CHAPTER 2

Communication and Patient Experience

Suffering … is real for our patients … We will not rest until
we have done all we can to alleviate their suffering.
—Thomas H. Lee, MD¹

Most of us would agree that the highest calling of medicine is to relieve suffering. To accomplish this, clinicians and health systems must look beyond medical interventions and instead prioritize truly caring for patients. By “caring,” we do not mean that clinicians should simply be nicer so that patients feel happier, or that every hospital should offer Ritz Carlton-style amenities. Rather, it means we must build healing relationships that promote partnership, empathy, respect, and understanding. It means we must realize that patient experience correlates with quality, safety, and patient loyalty. It means our health systems must embrace the human experience as central to their missions. On the flip side, we need to acknowledge that when communication fails to build connections—when patients experience their care as rushed, impersonal, and unfeeling—we may unwittingly deepen their suffering rather than relieving it. The good news is that communication skills can be taught and learned, and leading edge health systems can adopt relationship-centered care as the norm rather than the exception.² In this chapter, we describe key elements of the patient experience of care, and we highlight the links to communication. We use specific examples to illustrate the core principles of relationship-centered communication and describe practical considerations for one-on-one interpersonal encounters with patients and families and colleagues within the context of a healthcare team.

The Patient Experience Challenge for Leaders

Let’s begin with the challenges faced by Dr. Ahmed, CMO of a large health system. Dr. Ahmed is accountable for improving patient experience at his hospital. In each batch of patient experience surveys, he sees that the percentage of “top box” scores is disappointingly low. Dr. Ahmed is baffled. His hospital is fortunate to have great clinicians with the finest technical skills and resources. Still, patients report that something is missing in the human dimensions of care. Dr. Ahmed is concerned that if the scores fall any lower in the competitive market, they could threaten the hospital’s reputation, ranking, and value-based reimbursement. He understands that focusing on patient experience is good healthcare and good business, but he must admit that patients and families in his hospital don’t consistently feel cared for. Gazing at the scores on his computer screen, he wonders what he and the health system can do to improve them.

Patient experience scores, like the ones Dr. Ahmed reviews each week, provide a window into patient perspectives on the care we provide and they receive. Standardized national patient surveys like the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of surveys ask patients to evaluate communication skills by exploring if clinicians listen carefully, treat patients with courtesy and respect, and explain things in a way patients can understand.^{3, 4, 5} These questions do not merely measure patient satisfaction: they ask whether specific types of communication did or did not happen during an encounter, be it a clinic visit with one clinician or a hospitalization with multiple clinician interactions.⁶

In our experience reviewing years of comments on this set of communication questions, a common theme emerges. In both the positive and negative comments across the spectrum of clinical settings, what patients repeatedly note is their perception of whether the clinicians and staff show that they care. The clearest way of showing caring is through intentional and effective communication.

The Pitfalls of “Patient Satisfaction” for Clinicians

When busy clinicians are asked to improve patient satisfaction or experience scores, we often go on the defensive, questioning the metrics and survey data that generated the low scores. Many of us resent checking more boxes and adding yet more tasks to already overstuffed agendas. Rightfully, we push back against providing care that is inappropriate just to make patients happy. The term experience has been adopted as a replacement for satisfaction in an effort to place additional focus on quality and safety elements, rather than merely aiming to satisfy patients.

Even clinicians who believe the validity of the scores may feel that patient complaints link to systems failures and difficult personalities rather than our own skills. We frequently complain that our busy schedules simply don’t provide enough time to communicate well. As a CMO, Dr. Ahmed is acutely sensitive to these concerns and wants to ensure that his efforts to improve patient satisfaction will not be viewed as rubbing salt into the wounds of burnout. At the same time, he hopes that heeding the core principles embodied in these patient experience metrics could help clinicians better communicate the caring he knows they feel, while reconnecting them to purpose in their work and joy in their practice of clinical medicine.

Why Relationship-Centered Communication Drives Patient Experience Improvement

On the other side of the country, an Associate Chief of the Medical Service is rounding with an inpatient medical team, checking in on patients and making decisions about care for the day. Mr. Perez, admitted five days prior with a difficult problem of unrelenting abdominal pain and diarrhea, reflects to his team of doctors:

It’s the little things you do here that make a difference. It’s the smile and wave when you walk by my room. It’s when you take the time to sit down to speak with me, not at me. This is the best hospital I’ve been to.

