By Philip R. Fischer, MD, DTM&H
Synopsis: Unhurried conversations during patient encounters can improve outcomes for patients and enhance career satisfaction of physicians. Specific communication strategies can foster unhurried conversations without adding undue time to clinical care.
Source: Ballard DI, Mandhana DM, Tesfai Y, et al. Unhurried conversations in health care are more important than ever: Identifying key communication practices for careful and kind care. Ann Fam Med. 2024;22(6):533-538.
Unhurried conversations, Ballard and colleagues believe, are the result of intentional communication practices between a clinician and a patient that are free from distractions and whereby the patient senses the clinician’s availability. The authors see unhurried conversations as “a fulcrum around which effective healthcare operates.” This sort of communication and interaction can effectively lead to “kind care that is responsive and responsible to both patients and clinicians.”
With that shared belief, the authors formed a multidisciplinary team, performed an extensive literature review, and met weekly for six months to determine practical aspects of clinician-patient interaction that foster good, non-rushed care. They identified 10 communication practices that collectively allow clinicians and patients to co-create unhurried conversations during clinical encounters.
- Engaging in shared turn-taking. Patients do not always feel welcome to speak up during conversations with physicians. They often want to be invited (such as with questions along the lines of “How do you feel about that?”) to express their thoughts and feelings. Sometimes patients fear being seen as “difficult” if they ask too many questions. So, it is important to ensure that the clinician conveys to the patient that there is a genuine openness to dialogue. A simulation study revealed that patients actually speak less and say more important things when they are invited to speak than they do when they do not sense an openness on the part of the clinician to listen.
- Establishing rapport through discussion of off-task topics. Small talk can develop rapport between the patient and the clinician and also leads to deeper communication about subsequent topics. These brief dialogues extending beyond the actual clinical concern decrease hurriedness, reduce depersonalization (a key component of physician burnout), and enhance patient satisfaction. Only a few seconds of small talk are effective in yielding these favorable benefits.
- Pausing to allow the other person ample time to speak. Using and allowing pauses to reflect or think during conversations gives an unhurried flavor to the interaction and enhances communication and satisfaction. Brief moments of silence can be tolerated. Patient engagement is enhanced as clinicians wait for responses.
- Moderating the pace of spoken language. The tempo of speech should be appropriate for the topic. For instance, good news about results can be described quickly, with enthusiasm. More nuanced discussions about implications of concerning results can be done at a slower pace. The rate of speech influences perceptions of trustworthiness, truthfulness, and even how likable the clinician is. Patients and clinicians are most satisfied when the physician’s speech rate is matched to that of the patient.
- Avoiding conversational interruptions. Observational studies show that physicians speak over and interrupt patients 77% of the time, usually within the first 11 seconds of the patient’s initial comments. This leaves patients feeling disrespected and devalued. Gentle interruptions to request additional detail about the point the patient is making can be acceptable, as long as the patient knows the physician really wants to hear the patient’s responses.
- Minimizing external interruptions. One study showed that nearly a fourth of clinical encounters are interrupted, either by someone at the door, someone on the phone, or the clinician leaving the room. These interruptions disrupt the flow of the clinical conversation and are associated with higher levels of clinician stress and dissatisfaction.
- Triaging topics to create adequate time. Mutually, together, clinicians and patients can prioritize key topics and then spend more time discussing those topics; topics of lower priority can be left for subsequent conversations.
- Expressing emotions. Being emotionally available and sharing emotions with patients are effective techniques in fostering patient (and physician) satisfaction. Questions about psychosocial aspects of the patient’s situation can be helpful, and empathy should be expressed.
- Using inviting questions to encourage participation. The use of open-ended questions fosters patient engagement and helpful expression of important information while decreasing the sense of hurry that otherwise characterizes some patient encounters. More specific questions about important details can follow the initial open-ended questions. While some clinicians are afraid that open-ended questions will invite unnecessarily long responses, data show that open-ended questions usually lead to fairly brief answers while concurrently fostering patient satisfaction.
- Displaying open body language. Open body language includes leaning forward, smiling, and nodding. These behaviors enhance clinician-patient interaction and patient satisfaction. The clinician should be positioned in such a way as to convey openness even when documenting medical details in the electronic patient record.
A significant amount of medical literature confirms that unhurriedness matters. Implementation of the techniques described here can enhance satisfaction of clinicians and patients, without undue additional time being required.
