more facilitation (soliciting patients' opinions, checking that patients understand, and encouraging patients to talk). They also spent longer in routine visits than claims primary-care physicians (18.3 versus 15 minutes).

Bedside manner comes of age

If the links between good communication, more compliant patients, and reduced malpractice risk are so well established, why aren't more physicians gurus of good bedside manner? For one thing, it is not generally on the radar screens of physicians-in-training, and so may remain a vague concept as physicians mature.

"Some of this needs to be begun in med school but continued and finessed throughout, and that's been a huge challenge," says Barnett.

But it needn't be. "We really know a lot about the medical interview now and we can say a lot about what manner is productive and not productive," says Egener. In other words, it's not your father's bedside manner.

"When the term [bedside manner] was used, it was very ill-defined. People didn't think it could be learned or taught - it was a personality trait, or something you learned from your mother," says Barnett. "What has changed over the last 20 to 30 years is we [now] think communication skills are discrete skills that are learnable, teachable, and improvable. We have demystified bedside manner and made it into something that can be approached academically and intellectually, regardless of what sort of personality or person you are."

Levy concurs - and she's been able to convince at least one member of the "old school."

"My dad is a cardiologist who also did primary care. When he was late getting home, he would never say it was a really complicated patient [delaying him], it was that somebody needed to talk. I grew up thinking this is how you [practiced].

"When I started the AAPP work in 1997, my father's first comment was, 'You cannot teach people to do that - you can either do it or not.' And I said, 'Really? I learned how to do it, or at least learned how important it was, from you.'

"And over the years, entirely from listening to me talk about my experiences, he has become a complete convert to the idea that you can teach people how to communicate better."

Joanne Tetrault is director of editorial services for Physicians Practice. She can be reached at jtetrault@physicianspractice.com.

This article originally appeared in the October 2005 issue of Physicians Practice.