As many health systems have shifted attention to the patient experience of care as a component of the value provided to patients, the “secret sauce” of how to improve that experience has often seemed elusive. Yet here, in the middle of a busy morning of the hustle and bustle of admissions, discharges before noon, computer clicks, and notes written, Mr. Perez poignantly tells his doctors the answer. What transcends it all is how they relate to him. In a world where many things can be automated and systematized to get the best and most reliable outcomes, the interpersonal relationships in healthcare still rely on our own mindset and communication skills. Were the interactions respectful, caring, and compassionate? Were the patient’s and family’s goals and values acknowledged and included in decision-making? Was information conveyed with clarity?

Patient experience extends across the entire continuum of care, and every interaction counts. Each interaction conveys what the health system, patients, and clinicians value most. For clinicians, the challenge is to acquire and intentionally practice relationship-centered communication, starting with the very first moment of each encounter.

Patient Reflections on Communication Skills

When asked to comment about perceptions of their doctors, patients can describe what it looks like when communication works well:

Dr. Li is wonderful, very caring, and kind. Whenever I talked, she moved her hands from the keyboard and turned her head and her body toward me and away from the computer. She not only was listening but showed me with her body language that she cared and that what I had to say, no matter how trivial, was the most important thing to her in that moment. Absolutely exceptional care!

Dr. Moor was the first clinician to actually listen to my symptoms and not treat me like I didn’t make sense. That alone greatly increased my trust and confidence in him.

And conversely, patients can describe what it looks like when communication fails:

I know that Dr. Hall is a smart doctor and she knows her stuff, but she spends most of her time looking at the computer. I do not feel she is a poor clinician by any means. If she had focused on what I was most concerned with during the visit, I would have been very happy. But all of what I wanted to address seemed to be pushed to the side.

Whether a clinician hears and validates patient concerns or dismisses them can make all the difference in whether the patient feels cared for. Equipped with this knowledge, the case for strengthening evidence-based communication skills among our clinicians grows.

Which Communication Skills Matter?

The way many of us routinely approach medical care can unintentionally result in poor experiences for patients. We clinicians often go about our work of diagnosing and trying to help our patients as efficiently as we can, often unintentionally missing what is most important to the patient. Too often, we focus on what we think the patient needs or wants without asking to make sure we are on target. As a result, all of our care and attention can be misdirected, causing frustration across the board. We must change our mindset from just “What is the matter with you?” to “What matters most to you?” This simple, profound shift conveys respect for the patient’s role and perspective in his or her own health. It also helps us deepen our understanding of our patients.⁷ It’s important to emphasize that clinicians need not choose between building relationships and our commitment to biotechnical excellence: the approaches are complementary. Furthermore, there is growing evidence that skilled communication along with active patient engagement improves diagnostic accuracy, promotes shared decision-making, reduces the use of unnecessary and often costly tests, and may even lead patients to choose management plans with greater value and lower cost.^8–9

Communication Skills That Work: Agenda Setting

Dr. Williams, a busy obstetrician/gynecologist, was disheartened that despite his best efforts, patients rated his communication skills below those of his colleagues. He began to dread each quarterly review of his patient experience surveys. In retrospect, Dr. Williams realized that his communication skills must not be as good as he thought they were. He and his patients experienced a turning point after he attended a communication skills workshop where he learned how to elicit a patient’s full set of concerns and set the agenda early in a clinic visit (see Chapter 3).¹⁰ Prior to adopting this approach, he entered each exam room with a defensive mindset, worried that the patient would have more complaints than he had time to cover. His practice was simply not to ask, and his patients felt he was rushed and not interested in hearing their concerns. With agenda setting, all of that changed. Dr. Williams discovered that when he and his patient co-created a game plan at the beginning of the visit, he no longer felt pressured to cover everything. He was less defensive, listened better, and felt on more equal footing with his patients regarding expectations for their visits. His scores improved, and he went back to enjoying practice.