Commentary
In U.S. history, the final two decades of the 19th century sometimes are referred to as “The Gilded Age,” based on the title of an 1873 novel by Mark Twain. Those years were characterized by rapid economic growth and, sadly, also by growing poverty and disparities.1 Society suffers a profound loss when physicians no longer place patient interests ahead of commercial factors, when medicine becomes increasingly like any other business.1
Imposed pressures risk leaving physicians unable to spend unhurried time with patients, time that is necessary to provide truly patient-centered care. Nonetheless, we know that communication between clinicians and patients is very important. The quality and style of communication relates to significant patient outcomes — patient satisfaction, patient adherence to suggested treatment plans, hospital readmissions, and emotional health.2 In the inpatient setting, even the position assumed by the physician (at eye-level with the patient instead of standing) seems beneficial.2 Of course, good communication is the result of the concurrent combination of many factors and is not, as noted by Ballard and colleagues, easily remedied by merely adopting a single new strategy. Some of the recommended communication strategies require at least a little initial investment of time.
Effective use of time is critical in the establishment of a good doctor-patient clinical relationship. Doctors need to take time with patients, and patients need to feel like the doctor has time for them. The article by Ballard and colleagues suggests that reducing the “hurry” of patient interactions is very effective and not significantly time-consuming. Do we have time to try these techniques?
Physicians lament the time-consuming burden of electronic medical records. They strain under a loss of autonomy as institutional and documentation requirements limit their time with patients. They find themselves seeing their patients as tasks to complete rather than as people with whom to relate. Some physicians miss the fulfillment they once sensed in the medical profession.3 In fact, these are the cardinal characteristics of burnout: a sense of a loss of autonomy, depersonalization, and lack of fulfillment. Taking necessary time to avoid hurry demonstrates increased autonomy and, Ballard and colleagues suggest, reduces depersonalization and enhances a sense of fulfillment. That sounds like a desirable recipe to reduce burnout and improve professional satisfaction! Perhaps an intentionally added minute to each encounter would allow implementation of the communication behaviors identified by Ballard and colleagues. Might this little investment be able to save years of a career otherwise at risk for burnout?
Complaining about how difficult clinical work is in the present environment is unlikely to improve anything. However, Ballard and colleagues provide clear, tangible, learnable communication strategies that require very little time yet that markedly improve patient and clinician satisfaction. Most of us entered medicine with empathy and compassion for patients; the 10 tangible strategies proposed in this article can be implemented quickly in the current era of medicine, with the result of rapidly improving bidirectional satisfaction with clinical encounters.
Nearly two decades ago, post-care interviews of 192 patients allowed researchers to identify what patients saw as “ideal” physician behaviors.4 Interestingly, most of those behaviors were described by actions Ballard and colleagues have now linked to unhurried conversations: empathetic — attends to both verbal and non-verbal communication; humane — through “unhurried movements,” expresses willingness to spend adequate time with patients; personal — “asks patients about their lives”; forthright — asks to hear from the patient what the patient understands of what was said; and respectful — “listens carefully and does not interrupt.”4 The value of these qualities of patient interaction is not new, but they seem to be becoming increasingly rare in our current “gilded age of medicine.”
Poor control of the work environment by physicians is linked to burnout and consideration of reducing clinical load or even leaving the institution of current employment.3 Taking control of an extra moment with each patient might be a remedy to decrease hurry, enhance patient outcomes, and improve career satisfaction.
Philip R. Fischer, MD, DTM&H, is Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
References
- Khullar D. The gilded age of medicine is here. The New Yorker. Dec. 12, 2024. https://www.newyorker.com/culture/2024-in-review/the-gilded-age-of-medicine-is-here
- Houchens N, Engle JM, Palanjian R, et al. Effect of clinician posture on patient perceptions of communication in the inpatient setting: A systematic review. J Gen Intern Med. 2024;39(16):3290-3298.
- Sinsky CA, Brown RL, Rotenstein L, et al. Association of work control with burnout and career intentions among U.S. physicians: A multi-institution study. Ann Intern Med. 2024; Nov 26. doi: 10.7326/ANNALS-24-00884. [Online ahead of print].
- Bendapudi NM, Berry LL, Frey KA, et al. Patients’ perspectives on ideal physician behaviors. Mayo Clin Proc. 2006;81(3):338-344.
Unhurried conversations during patient encounters can improve outcomes for patients and enhance career satisfaction of physicians. Specific communication strategies can foster unhurried conversations without adding undue time to clinical care.
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