Dr. Williams’s experience demonstrates that learning a new communication skill can change a clinician’s mindset and improve the experience of his patients. Hearing the patient’s list of concerns went from a dreaded burden and time sink to a means to build connection and make the most efficient use of limited time. The experience of both patient and doctor was improved. Dr. Williams noticed improvement in his own sense of efficacy and “joy” in doctoring; he became a champion of communication skills training for his multispecialty group.

Communication Skills That Work: Showing Empathy

Health problems and medical care nearly always bring up emotions. Emotions are typically related to fears, uncertainty, and perceived or actual threats to one’s identity, livelihood, or function. When we focus exclusively on biomedical care, we fail to address these emotions, which deeply affect patient experience.¹¹ In a study looking at the use of empathic statements with hospitalized patients, only a third of physicians used an empathic statement in response to emotion expressed by the patient. Meanwhile, each empathic response was independently associated with a significant decrease in patient anxiety and more positive patient impressions of the physician.¹²

Learning how to show empathy is something that can benefit all clinicians. We must learn how to listen for and recognize emotion in another and express that recognition. We can do so with brief statements of partnership, emotion, acknowledgment, respect, legitimization, or support (see Chapter 4). As a result, we increase our effectiveness and patients and families internalize our support. When the medical condition or its impact cannot be “fixed,” this ability to provide empathy becomes a cornerstone of the care. The following example shows the power of empathy in affecting the patient experience.

Mr. Walker hadn’t eaten for nearly 24 hours, and he was getting angrier by the minute. His endoscopy had been cancelled the day before due to a high volume of emergency cases. The orders read “NPO,” so he hadn’t received a dinner or breakfast tray. At the time of rounds, he still didn’t know if he’d be having an endoscopy that day and had already made two calls to the patient relations office to complain about his care. He vented his anger and frustration as soon as the care team entered his room.

Rather than reacting defensively or attempting to mollify Mr. Walker, the rounding physician intentionally chose to convey empathy for the patient’s predicament. “Wow—you’ve had a terrible 24 hours! I can only imagine how frustrated, angry, and hungry you are. I think anyone would be at least as frustrated as you are. I apologize that you’ve been left in the dark about when the endoscopy will be done, and I appreciate your hanging in there with us. I don’t personally do the procedure, but I can promise that I’ll do my best to find out when it’s scheduled. I’ll be back with you in a few minutes to let you know. I suspect that not knowing what’s causing your blood loss makes the waiting even worse for you. You want answers.”

Mr. Walker replied, “Yeah—you got that right.”

With Mr. Walker, the clinician repaired their relationship by expressing empathy, legitimization, apology, appreciation, support, respect, and partnership. After this exchange, Mr. Walker called patient relations to “cancel the complaint.” His concerns had been heard and acted on. In this case, empathy benefited the patient, and the hospital’s service excellence department had one less complaint to manage. This is what we mean by the “secret sauce” of relationship-centered communication.

Communication Skills That Work: Understandable Explanations

Relationship-centered communication is not only critical in primary care, where relationships develop over time. In brief or episodic interactions like emergency department visits and procedural disciplines where the stakes are high and time is short, these skills may be even more important.

Dr. Anderson, a senior anesthesiologist, reported the following vignette. For years, he used a standard “spiel” with patients prior to induction that covered pretty much everything he thought was important for them to know. He’d end by asking, “Do you have any questions?” This interaction always felt rushed, but he accepted that as the reality of anesthesia practice. After attending a communication skills workshop and learning how deeply patients appreciate having their concerns heard, Dr. Anderson tweaked his approach. He decided to reverse the order of his pre-anesthesia routine. He now begins by pulling up a stool and asking for the patient’s list of concerns about the anesthesia (see Chapter 3) before giving his spiel—which he then tailors according to the patient’s concerns (see Chapter 5). For example, when asked up front about his fears regarding anesthesia, a patient told Dr. Anderson that his biggest worry was that intubation would leave him with no voice, preventing him from singing with his church choir at a big event in two weeks. The beauty of the new approach is that Dr. Anderson not only heard about the patient’s concerns but he also had time to specifically address them during an encounter that lasts an average of four minutes. In terms of the CAHPS question, Dr. Anderson truly “explained things in a way that the patient could understand.”

Intentionally addressing items of importance to patients ensures that their concerns are heard and addressed. The end result is a more efficient encounter, a deeper connection, and a sense of effectiveness and meaning for the clinician that might otherwise be missed in simply going through the motions.

Communication and Systems Design

Relationship-centered communication can have a transformative impact on how team members provide care. When members of a team prioritize relationships with patients, families, and other team members, all parties benefit, including the health system itself.¹³ On the other hand, when medical teams fail to make authentic connections with patients, they often experience their care as fragmented, poorly coordinated, and confusing. Another factor that can influence patient experience is how we structure our medical rounds. If, rather than seeing inpatients separately, doctors and nurses choose to routinely conduct rounds together, it’s far easier for them to be on the same page when responding to patient concerns and questions. Structured interprofessional bedside rounding (SIBR) is most effective when the opinions of the patient and every team member are valued and everyone knows that his or her voice is heard. To make rounds run smoothly and optimally, team members agree to a choreography that guides how they respectfully enter the room, greet the patient and family, make introductions, set an agenda, make a personal connection, use the computer, and invite participation.^14–15

Why go to all of this effort? SIBR has been proven to enhance patient experience.^16–17 Seeing their clinicians working together helps patients gain confidence in their overall care and decreases concerns about whether “the right hand knows what the left hand is doing.”¹⁸ While doing rounds together, we can engage patients further using relationship-centered communication skills such as empathy; asking about the patient’s ideas, concerns, and expectations; and conducting teach-back during every encounter. Especially in complicated cases, care decisions evolve during bedside discussions with outcomes that are tangibly better than the starting points. Let’s look at an example of how a team’s relationship-centered communication can improve patient experience during the discharge process.

Sarah was nearing the end of a complicated two-week hospitalization. She and her husband, Dave, were anxious to get home but worried about how things would go without the support of the nurses, doctors, and the rest of the team. The medical team told Dave and Sarah to expect discharge SIBR rounds on the afternoon before Sarah left the hospital. Rounds would include her physician, charge nurse, bedside nurse, case manager, and pharmacist. This interaction took less than 15 minutes and concluded with Sarah and Dave summarizing their understanding of the plan (see Chapter 5). Sarah’s and Dave’s unique ideas, concerns, expectations, circumstances, and resources provided a foundation for shared decision-making.

The following morning the team members asked, “So, what did you think of SIBR?” The discussion continued:

Sarah (looking at Dave): Dave and I were just talking about that before you came in. Dave called it NASCAR rounds, didn’t you, Dave?

Physician: NASCAR rounds—that sounds like it was pretty hectic.

Dave: No, hectic is not at all what I meant. “Thorough” would be a better word. Everyone we needed was there. It was crowded but efficient—like a NASCAR pit crew. We really felt like we were part of the team. I can’t tell you how much that means to us.

Sarah: Yes. We felt like you guys really know me—not just my medical problems—but me as … well, as me, and that you’re taking me into account in the plans.

Dave: I’m a planner so I appreciated when you guys asked what concerns we have about going home. That hit the mark better than asking if we have any questions. It got us thinking more concretely.

For Sarah and Dave, interprofessional bedside rounds and relationship-centered communication led to a “top box” patient experience and improved the quality and safety of her discharge plan.

Conclusion

Our conversations with patients and the broader design of our everyday work provide great opportunities to revisit our communication approaches in an effort to convey greater compassion and caring. With small adjustments and mindful awareness of the perspectives of the patients and families, it becomes natural to build relationship and create connection. Strengthening our understanding of where our patients are allows us to meet them there more effectively, where we can help the most. The ripple effects of relationship-centered communication reach both individual clinicians and interdisciplinary teams and help everyone work toward the common goal of enhanced patient experience. We often find that clinicians welcome rather than resist opportunities to deepen their connections with patients because it makes their work more effective and meaningful. Stronger relationships serve as the antidote to the discord and burnout that ensues when we do not attend to these core principles. It is this attention to relationship, beginning with how we are together one-on-one, that stimulates culture changes in organizations to alleviate suffering so that all patients can authentically feel our caring.